Publishing in the time of pandemic: Editorial policy of a dermatology journal during COVID-19

Saumya Panda

 Editor-in-Chief, IJDVL,

Correspondence Address:
Saumya Panda
Editor-in-Chief, IJDVL, Ashok-Swapna, 122/4, Dr Jiban Ratan Dhar Road, Kolkata 700028, West Bengal, India

“The only thing worse than bad health is a bad name.”
―Gabriel Garcia Marquez, Love in the Time of Cholera

As we navigate the uncharted waters of an unprecedented pandemic, we are being forced to reorient many of our long held beliefs, habits and the ways in which we conduct our lives. The same holds true for the world of publishing and biomedical literature. The World Health Organization Strategic and Technical Advisory Group for Infectious Hazards has emphasised the importance of rapid sharing of data of public health importance in medical journals by providing rapid peer review, noting the gravity of the health emergency affecting human kind across the globe.^[1]

How to effectively share information in the wake of a rapidly spreading disease is a fraught question that does not have easy answers. An inherent limitation in the peer review system with regard to rapid dissemination of results in a time of crisis is that the processes that ensure careful evaluation come at the expense of immediate dissemination. Generally speaking, journal editors would maintain that high impact papers generated by such emergencies need intense scrutiny; otherwise, public health would suffer from the premature publication of unreliable results. But in the case of a public health emergency such as the present one, are these concerns enough to override the need for information-”any information-”however preliminary and unconfirmed? Should we rethink, and relearn, the whole paradigm of publishing in such instances, as a PLoS Medicine editorial thought aloud 10 years back in the aftermath of another pandemic?^[2]

A study assessing 669 articles across 14 medical journals has provided enough evidence to suggest that the COVID-19 pandemic has propelled the journal editors to drastically speed up their publication process. Compared to articles published in the same journals before the pandemic, turnaround times have decreased on an average by 49%. As expected, the largest decrease in number of days between submission and publication of articles has been due to a decrease in the number of days required for peer review.^[3]

What has been the impact of this accelerated review process on the quality of data regarding COVID-19? We are all aware by now how well meaning attempts at educating the medical community must be interpreted with caution. Indeed, a lot of data have emerged quickly at a time of a global health crisis, and the authors deserve credit for their laudable pursuit to care for patients while at the same time collecting data to share with the rest of the world. Those outside the processes of generating medical information cannot imagine the hurdles at every step. The global lockdown has forced researchers to huddle at home, with their labs, hospitals or clinics closed and their groups dispersed. ^[4] Even if they have nothing to do but to write, it is a humongous job without access to their workplaces or clinical subjects or with kids at home. All of this could not have been possible without the high impact journals leaving aside the rigour of peer review and opting for rapid publication out of concern for rapid mitigation of the pandemic. Unfortunately, as it turns out, much of it is bad data. There are a huge number of startling examples of such data not only flooding the scientific literature but possibly leading the public health efforts astray, giving rise to a scathing observation in the lay media: “The dynamics of a crisis are not conducive to reliable science”.^[5] We shall briefly focus on five of the particularly egregious examples of bad science to illustrate this phenomenon:

• Didier Raoult's dramatic announcement of his study with hydroxychloroquine and azithromycin claiming spectacular efficacy and safety led to media frenzy until it was found to be based on a research that was neither randomized nor controlled. At the time of preprint publication, 8 patients had succumbed out of 1,061, five remained in the hospital, while a total of 46 had a 'poor clinical outcome'. The findings were summarized thus: '98.7% of patients (had been) cured so far'. According to the authors, it was 'a safe and efficient treatment for Covid-19'. The peer-reviewed version of the final study noted that another two patients had died in the interim, bringing up the total number of deaths to 10.^[6] The earlier 'safe and efficient' claim had been brought down by the authors to only 'safe', buffeted as they were by a maelstrom of criticism by this time.
• At the other end of the spectrum, a negative observational study on the effects of hydroxychloroquine on patients hospitalized with COVID-19, published in NEJM, should have been a nonstarter as hydroxychloroquine-treated patients were more severely ill at baseline than those who did not receive the drug (median ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen, 223 vs. 360).^[7] All the conclusions drawn from the study, based on carefully crafted multiple multivariate regression models, are untenable as the groups cannot be compared at the baseline itself.
• An equally remarkable saga played out with remdesivir, an anti-Ebola drug, after Lancet published an underpowered^[8] randomized controlled trial carried out in Wuhan that had come up with inconclusive findings on the prespecified primary outcome of time to clinical improvement.^[9] As if that was not enough, it was followed by a study with fifty shades of grey being published, once again, in NEJM^[10] (no control group, selection bias, erroneous data censoring, no estimation of sample size, no predefined outcome points, scanty baseline clinical data, etc). Still, thanks to the media hype fuelled by these high profile publications, a lot of unreasonable hope is being pinned on this molecule.
• Not only interventional studies, determining risk factors of this pandemic has been fraught with difficulties in interpretation of data in view of such data having been shoddily presented in various publications. For example, whether patients with cancer are at higher risk for being infected with COVID-19 and whether they will experience greater morbidity are important questions. One of the early studies that examined a cohort of 1,524 patients hospitalized with cancer identified 12 patients with COVID-19 infection (0.79%), compared with 0.37% of individuals who were positive with COVID-19 in the general population of Wuhan.^[11] It is impossible to tell from this data whether these data represent a higher risk of COVID-19 infection in patients with cancer, or whether they represent a selection bias in which patients with COVID-19 with cancer are more likely to be hospitalized. Such limitations make it difficult to draw any conclusions about the risk of COVID-19 infection in these settings.^[12]
• Lastly, we mention here the well-meaning but ill-founded recommendation by a group of researchers, in the early days of the pandemic, to discontinue angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers for those at high risk of infection. Lei Fang and colleagues^[13] extrapolated results from a molecular study of coronaviruses showing that this group of viruses uses ACE2 to target cells on the epithelium of the lungs, intestine, kidneys, and blood vessels.^[14] Whether an association exists between increased ACE2 expression and risk of infection with SARS-CoV-2 or severity of COVID-19 is currently not fully understood. Nevertheless, Fang and colleagues^[13] suggested that alternative treatment could be sought for those at high risk of infection, and broader public knowledge of this hypothesis had led to uncertainty and concern.^[15]

