Pandemic outbreak of COVID-19 is the largest of its kind of this century. All countries throughout the globe are trying their best to contain the disease and eliminate at the earliest. Efforts are continuing to improve the outcome of the infection in terms of minimizing the morbidity and mortality. As a public health strategy every state has the responsibility of protecting the health of the community and such measures includes the preventive measures like social distancing or even lockdown of the state as a whole restricting the movement of the people, diagnostic measures like testing the suspects, contact tracing and isolation of the patients. Treatment of the infected requires decisions in resource constraint situation particularly ICU beds and ventilators. In the meantime, protecting doctors, nurses, other health workers as well as frontline workers need personal protective equipment (PPE) which is a scarce commodity. While doing so there might be a compromise in the individual autonomy, privacy, confidentiality, and social justice for the beneficence for the larger community. This is an attempt to explore the ethical quandaries in relation to combating COVID-19 in Nepal by relating the issues with the principles of biomedical ethics. In the present context, every state has the responsibility to protect the health of its population which needs crucial public health strategies and interventions accordingly.The global spread is demanding huge public health and prompt medical responses which include detection of sources, testing of anticipated positive cases, contact tracing, and combating further spread. Nepal government has imposed travel restrictions as well as lockdown of the country sealing land borders with India and China and halting all the national and international flights. In the meantime, spreading health education for social distancing, avoiding handshakes and hugs, and doing “Namaste” is becoming more acknowledged as a way of greeting.2 China succeeded in combating the situation by effective enforcement of restriction of movement, quarantine, and isolation and labeled it as the ‘China model’.3Protection of the health of the population needs crucial public health planning and rigorous enforcement of certain public health measures. As a strategic planning phase 1, one has to get ready for the surveillance system to detect suspected cases of COVID 19 infection and isolate them. Following with contact tracing and putting suspected cases in quarantine for 14 days. The lessons learned from Italy suggest that the right to individual liberty and the right to mobilize, communicate or socialize have to suspend, to prevent the progression of stage 1 to other stages.4News reports of people being assaulted when they violate the lockdown by coming out of their homes by law enforcement agencies are starting to surface. Migrant workers trying to enter Nepal from India are denied entry. People are taking desperate measures like crossing rivers to enter into Nepal. Those who are caught have been arrested of benefit to the community, but are deprived of their autonomy. The restrictions made on the individual liberties should meet the principle of proportionality and it should not exceed to the extent it exceeds anticipated risk.The health workers assigned on duty without PPE in the frontlines are at increased risk not only to themselves but also to their family members and other patients. Thus, it poses an ethical issue of harming others. In addition, there is fear and hesitancy in care providers who are refusing to attend the patients. Patients with fever are being stigmatized for COVID-19 even though they have tested negative. At times, patients suspected of COVID-19 died in isolation wards but so far all of them were negative for the disease. However, obviously the dead body could not be cremated until receiving the test report. Even after that their funeral, their families have been boycotted by near and dear ones.Distribution of scarce medical supplies including PPE to government institutions only has augmented the undue referral or even refusal of patient care. The question is whether the ethics have been violated in the war of combating the COVID-19 pandemic?After the declaration of a pandemic by the World Health Organization (WHO), all nations were alerted. Nepal had to be more vigilant due to its border to the originating country China and open border with the giant neighbor India. Even the number of cases is still low, a country like Nepal could not ignore the context.1 Generally, ethical values in outbreaks or pandemic involve tradeoffs between the individual versus public health interest.5 Stay-at-home popularly called as ‘lockdown’ was enforced in Nepal as per the Contagious Disease Act, 1962.Several measures are taken to tackle the COVID-19 pandemic, like banning public gatherings, stay-at-home orders, quarantine of returning travelers, and isolation of patients, jeopardized not only the ethical principle of ‘respect for autonomy’ but also the basic human right. However, individual freedom had to be balanced against compelling public health need.6Isolation of the patient and contact tracing carried the risk of violation of the ethical principles of ‘respect for autonomy’ as every suspected case must be reported with personal identifiers, and as per the ethics of pandemics, consent from the individual is not mandatory. This means it is ethically justifiable to breach the issues of privacy and confidentiality because the particular person has to be identified, reported, and isolated to reduce significant harm to the community keeping in mind this overriding should be kept to the minimal.7 Providing appropriate information, truth-telling, and transparent actions augmented the sense of civic responsibilities, and volunteerism was observed in the public.11 Risk communication and community engagement is a critical component of the response to COVID-19 that helps people make the right decisions about how to protect themselves when to seek care, and to avoid contributing to panic about the disease12. Managing the ‘infodemic’ and maintaining trust in public health authorities is critical to the ongoing management of the outbreak.13 Trust begins with communication, and communicating information during outbreaks is challenging, especially as our knowledge of the disease is rapidly evolving.14Like other parts of the world, punitive measures eroded public trust.16 In addition, containment measures must not be a subterfuge for discrimination.8Like in many countries, separate clinics named either ‘Fever Clinic’ or ‘COVID-19 Outpatients Clinic’ were established in the hospitals so as to identify and triage COVID-19 cases. A suspected case would be shifted to an isolation ward. These measures not only ease the patients but also protect other patients and healthcare providers. Though there was an acute shortage of PPE, gradually specific clinics and wards received them in fair quantities. In any given context, a mechanism of supporting vulnerable individuals to mitigate the effects of these measures has to be ensured.The government decision to implement lockdown adversely affected the poor, the marginalized, and the vulnerable population . Even though the government tried to alleviate these deprivations of basic daily needs through local government, it was not possible to reach all those who need it.9 Some of the incidents included discrimination against doctors, nurses, and other health care professionals. They were asked by the landlords to leave their rented accommodation. However, in the level of society, the health care professionals were highly appreciated for their services irrespective of their risks of COVID-19. Labeling the special clinic as “Fever Clinic” created discrimination of the patients presenting with fever because all patients with fever were regarded as COVID-19 and there was denial or inappropriate management of febrile patients.Categorical exclusion for care based on sex, race, religion, intellectual disability, citizenship, social status, etc. is morally irrelevant and must be avoided in any circumstance. Categorical exclusions are not necessary because less restrictive approaches can be explored. For example. allowing all patients to be eligible and giving priority to those most likely to benefit.9 While caring for a case of COVID-19, mortality among elderly is an issue and thus, there is a risk of age-related discrimination for care. In this case, prioritization should actually not be based on age-wise categorical exclusion but based on chances of survival and the opportunity to live through the stages of life - childhood, young adulthood, middle age, and old age.17Non-critical medical care and treatments were limited or even unavailable in some places. Rationing of health care was necessary because the crisis was beyond the existing capacity. In such a situation the ethical dilemma is on deciding who should get the priority for care? ‘Greatest good for the greatest number’ seems logical but at times cannot address some ethical considerations. For example, the allocation of scarce beds in the intensive care units or ventilators for critically ill patients which are generally prioritized to those most likely to be discharged alive after the treatment.Another global problem of ethical concerns in the allocation of resources is the availability and distribution of PPE. During a pandemic, keeping medical workers safe is very important. Of course, there is increased vulnerability but the sense of safety needs to be ensured with standard safety measures. Awareness among the medical workers particularly in terms of levels of protection is required. Inappropriate use of PPE by the leaders and nonmedical staff has also reported in the press and must be condemned.21 International health regulations of the World Health Organization (WHO) might need to be upgraded to global regulations for an international response.After the blockade of the Nepal-India border particularly following the lockdown, hundreds of people were stranded at both sides of the border. At least one of them turned out to be positive for COVID-19 and thus, contact tracing in this particular case was impossible. Capacity building and collaboration between countries are needed to strengthen the system for the control of any Public Health Emergency of International Concern (PHEIC).Strategies like social distancing by the lockdown, quarantine or isolation are some of the public health measures which are enforced to the public for the benefit of the community in a situation of pandemics. It might impose ethical issues of compromise in the autonomy of the individual, ban on the right of transportation, loss of job or income, inaccessibility of marginalized population to basic needs like food, shelter or treatment. Similarly, judicious allocation of limited resources like PPE, test kits, beds, medical equipment, ventilators will help in mitigating the situational crisis and lessening the chances of posing social injustice to the vulnerable population. Beneficence to the large community is acceptable although there might be ethical challenges compromising individual dignity and rights.None.


To identify the distribution of asthma education programs that are currently active in Texas and examine whether there is a geographical disparity between asthma prevalence and locations of asthma education programs in the Public Health Regions (PHRs) of Texas.  The data for adult asthma prevalence in PHRs was obtained from the Texas Department of State and Health Services (DSHS) 2015 Texas Behavioral Risk Factor Surveillance System (BRFSS) Public Use Data File. The Geographic Information System (GIS) program was used to show the distribution of asthma education programs and visually identify the isolated areas for asthma education programs on the maps. To examine the areas covered by the asthma education programs, we illustrated 50 miles and 70 miles of buffer zones from each program by proximity (multiple ring buffer) functions in GIS. Discussion. This study revealed the marginalized regions in Texas lacking asthma education programs. The findings could help policymakers and health care professionals enhance opportunities to develop asthma education programs using different venues in isolated areas and prioritize these regions, for funds, to establish new asthma education programs. We identified that 27 asthma education programs are active in Texas as of July 2019. The analysis showed that PHRs 1, 2, and 7 had the highest rate of asthma prevalence but had fewer asthma education programs. Also, the distribution of asthma education programs is concentrated around major cities, leading to a regional imbalance between asthma prevalence and locations of asthma education programs. The central and western areas of Texas proved to be marginalized areas for asthma education programs, particularly PHRs 2 and 9 because they may not be covered by the buffer zones of 70 miles from any asthma education programs.  Asthma is a chronic medical condition in which a person's airways in the lungs become narrowed and swollen, which makes it difficult to breathe causing coughing, tightness in the chest, wheezing, and shortness of breath . Currentp < 0.05), while those with SAC with asthma and an Emergency Department/Inpatients visits missed 1.8 times more workdays (p < 0.01) than the parents of SAC without asthma [Asthma has caused substantial burdens, both clinically and financially, and has become a significant health issue in the US. According to the CDC in 2017, there were 3,564 deaths attributed to asthma in the US, signifying that about 10 people per day lose their lives due to asthma [The older adult population is increasing worldwide, and a significant percentage has asthma, which is frequently underdiagnosed and has higher morbidity and mortality rates compared with their younger counterparts . StudiesAsthma self-management education consists of information on asthma, self-monitoring, regular medical follow-ups, a written asthma action plan, instructions on the use of prescribed inhalers, education about recognition of early signs and symptoms of an asthma episode, and appropriate responses and advisement to reduce environmental/allergen exposure as appropriate , 12. SomPrevious studies have shown that asthma education provided in various settings such as health care facilities, schools and communities helped people with asthma and their caregivers to detect the asthma triggers and symptoms in the early stage, as well as prevent asthma attacks and frequent emergency room visits , 15. A sIn addition, asthma education programs that are culturally competent are significantly effective in improving asthma-related outcomes such as medication adherence, cost-effectiveness, asthma knowledge, and emergency room visits, especially for ethnic minorities , 17. TwoHowever, multiple factors cause disparities in asthma management/education among ethnic minorities. These factors include low socioeconomic status, lack of accessibility to health care due to transportation issues, inadequate insurance coverage, communication difficulty due to language barriers, insufficient knowledge of asthma care and management, lack of knowledge about asthma triggers, concerns regarding dependency, and side effects of medications in the long term , 21–26. The Texas Asthma Control Program (TACP) was established in 2002 but was discontinued in 2014 due to lack of funds. As of August 2019, the state of Texas was not funded under CDC's National Asthma Control Program ; howeverThe Asthma Coalition of Texas was formed by the Texas Department of State Health Services (DSHS) and the coalitions that were initiated by the seed money provided by TACP . UnfortuThere is still a paucity in studies to identify the distribution of the current asthma education programs and marginalized areas with high needs for asthma education programs. Therefore, the objective of this study is to identify the distribution of asthma education programs that are currently active in Texas and to examine whether there is a geographical disparity between the prevalence of asthma and asthma education programs in the level of the Texas Public Health Regions (PHRs).This is a descriptive study to identify the distribution of the current asthma education programs and examine whether there is a regional disparity between asthma prevalence and the distribution of asthma education programs in Texas. In this study, adult asthma prevalence data in the PHR level of Texas was obtained from the 2015 Texas Behavioral Risk Factor Surveillance System (BRFSS) Public Use Data File of the Texas DSHS. The prevalence of asthma was weighted to reflect the total adult population by demographic characteristics, based on a complex population-based weighting methodology known as iterative proportional fitting. The total unweighted sample size of adults who answered questions about asthma status was 14,588, and the population-weighted prevalence was estimated based on the total adult population in each region .The total number of adults older than 18 years with asthma was based on the response to the following two survey questions: “Has a doctor, nurse, or other health professionals ever told you that you had asthma?” and “Do you still have asthma?” In a report developed in the spring of 2014 , a list The Texas DSHS divides the state of Texas into 11 PHRs. These 11 PHRs comprise all regions in Texas, and they are responsible for delivering comprehensive health services to the counties under them . All of The adult asthma prevalence was measured as the percentage of adults diagnosed with asthma in each PHR in the 2015 Texas BRFSS Public Use Data File. Using the Jenks natural breaks classification method , we cateWe conducted a descriptive analysis to calculate mean, median, standard deviation (SD), and interquartile range (IQR) of the number of people with asthma, the adult asthma prevalence, the number of asthma education programs per PHR, and the number of population with asthma per program. A correlation test was performed to examine the relationship between adult asthma prevalence and the number of asthma education programs among PHRs using STATA, version 14 . In addition, the Geographic Information System (GIS) program was used to show the distribution of asthma education programs and visually