It is very apparent from the above examples that while rapid review (or diminished review) has certainly resulted in a glut of data, it has, at the same time, jeopardized quality. Even the journals with the best of infrastructure and resources must be struggling under the current circumstances which are challenging, to put it mildly.

The journal editors and reviewers have to face and overcome the same challenges as described earlier for the authors. The situation is particularly arduous for women with their increased caregiving responsibilities, including day-long minding of children due to school and day care closures, homeschooling, and the cooking and cleaning associated with having one's family at home all day, every day.^[16] Our journal, which has an enviable proportion of women editors, has provided a glimpse to me of this gender disparity in working situations during this pandemic. While men, on the whole, have worked on an even keel, it has been a challenge for many women, most of whom are normally quite efficient in their editorial assignments. One can imagine what a challenge it would be to embrace rapid reviewing as journal policy under these conditions. Journals have been strategising, with varying efficacy, various options previously not tried in this scale, e.g. curtailing requests for additional evidence during revisions, putting no time limits on revisions, making the posting of preprints to bioRxiv or medRxiv the default for all submissions, extension of 'scoop protection' policies to cover competing work that is published on preprint servers prior to submission, mobilizing early-career researchers, etc.^[17] Publishing, a multidimensional task with complex interfaces at the best of times, has become suddenly much more complicated.

What has been the impact of COVID-19 pandemic on dermatological literature? There has been a surfeit of articles on the effect of the pandemic on dermatology practice, putative dermatologic signs of the infection, the effect on and of the disease among those patients being treated by dermatologists with biologics and other immunosuppressives, etc. This is despite the infection being of marginal influence to our discipline, and vice versa, at least in the starting phases of the pandemic. The cutaneous manifestations of the infection, which are also nonspecific in nature and present in a minority of the infected cases, have been apparent only of late.^[18],[19] As the impact of SARS-COV-2 on skin, and by extension, on dermatology literature, has been tangential at most, IJDVL has been lucky having not to confront headlong into deciding between junking its multilayered decision making model (involving the assistant editors, section editors, external reviewers, post-peer review content editors, image editors and the editor-in-chief), that takes time but ensures quality, in favour of a trimmed-down decision making apparatus that would, in all probability, have led to accelerated turnover time but would have produced a lot of bad and inconsequential data. Our speculation seems to be justified in view of the examples cited above, almost all of which are courtesy very large, high impact, high quality journals endowed with far greater resources than the IJDVL. As a result of its policy decision not to dilute the editorial and review processes, primarily because the infection is not essentially a dermatologic one, our journal has been bucking the global trend of publishing just about anything on COVID-19. Does that mean that we have anything against publishing any article that concerns SARS-COV-2/COVID-19? This question itself might seem to be ludicrous but is being asked in view of there being not a single publication on these in our journal until now – a lonely outlier position among major dermatology journals in the world – and we have found it prudent to elaborate the journal policy on such articles. Our prioritization took its cue from a JCO editorial,^[12] that has, of course, been thoroughly customized to suit the needs of the Indian clinical dermatologists, who happen to constitute our primary readership base.

The following will be high priority research articles deserving accelerated processing:

• Research that definitively shows which dermatological conditions, if any, encompass populations (including patients and physicians) who are at higher risk for COVID-19 infection and that convincingly identifies variables that confer higher risk of serious morbidity and mortality attributed to COVID-19 infection.
• Research that examines interventions to mitigate transmission of COVID-19 and its downstream effects in dermatological patients and dermatologists and demonstrates whether such interventions are effective-”in other words, high-quality research that asks a clinically relevant and actionable question and provides reproducible answers, so that our readers can bring definitive improvements in their service delivery in the short-term.
• Prospective research, especially if it represents a collaborative effort resulting from centralized, comprehensive databases that provide large enough numbers for meaningful analysis.