identify the isolated areas for asthma education on the maps. The location of all current asthma education programs was geocoded on the map of Texas, based on latitude and longitude of each program's address. To examine the areas covered by the asthma education programs, we illustrated 50 miles and 70 miles of buffer zones from each program by proximity (multiple ring buffer) functions in GIS. The buffer zones were indicated with different colors. Spatial analysis was conducted using ArcGIS software 10.4 .Twenty-seven asthma education programs, which are currently active in Texas, were obtained for this study . Based on = 3) had fewer education programs than the latter (n = 4). Therefore, we found that there is a regional imbalance between asthma prevalence and locations of asthma education programs. In particular, PHR 2 is one of the highest regions for the asthma rate; however, there are no asthma education programs, which indicate that people with asthma living in PHR 2 have limited access to the education programs. In addition, the correlation test between asthma prevalence and the number of education programs showed that there was a negative correlation (−0.342), indicating that adult asthma prevalence is associated with the decreased number of asthma education programs. However, this was not statistically significant (p=0.304).The distributions of adult asthma prevalence and asthma education programs are shown in When we displayed the buffer zones of 50 miles or 70 miles, which may be covered by the current asthma education programs see , the marThe results of this study showed that there is a lack of asthma coalitions/programs in PHRs 2 and 9 and a high number in PHR 6. There is a need to implement new coalitions in PHRs where the number of adults with asthma is high and no asthma resources are identified. Depending upon the PHR that an adult with asthma lives, if there is an asthma program that could provide education in signs, symptoms, self-management, and asthma triggers, they will benefit greatly from it. It is known that environmental and social barriers for adult's asthma self-management, extreme living conditions, make it difficult or impossible for patients to attend medical visits and adhere to optimal asthma care. Lack of knowledge of these barriers does not help health providers to create tailored, personal, and empathetic approaches to asthma management. Depending on their economic situation, adults with asthma might have high morbidity, many hospitalizations and emergency department visits, other comorbidities, and significant barriers including difficulty with transportation to regular outpatient visits . To adeqHealth care professionals play an essential role in the dissemination of education to people with asthma; however, due to limited resources and time constraints, it may not seem possible. It is imperative to provide or make available information on asthma coalitions and programs to health care professionals as it can help them provide education to patients and their caregivers at convenient places. The knowledge that the patients acquire will be useful to help identify the triggers of asthma, recognize the signs and symptoms of asthma, and adhere to treatment –43. TherUnfortunately, information about coalitions and programs that offer asthma education is not easily obtainable by everyone, and the availability of adequately trained educators/professionals in asthma is vital. The absence of asthma education is related to factors such as language barriers, lack of resource knowledge, nonintegration of asthma education by physicians into current practice, and lack of knowledge of those programs or coalitions in their cities. Patients are sometimes reluctant to attend educational programs, even when available at minimal or no cost. Participating in those asthma programs may be difficult due to lack of transportation, inadequate motivation, lack of time, or the perception that they do not need this intervention . Asthma This study demonstrates the distribution of the current asthma education programs in Texas and provides a visual representation of the marginalized areas for asthma education programs. The information presented in this study is needed at many levels, such as academic, government, state, nonprofit organizations, and communities. During the existence of TACP, information regarding asthma was readily available from the Texas DSHS. Since its closure in 2014, current asthma information in Texas and its counties are scarce, outdated, and only researchers, working with asthma in affected communities might have the current statistics; however, now that it is funded again, we hope to have the information that is needed to develop new asthma programs where they are needed. This study provides information about the available coalitions and programs functioning as of July 2019, with their contact information in the state of Texas.However, this study has several limitations. First, the process used for data collection had several limitations identifying programs because some of them were not available through the website search or embedded in larger chronic disease initiatives. Therefore, there are additional asthma program resources available in the state of Texas, which are difficult to identify and access. These programs require improved presence through the Internet. Among calls to the 51 programs, only 23 representatives followed up and provided detailed information about their programs. Secondly, the information about the age range and number of participants attending their programs was not included in this study. Thirdly, we used the level of PHRs as boundaries considering the data availability for asthma prevalence. In addition, we did not have the data about the estimated number of population with asthma within each buffer; therefore, it was hard to see how many populations are covered by current asthma education programs. Future research needs to use smaller boundaries, such as counties and census-tract level, to identify the regions with high demands for asthma education. Fourthly, we covered only adult asthma prevalence in this study due to data availability. Child asthma prevalence will need to be included in further studies. Lastly, only on-site education programs were considered in this study, although there might be other types of educational programs like online-based and telehealth education. Therefore, further studies should include these kinds of educational programs.We concluded that there is a regional disparity between adult asthma prevalence and the distribution of asthma education programs in Texas. This study identified the marginalized regions in Texas with high demands for asthma education programs. The findings could help policymakers, and health care professionals to enhance opportunities to develop asthma education programs. Diverse venues can be identified for isolated areas for asthma education programs and prioritize these regions for funding innovative programs. The government, foundations, and other health care agencies could consider providing funds for initiatives that could reduce geographic disparity for asthma education programs.


Credible, reliable and consistent information to the public, as well as health professionals and decision makers, is crucial to help navigate uncertainty and risk in times of crisis and concern. Traditionally, information and health communications issued by respected and established government agencies have been regarded as factual, unbiased and credible. The U.S. Centers for Disease Control and Prevention (CDC) is such an agency that addresses all aspects of health and public health on behalf of the U.S Government for the benefit of its citizens. In July 2020, the CDC issued guidelines on reopening schools which resulted in open criticism by the U.S. President and others, prompting a review and publication of revised guidelines together with a special “Statement on the Importance of Reopening Schools under COVID-19.” We hypothesize that this statement introduced bias with the intention to shift the public perception and media narrative in favor of reopening of schools. Using a mixed methods approach, including an online text analysis tool, we demonstrate that document title and structure, word frequencies, word choice, and website presentation did not provide a balanced account of the complexity and uncertainty surrounding school reopening during the COVID-19 pandemic. Despite available scientific guidance and practical evidence-based advice on how to manage infection risks when reopening schools, the CDC Statement was intentionally overriding possible parent and public health concerns. The CDC Statement provides an example of how political influence is exercised over the presentation of science in the context of a major pandemic. It was withdrawn by the CDC in November 2020. Credible, reliable and consistent information to the public, as well as health professionals and decision makers, is crucial to help navigate uncertainty and risk in times of crisis and concern. The COVID-19 pandemic has generated an information surge, based on an unprecedented amount of rapidly evolving and accessible data, amplified by modern mass communication channels, oftentimes unvetted in terms of quality, truthfulness or scientific evidence. The individual's ability to distinguish real from fake or important from hyped is tested to the maximum in what the World Health Organization calls an “infodemic” , 3.Traditionally, information and health communication items issued by respected and established government agencies have been regarded as factual, unbiased and credible. The U.S. Centers for Disease Control and Prevention (CDC) is an agency that addresses all aspects of health and public health on behalf of the U.S. Government for the benefit of its citizens. The CDC's pledge is to “base all public health decisions on the highest quality scientific data that is derived openly and objectively,” which sets a high bar of scientific integrity for information and guidance that is provided for health professionals, political decision makers, media and the public at large .The COVID-19 pandemic has exacerbated pre-existing tensions between science and politics in the U.S. (and elsewhere), challenging the role and credibility of science and the translation of scientific advice into effective public health policy and action. Such conflicts have recently resulted in a situation where the CDC was requested to reconsider its draft guidance on reopening of schools during the COVID-19 pandemic . AccordiReacting to the criticism, Vice President Mike Pence and CDC Director Robert Redfield announced that revised guidelines would be released the following week. According to the New York Times, the Department of Health and Human Services took control of the revisions with minimal input from the CDC . When thIt is our hypothesis that the introductory Statement of the revised guidance introduced politically motivated bias into a scientific discussion. To test this hypothesis we analyzed the CDC Statement, using language and contextual analysis tools to determine whether the information is presented objectively, in accordance with CDC's pledge. In this paper we do not enter into details of the politics of the relationship between the CDC and the U.S. Government. Neither do we assess the scientific evidence of the arguments put forward against or in favor of a return to regular school attendance.http://www.voyant-tools.org, University of Alberta, Canada, and McGill University, Canada), we undertook simple automated analyses of the Statement's main body, excluding footnote text. We analyzed word frequencies to compile a ranking of words according to frequencies; a predetermined set of stopwords was excluded, based on a standard list of English stopwords available from Voyant-tool.org). We tabulated the first five most common terms and three additional selected words related to the pandemic . In addition, the authors manually analyzed the document structure and performed a word-by-word content, contextual and emotional connotation analysis  is declarative, identifying the document's view, rather than an evaluation of risks and benefits.The Statement is structured into eight broad sections, starting with an introduction. Only the second section with the heading “COVID-19 and Children” briefly discusses the health risks of COVID-19 and the particular situation of children. From the total word count of 2,315 words only 307 are dedicated to this topic see . The othThe choice of words and phrasing of the Statement demonstrate vagueness and bias, as illustrated in this annotated version (annotations in square brackets) of the second paragraph of the section with the heading, “COVID-19 and Children:”Scientific studies suggest  that COVID-19 transmission among children in schools may [indicates uncertainty] be low. International studies [no references] that have assessed how readily COVID-19 spreads in schools also reveal  low rates of transmission when community transmission is low.  Based on current data, [references missing] the rate of infection among younger  school children, and from students to teachers, has been low, especially if proper precautions are followed.  There have also been few reports  of children being the primary source of COVID-19 transmission among family members. [Were these children attending school?] This is consistent with data from both virus and antibody testing, suggesting [“suggesting” is not proving.] that children are not the primary drivers of COVID-19 spread in schools or in the community. No studies are conclusive, but the available evidence provides reason to believe [vague] that in-person schooling is in the best interest of students, particularly in the context of appropriate mitigation measures similar to those implemented at essential workplaces. [The appropriate mitigation measures are not discussed in this statement. This blanket assertion is not helpful to those seeking advice on how to safely reopen schools.]https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/reopening-schools.html).The Statement is presented on a webpage separate from the technical guidance documents. The latter are accessible via a left-hand menu of searchable tabs, requiring additional clicks to unfold sub-menus in order to find and select guidance related to school reopening. Users reaching the website through a search engine may have difficulty finding the technical content or mistake the statement as the main guidance (see the website screenshot in The CDC Statement provides an example of how political influence is exercised over the presentation of science in the context of a major pandemic. The fact that the original draft of the CDC's guidelines on school reopening was publicly questioned by the U.S. President; that an additional statement was crafted to precede and pre-empt the revised guidelines without actually incorporating them; and that the title of the Statement itself contains no reference to “safety,” all combined suggest that there was a deliberate intent to spin the CDC's scientific guidance toward reopening of schools. Our analysis confirms this initial hypothesis and provides evidence of biased and selective presentation of science, intended to downplay the COVID-19 infection risks for children, teachers and staff returning to school. However, we acknowledge a potential and virtually unavoidable analysis bias. The extent of White House interference in CDC matters was the subject of multiple media reports and became the origin of our interest in undertaking the presented analysis .Unlike an earlier CDC communication on school reopening from May 19, 2020, the new CDC Statement neither addresses the risks of reopening in detail nor discusses how to manage them safely. Instead, it elaborates at great length on the benefits of reopening and the missed benefits of not doing so. In seven of the eight sections the Statement speaks about the educational needs of children, the benefits of attending school and, in particular, the detriments of not attending, none of which is questioned by anyone. It is interesting to note that the Statement boasts about school-related benefits that have been under pressure, limited, or