The following will be medium priority articles to be judged on a case-by-case basis, for which the scientific rigor will be high and the regular reviewing process of the journal will apply:

• Retrospective research leading to a sufficiently novel hypothesis that might be important for our readers to consider
• Hypothesis-generating single case reports or case series
• Reports that belong to the high priority category but not novel -” yet relevant-” for understanding and mitigating Covid-19 in India

The following will be low priority articles and will, in all probability, not be published:

• Articles that draw conclusions from or outline strategies that echo existing standards of care during this pandemic and that overlap with guidance from professional societies and regulatory agencies readily available in the public domain.

In other words, IJDVL has kept its editorial policies and priorities essentially unchanged. Unlike some other journals, those have thought it prudent to embrace rapid reviewing as part of their social responsibility,^[20] we have sought the straight and narrow path of pulling the plug on bad scientific evidence wherever and whenever we possibly can. Only time can tell whichever course serves history more positively, as a veteran editor has summed up the situation quite succinctly last month:

“...much of the scientific literature, perhaps half, may simply be untrue.”^[21]

1.	Bedford J, Enria D, Giesecke J, Heymann DL, Ihekweazu C, Kobinger G et al. COVID-19: towards controlling of a pandemic. Lancet 2020; 395: 1015-8. [Google Scholar]
2.	The PLoS Medicine Editors. Journals, academics, and pandemics. PLoS Med 2010; 7: e1000282. [Google Scholar]
3.	Horbach SPJM. Pandemic publishing: Medical journals drastically speed up their publication process for Covid-19. bioRxiv 2020.04.18.045963; doi: https://doi.org/10.1101/2020.04.18.045963. [Google Scholar]
4.	Widener A. Journal publishers promote flexibility during COVID-19 pandemic. Chemical and Engineering News (C & EN) 2020; 98: 13. [Google Scholar]
5.	Sayare S. He was a science star. Then he promoted a questionable cure for Covid-19.The New York Times Magazine, May 12, 2020. [Google Scholar]
6.	Gautret P, Lagier JC, Parola P, Hoang VT, Meddeb L, Sevestre J et al. Clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six-day follow up: A pilot observational study. Travel Med Infect Dis. 2020 Mar-Apr; 34: 101663. [Google Scholar]
7.	Geleris J, Sun Y, Platt J, Zucker J, Baldwin M, Hripcsak G et al. Observational study of hydroxychloroquine in hospitalized patients with Covid-19. N Engl J Med 2020 May 7. doi: 10.1056/NEJMoa2012410. [Epub ahead of print]. [Google Scholar]
8.	Norrie JD. Remdesivir for COVID-19: challenges of underpowered studies. Lancet 2020; 395: 1525-7. [Google Scholar]
9.	Wang Y, Zhang D, Du G, Du R, Zhao J, Jin Y et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet 395; 1569-78. [Google Scholar]
10.	Grein J, Ohmagari N, Shin D, Diaz G, Asperges E, Castagna A, et al. Compassionate use of remdesivir for patients with severe Covid-19. N Engl J Med 2020 Apr 10. doi: 10.1056/NEJMoa2007016. [Epub ahead of print]. [Google Scholar]
11.	Yu J, Ouyang J, Chua MLK, Xie C. SARS-CoV-2 transmission in patients with cancer at a tertiary care hospital in Wuhan, China. JAMA Oncol 2020 Mar 25:e200980. doi: 10.1001/jamaoncol. 2020.0980.[Epub ahead of print]. [Google Scholar]
12.	Cannistra SA, Haffty BG, Ballman K. Challenges faced by medical journals during the COVID-19 pandemic. J Clin Oncol 2020 Apr 8: JCO2000858. doi: 10.1200/JCO.20.00858. [Epub ahead of print]. [Google Scholar]
13.	Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med 2020; published online March 11. https://doi.org/10.1016/S2213-2600 (20) 30116-8. [Google Scholar]
14.	Wan Y, Shang J, Graham R, Baric RS, Li F. Receptor recognition by the novel coronavirus from Wuhan: an analysis based on decade-long structural studies of SARS coronavirus. J Virol 2020; 94: e00127–20. [Google Scholar]
15.	Brown JD. Antihypertensive drugs and risk of COVID-19? Lancet Respir Med 2020; 8: e28. [Google Scholar]
16.	Flaherty C. Early journal submission data suggest COVID-19 is tanking women's research productivity. Inside Higher Ed. April 21, 2020. (https://www.insidehighered.com). [Google Scholar]
17.	Eisen MB, Akhmanova A, Behrens TE, Weigel D. Publishing in the time of COVID-19. eLife 2020;9:e57162. [Google Scholar]
18.	Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395: 497–506. [Google Scholar]
19.	Joob B, Wiwanitkit V. COVID-19 can present with a rash and be mistaken for dengue. J Am Acad Dermatol 2020; 82: e177. [Google Scholar]
20.	Hamid ARAH. Social responsibility of medical journal: a concern for COVID-19 pandemic. Med J Indones 2020; 29: 1–3. [Google Scholar]
21.	Horton R. Offline: What is medicine's 5 sigma? Lancet 2020; 385: 1380. [Google Scholar]