otherwise challenged by the Trump administration's policies aimed at weakening the public school system , 12.Building on extensive evidence, several practical health communication tools have been developed for the context of pandemics and the COVID-19 pandemic in particular –15. AmonEven though the CDC's technical guidelines and tool tabs on the website provide a more balanced risk-benefit analysis of reopening and offer recommendations on how to keep children, teachers and staff safe at school, they remained hidden by separating them from the Statement in an obvious effort to strengthen the case for re-opening see . It woulCritical in the broader frame of transparency and accountability is the fact that the Statement was published under the CDC's name and brand, as part of a set of technical guidelines. The fact that the Statement was conceptualized and largely drafted by people not within the CDC, and that CDC was given limited opportunity to provide input is not communicated openly . ReadersThe Statement was withdrawn by the CDC on November 17, 2020, 2 months after our analysis presented here . The delThe U.S. and many other countries witnessed heated and politicized public discussions about the risks and benefits of open or closed schools amidst an ongoing pandemic with continued high rates of disease transmission. The importance of reopening school is widely recognized and acknowledged, but it is only safe if available scientific guidance and practical evidence-based advice on how to manage infection risks when reopening schools are duly observed. The additional Statement simply overrides all public health concerns by pushing technical details and balanced risk assessments into the background. The fact that the Trump administration felt the need to add an interpretative layer to the CDC's science-based guidance is an expression of its general disregard for science and its preference that favors economic returns over potential harm to children, teachers, school staff and families . PoliticIn the context of effective health communication in a pandemic, “wise politicians realize the limits to their knowledge and their ability to spin things in the real world. This is a disease, it doesn't care what we think and say, it only cares about what we do. If politicians have a short-term agenda and cherry pick the data, or find a scientist who happens to agree with them, they might win in the short run, but they leave themselves vulnerable in the long run. Wise policy advisers encourage policy-makers to respect the science, and, of course to communicate evidence-based messages as effectively as possible.”  We wholeIt is hoped that vigilant science, media and civil society will defend the CDC's independent science-based work and urge political leaders to respect science and act accordingly, in the best interest of the people they serve. The eventual deletion of the Statement from the CDC's website is testimony to the critical need and power of such public vigilance.The original contributions generated for this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.All authors contributed equally to the concept, analysis and interpretations presented in the manuscript.NS was employed by company The Health Bureau Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Economic growth and the rapid increase in the world population has led to a greater need for natural resources, which in turn, has put pressure on said resources along with the environment. Water, food, and energy, among other resources, pose a huge challenge. Numerous essential resources, including organic substances and valuable nutrients, can be found in wastewater, and these could be recovered with efficient technologies. Protein recovery from waste streams can provide an alternative resource that could be utilized as animal feed. Membrane separation, adsorption, and microbe-assisted protein recovery have been proposed as technologies that could be used for the aforementioned protein recovery. This present study focuses on the applicability of different technologies for protein recovery from different wastewaters. Membrane technology has been proven to be efficient for the effective concentration of proteins from waste sources. The main emphasis of the present short communication is to explore the possible strategies that could be utilized to recover or restore proteins from different wastewater sources. The presented study emphasizes the applicability of the recovery of proteins from various waste sources using membranes and the combination of the membrane process. Future research should focus on novel technologies that can help in the efficient extraction of these high-value compounds from wastes. Lastly, this short communication will evaluate the possibility of integrating membrane technology. This study will discuss the important proteins present in different industrial waste streams, such as those of potatoes, poultry, dairy, seafood and alfalfa, and the possible state of the art technologies for the recovery of these valuable proteins from the wastewater. The most important driving force for recovering nutrients from wastewater during the treatment is the increasingly limited accessibility of resources. Population growth, fertilizer use, agricultural restrictions, soil erosion, and extreme weather events have had drastic effects, including malnutrition resulting from protein shortage. Globally, protein for animal feed is not sufficiently available; in order to meet this demand, many countries rely on the import of feed protein. At present, soybean protein (imported from other countries) serves as the main share of protein nourishment in animal feeding in Europe . The potential of purple phototrophic bacteria (PPB) and microalgae to treat diverse waste streams from agricultural and industrial sources was investigated by  along with ammonium and phosphate in a ratio of 100: 11: 1.6, respectively. The performance of PPB for the treatment of pork flesh and dairy wastewaters was reasonable but overcoming losses of organic matter is a question that still needs to be taken into consideration. However, the wastewater from the sugar industry had a higher COD value. Treating this by microalgae and PPB proved to be noxious as negligible removal of soluble amounts of COD, NHAlcaligenes eutrophus Z1, Ralstonia eutropha B5786, and the carbon monoxide resistant strain carboxydobacterium Seliberia carboxydohydrogena Z1062. The work indicated a massive amount of protein synthesized by the above-mentioned species, along with the sequences of essential amino acids. Certainly, the amino acids are more likely those of yeast, but, at about 70%, the ultimate concentration of protein, also known as dry weight in the case of hydrogen-oxidizing bacteria, is much higher than that of other species (50% in the case of yeast) )  process to efficiently remove pollutants and recover nutrients from high-COD, non-toxic wastewaters , depending on the dose of this enzyme. The action of enzyme carbohydrases  on pulp hydrolysis did not yield any significant production of protein  due to their interrelated pore assemblies, so they efficiently improve adsorption ability. Still, the practical application of these materials in the immobilization of biomolecules brings complications, as there is a hindrance linked to the mesoporous silica due to its electronically neutral silica skeleton. However, the efficiency of silica-based adsorbents can be enhanced by the surface modification of this mesoporous silica by setting organic functional groups such as the carboxylic (-COOH), phenyl, vinyl, and amine groups for the formation of active sites for the adsorbates (protein/enzymes)  type 1 nanoparticles, which possess a distinctive pattern and surface characteristics. Their practice as grounds for the immobilization of papain is described. In this study, different pore sizes of these mesoporous silica particles were synthesized using the carboxylic functional group by means of co-condensation   of about 89%, which is comparatively high compared to that of many other proteins present in plants and animals , and many more techniques were used to restore protein from potato fruit juice (PFJ). These approaches have been proven to obtain a high yield percentage of protein, but some processes, such as the application of heat and a harsh environment like acid or alkali, have been unsuccessful in recovering completely intact (non-denatured) high-quality protein , and other proteins remain intact during the sequence of several treatment stages . The amount of protein is 100% in the feed of the ultrafiltration membrane. After filtration, the concentration of protein present in the UF permeate was negligible, which indicates that approximately all the protein present in the feed of UF revealed by LC-OCD was removed in the retentate. It was concluded from the work done by the researcher that the desired protein from the PPW can be accumulated up to 3.5 times that of its initial concentration using an efficient membrane. The polyethersulfone UF membrane with an MWCO of 10 kDa was proven to be efficient in concentrating the protein from potato waste streams  is growing at an even higher rate than that of other popular meats such as beef or pork  method (EPA Methods 5520 B).A flat-sheet compartment with a membrane with a specific area of 30 cmA distinctive flux report and variation in protein concentration through the membrane process are shown in Table UF treatment can decrease the COD in the main waste stream by 58.86% , was used to purify water and protein.In the case of the last stated procedures, practically all the protein obtained in the feed that is the permeate of the ultrafiltration process can be restored in the retentate. The solution proposed, using an integrated process, allows an almost nine-fold decrease in the capacity of waste produced. This method also gave the outlook to use the recovered protein concentrate as a feed and for food production  process shown in Fig. In the filtration process of alfalfa wastewater using the UF membrane, the filtration efficiency decreases over time because membrane fouling leads to an effect known as concentration polarization  was treated with different flocculants at different pHs to recover protein using flocculation and sedimentation techniques. The results obtained during this study indicated a maximum sedimentation of up to 80% of proteins from the biomass at pH 4 (Forghani et al. Over the last decades, the importance of the shrimp industry to global economic development has been evident through shrimp exports and imports and the associated research performance. Wastewater produced in aquaculture needs an urgent management process to reduce its effects on the environment (Ng et al. The increase in the consumption of fish because of its high protein content and other nutritious values, especially tuna, leads to an increase in the wastewater produced during the processing in the industry. Several studies are being conducted on the recovery and separation of valuable components from the wastewater coming from the fish processing industry. The work performed includes the valorisation of tuna processing waste biomass for the recovery of valuable proteins and peptides with the integration of enzymatic hydrolysis and the membrane fractionation process (Saidi and Ben Amar Membrane fouling is identified as the irreversible deposition of sediments on the active surface of a membrane, resulting in flux decline during the process and a loss of active operation. This is a problem during the filtration of high organic content wastewater such as industrial water, brackish water, and seawater (Penña et al. The filtration of high organic content wastewater through membranes is prone to fouling, and that leads to a significant increase to the cost with regard to the industrial-scale process. Consequently, there is a vital need for the potential cleaning procedure to minimize the membrane fouling for the efficient process and durability of membranes (Humpert et al. Most of the membrane process plants designed for the purification of wastewater from several sources utilize repeated cleaning of the membranes and their modules, using a range of chemicals to reestablish the membrane performance to the same level as before fouling. As mentioned in Table The recovery of protein from wastewater using several techniques, including membrane technology, will always remain an interesting topic for researchers and scientists all over the world. New advances day by day concerning new membrane materials and the integration of membranes with other processes is a matter of interest when the protein recovery is involved. However, we should explore the proper functional and environmental benchmarks for membrane-technology-assisted protein recovery from a variety of waste streams to overcome the hindrance that lies within the transfer of this process from laboratory-scale studies to the profitable market (Shahid et al. As discussed, there are several pathways towards the promising recovery of proteins from different waste sources. A variety of wastewaters have been investigated for the efficient recovery of protein using different techniques in the state of the art. It was demonstrated that purple photosynthetic bacteria along with microalgae are the most efficient and dominant mediators for the removal of organic substances and nutrients from red meat, pork- and poultry-processing wastewaters. Microbial protein is proven to be a worthwhile and available protein supply to satisfy the need for human as well as animal diet stability. A simple one-step treatment using bacteria provides both benefits, including the supply of protein sources and treatment of high-COD non-toxic organic wastewater. The process of protein recovery by bacteria can fulfil the requirement to release wastewater streams without any treatment. The obtained bacteria cells contain high concentrations of valuable molecules including proteins, polysaccharides, carotenoids, bacteriochlorophyll and coenzyme Q10. However, there are some drawbacks to this process, including the existence of many nucleic acids in some entities, which makes its utilization by human beings unsuitable, and these molecules should be handled properly and within the limit range. Moreover, post-treatment of the obtained single-cell protein is also significant because of its susceptibility to any impurities. In the coming years, it has been predicted that microorganisms will be an important source of food additives due to their efficiency in manufacturing high-quality protein from waste substances.However, to cover the future need for protein and achieve self-sufficiency, there is still a gap to developing new technologies for large-scale manufacturing that needs to be overcome. The implementation of membrane technology for protein recovery has also been proven to work effectively. Also, the integration of MF, UF, and VMD can allow a reduction in the volume of waste generated that is almost nine times greater and can establish an option to make a protein concentrate suitable for human and animal needs. The recovery of different types of proteins from wastewaters using membranes has been discussed in detail in this paper. The advantages associated with using membranes in the recovery of proteins along with other valuable products from the potato processing, dairy and seafood processing industries has been taken into special consideration in this study. Membrane fouling is always associated with the process of protein recovery. The backflushing of the membrane with available cleaning reagents was found to be proficient in improving the restoration ability of the membrane. The development of efficient technologies and improvement in traditionally available techniques of protein recovery from waste streams can provide high-quality protein and reduce the gap between the demand for and supply of proteins, making them available for humans and animals. However, there is still a need for more research to find new and more potential wastes as a protein source via the implementation of membranes for the sake of the long-term stability of our system.


The term “alexithymia” was introduced in the lexicon of psychiatry in the early ‘70s by Sifneos to outline the difficulties manifested by some patients in identifying and describing their own emotions. Since then, the construct has been broadened and partially modified. Today this describes a condition characterized by an altered emotional awareness which leads to difficulties in recognizing your own and others' emotions. In half a century, the volume of scientific products focusing on alexithymia has exceeded 5,000. Such an expansive knowledge domain poses a difficulty for those willing to understand how alexithymia research has developed. Scientometrics embodies a solution to this issue, employing computational, and visual analytic methods to uncover meaningful patterns within large bibliographical corpora. In this study, we used the CiteSpace software to examine a corpus of 4,930 publications on alexithymia ranging from 1980 to 2020 and their 100,251 references included in Web of Science. Document co-citation analysis was performed to highlight pivotal publications and major research areas on alexithymia, whereas journal co-citation analysis was conducted to find the related editorial venues and disciplinary communities. The analyses suggest that the construct of alexithymia experienced a gradual thematic and disciplinary shift. Although the first conceptualization of alexithymia came from psychoanalysis and psychosomatics, empirical research was pushed by the operationalization of the construct formulated at the end of the ‘80s. Specifically, the development of the Toronto Alexithymia Scale, currently the most used self-report instrument, seems to have encouraged both the entrance of new disciplines in the study of alexithymia  and an implicit redefinition of its conceptual nucleus. Overall, we discuss opportunities and limitations in the application of this bottom-up approach, which highlights trends in alexithymia research that were previously identified only through a qualitative, theory-driven approach. The word “Alexithymia” stems from old Greek and literally means “without words for emotions” . This tIn a short time, this psychological construct captured the attention of a number of researchers within the psychiatric community interested in the treatment of psychosomatic diseases. Indeed, in 1976, alexithymia was the main theme of the 11th European Conference on Psychosomatic Research (ECPR) held in Heidelberg, Germany . After aThe search for a more precise definition of this construct was accompanied by the need to identify reliable instruments for its assessment. First of all, Sifneos developed the Beth Israel Hospital Questionnaire ; shortly thereafter with a colleague, he put forward the Schalling-Sifneos Personality Scale , 9. At tA psychometrically sound measure of alexithymia started to be developed at the University of Toronto by the “Toronto group” in the mid-80s under the name of Toronto Alexithymia Scale . This aThe development of a standardized instrument allowed researchers to study alexithymia in relation to various clinical and non-clinical phenomena. This has made it possible to substantiate the observation that alexithymia is related with psychosomatic diseases. Moreover, alexithymic characteristics were found in various clinical conditions characterized by a disordered affect regulation , such asToday, alexithymia is regarded as a personality trait and as a “sub-clinical phenomenon”  and it wAs this introduction briefly illustrates, the history of the alexithymia construct is quite complex. Even though this is originally defined in a restricted domain, in time it has become more transversal and relevant for the study of a wide range of phenomena. In fact, today alexithymia appears to be essential to understand–among other things–how emotions and emotion regulation work. For this reason, the literature counts a dozen books and more than 5,000 scientific publications on alexithymia, retrievable from the main bibliographic databases . Many attempts have been made to analyze this literature in order to identify how the debate on this construct is articulated. According to the Web of Science database, there are more than 200 reviews issued on this topic from the beginning of the discussion on alexithymia till now. Some of these played a significant role in the development of this concept. Considering only the most recent times (from 2005 to 2020), 50 systematic reviews based on meta-analytical methods were published. These papers usually focus on specific aspects of alexithymia  and they are often aimed at disambiguating the divergence in empirical results of single studies.Despite previous literature providing a widespread overview of specific theoretical and empirical aspects of alexithymia, to our knowledge none of these works make use of a quantitative approach to investigate the complex and transversal character of this construct in its evolution and multiple ramifications. In fact, different from previous meta-analyses focusing on individual aspects of alexithymia, our study aims at approaching alexithymia research as a whole and analyzes how the scientific production on this condition is organized. Among other things, we would like to identify distinct areas in alexithymia research and explore how they change with time. We also aim to investigate which topics of interests are in the various development stages of the construct and which methods and techniques have been used to address alexithymia. In this way, we aim to reconstruct the same organic image of alexithymia research previously portrayed in theoretical and historical literature reviews, but through a bottom-up approach borrowed from Scientometrics.Scientometrics applies quantitative methods to measure and shape the development of science, seen as an informational process . Some ofThe bottom-up approach used in scientometric reviews has already been proved successful to assess trends and the evolution of assessment instruments or techniques developed in narrow disciplinary domains such as linguistics and psychology , 47.In the present study, (i) a corpus of scientific documents is identified via the Web of Science (WoS) search algorithms; (ii) the identified articles and their references are segmented and classified by co-citation techniques developed by CiteSpace software –50; and Within Citespace, cited papers are represented by interactive maps across the domain of space and time to obtain a depiction of almost 50 years of research in alexithymia across the world. The algorithms developed to measure the strength of links between citing and cited publications are able to create clusters of papers or journals focusing on thematically distinct aspects of alexithymia. In addition, reliable parameters implemented in the software can estimate the impact of publications or editorial venues on their specific cluster and on the overall corpus of documents retrieved on the topic. This allows us to identify the most influential publications on alexithymia and the most pursued issues considered by the research in relation to different time frames. Moreover, we can pinpoint the shifts in the research lines on this subject as well as of the approaches employed to investigate this condition.To summarize, this study examines the extent to which the historical reconstructions of alexithymia research suggested in traditional narrative reviews are replicable using a bottom-up scientometric approach based on knowledge mapping techniques.The data used for the analyses include 4,930 publications on the conceptual analysis, assessment and neurophysiological correlates of Alexithymia published between January 1st 1980 and May 1st 2020, with 100,251 references downloaded from the WoS Core Collection. The reason for using WoS is due to its coverage of published research on alexithymia, which is higher than alternative databases such as Scopus, Pubmed or EBSCO. The search syntax adopted for this study was Topic (“Alexithymia”) OR Topic (“Alexithymic”). By means of the search field Topic, WoS extracts title, abstract, and keywords. From an initial pool of 5,390 documents, we excluded those that were written in languages other than English, thus arriving at a final sample of 4,930 publications with their 100,251 references see .The data were exported from the WoS, producing text files containing the “full record and cited references” for each of the 4,930 publications retrieved. CiteSpace software, Version 5.6.R5 –50, was CiteSpace was used to generate and analyze two types of networks of co-cited references via DCA and JCA. The DCA and JCA networks were computed separately, using the same criteria described below. The time span of the two networks ranged from 1980 to 2020, with the time slicing configuration at 1 per year. We compared three criteria for node selection to identify the optimal DCA and JCA networks: Top N, Top N%, and g-index. Top N function picks up the N most cited articles and uses information from them to form the network for each time slice. Similarly, Top N% includes the Top N% most cited articles in each time slice to construct the network. G-index criterion  represenModularity Q index and average silhouette metrics were considered to detect the overall structure of the networks, while burstness, betweenness and sigma metrics were considered to assess how the structural and temporal properties of single nodes  impact the networks.A network's modularity is a global measure of the overall structure of the network , 55, whiThe silhouette value of a cluster measures the quality of a clustering configuration. Its value ranges between −1 and 1, where values over 0 indicate major homogeneity . A silhoCitation burstness measures the burst of citations to a given node. CiteSpace explores the bursts of nodes within a given network through Kleinberg's algorithm . BurstneBetweenness centrality , 58 measburstness urstness , with hiThe clustering function in CiteSpace has been used to find the major entities in which single nodes could be grouped inside the network. Clusters are numbered depending on their size, starting with the largest (#0) to the smallest (#5). In CiteSpace, version 5.6.R5, three functions are available to label clusters: Log-Likelihood Ratio (LLR), Latent Semantic Indexing (LSI) and Mutual Information (MI). The three methods have been applied to the current DCA networks. We implemented the LLR function, given the higher informative content associated with the output labels. This approach is supported by the same software creator, who pointed out the best performance of LLR in terms of “uniqueness and coverage” of labels . TherefoThe document co-citation analysis produced a network with modularity Q index and average silhouette metric of 0.51 and 0.75, respectively, suggesting moderate modularity and high homogeneity , 2.To understand what the most active areas in the network are, the document bursts have been computed via document co-citation analysis. Among the initial pool of publications and their references, citation bursts sustained for at least 2 years were found for 407 references. In addition, in order to detect which documents had a strategic role in connecting more clusters, we computed betweenness centrality, while publications with potential scientific novelty were explored through the metric sigma.Analyzing the documents with highest sigma values see , we coulThe JCA produced a network with a total modularity Q score at 0.47 and an average silhouette score of 0.74, indicating moderate modularity and high homogeneity. JCA represents an aggregation at a higher level than DCA, since articles published in the same journal are lumped together to form a supernode in a network of journals. Inside the JCA network, 332 nodes  had a burst history of at least 2 years.Psychotherapy and Psychosomatics (strength = 164.51) and “Psychosomatic Medicine.” These journals stand out also for the longest duration of their citation burst, estimated at 26 years. The citation burst for these journals dated back to 1980, but it could be more distant in reality, considering the time limitation of the WoS database, which collected documents starting from 1980. Other journals whose citation burst started in the early ‘80s report all in their titles the terms “psychosomatics” and “psychotherapy” . From DCA, we observed that the papers with the highest citation burst, centrality and sigma . Other journals within the psychiatric discipline were the Journal of Nervous Mental Disorders, the British Journal of Psychiatry, Psychiatric Clinics of North America and the General Hospital Psychiatry. Influential journals with still active citation bursts were Frontiers in Psychology and Plos One, which were fourth and fifth ranked for burst strength respectively, despite the limited burst duration (4-5 years). Lower in the list, there were Frontiers in Psychiatry, Social Cognitive and Affective Neuroscience, Scientific Reports—UK, Frontiers in Human Neuroscience, and Neuroscience & Biobehavioral Reviews, all active between 2015 and 2020.The journals in the first two positions for burst strength were, respectively, nd sigma  publisheThe content of major clusters obtained via document co-citation analysis (DCA) is discussed below. Cluster presentation follows a chronological order  refers to one of the original assessment instruments, developed by Kleiger and Kinsman . This isIn brief, Cluster #1 collects the early literature on alexithymia that goes from the '70s to the mid-1980s, a period which is antecedent to the advent of the Toronto Alexithymia Scale and was focused on the theoretical definition of the construct mainly in connection with psychosomatic diseases.The title of this cluster refers to the Toronto Alexithymia Scale  and it To sum up, the cited publications within cluster #2 cover the period between 1985 and the early ‘90s. They include studies which are mainly related to the first version of the Toronto Alexithymia Scale. In the clinical contexts, these studies focused primarily on the relationship between alexithymia and eating disorders, anxiety or depression.This cluster, with its 185 cited references, is the largest one. Here, the most influential publications start from 1994, in other words, after the development of the new 20-item Toronto Alexithymia Scale. Notably, the two publications presenting the psychometric properties of the new TAS-20 , 87 sharIn short, this cluster covers research on alexithymia spanning from the mid-1990s to the late 2000s. This period follows the development of the TAS-20 and it is largely influenced by the research of the Toronto Group. Articles by other groups employ this new self-report instrument to investigate the relationship that alexithymia entertains with a variety of clinical conditions or emerging constructs related to personality and emotional competence.This cluster is relatively small, comprising exactly 27 cited papers. The majority of cited publications are contemporary to a number of those included in Cluster #0  and in Cluster #3 (“Emotion Information Processing”), dating back to the second half of the ‘90s. Thematically, publications within this cluster address alexithymia as a risk factor for mental and physical health conditions. The relationship between alexithymia and depression is explored in a paper by Honkalampi et al. , first fOverall, cluster #5 collects a small number of publications, posterior to the TAS-20, whose primary aim is to explore alexithymia in psychopathology and physical illness.The major publications within this cluster chronologically follow the development of TAS and TAS-20, while they precede chronologically the papers included in cluster # 4 (“Autism Spectrum Disorder”). The title automatically extracted by the LLR method does not capture the main topic of the cluster, although it captures the fact that the majority of empirical studies mentioned here employ the TAS-20 in their design. In accordance with Aryadoust et al. , highligper se but they used the construct of alexithymia in conjunction with others to investigate how emotions are processed. This hypothesis is supported by the presence of a set of highly cited articles referring to instruments which measure people's emotion processing capacities, mainly the Interpersonal Reactivity Index [IRI, . Also the studies that introduce new assessment tools for alexithymia  or examine alexithymia in conjunction with parallel constructs  adopt a cognitive and neuroscientific approach.This cluster represents the latest trends in alexithymia research and describes an ongoing line of research. The title “Autism Spectrum Disorder” aptly reflects the main point investigated by this cluster of papers, i.e., the comorbidity between alexithymia and Autism Spectrum Disorder . This exIn summary, Cluster #4 collects the most recent trends of research which are centered on the relationship between alexithymia and ASD. More specifically, the studies included in this group suggest that alexithymia plays a role as for the socio-communicative deficits exhibited by people suffering from ASD.Typically, journals are the point of reference of specific research communities: they do not only focus on particular subjects, but they also share a common perspective on them as well as preferred methods for their investigation. To scrutinize which journals published salient research on alexithymia in which periods is relevant to understand how this construct was approached by different research communities in different times. Therefore, JCA was applied to identify journals cited together in one paper.Social Cognitive and Affective Neuroscience, Frontiers in Human Neuroscience, Neuroscience & Biobehavioral Reviews). This suggests that the neurobiological dimension of alexithymia has piqued the interest of researchers and that the field is actively working toward achieving a multifarious understanding of the condition. Moreover, the burst of journals covering a multitude of topics in the psychological sciences (Frontiers in Psychology) or, even, the presence of multidisciplinary journals such as PLOS ONE and Scientific Reports suggests that alexithymia is no longer a narrow niche subject of study. In fact, in this period the construct of alexithymia has become relevant for personality assessment as well as for research on emotional regulation/dysregulation. This is the reason why alexithymia is the object of growing attention by a wider, interdisciplinary scientific community represented by researchers and clinicians active in fields like psychology, psychiatry, medicine, and neuroscience.Journal titles reported in Any scientific domain–as well as any knowledge domain in general–subtends objective relations between different actors: i.e., institutions, authors, and journals. Network analysis represents an opportunity to computationally analyze and graphically represent the relations that characterize specific domains of knowledge.Here we addressed the construct of alexithymia using co-citation analysis. Although the visibility of a paper is not a sufficient condition to assess its quality and relevance, it would at least be a necessary condition for gaining authority and for exercising an influence in a field. We applied this method to explore the macroscopic changes that occurred in this first half century of research on alexithymia. Specifically, our approach highlights the major thematic and methodological shifts that occurred within the community interested in alexithymia construct. Document Co-citation Analysis (DCA) and Journal Co-citation Analysis (JCA) suggest that the construct of alexithymia experienced a gradual conceptual and disciplinary shift. The analysis of the clusters shows that the body of research on alexithymia might be divided into three temporarily and logically distinct coarse units.The first unit includes all the early articles published in the so-called “Pre-TAS era,” during which the researchers worked at a definition of the construct. The studies of this phase belong mainly to the area of psychosomatic medicine, psychiatry, and psychoanalytic treatment.The second unit is centered around the activity of the “Toronto Group.” This includes the papers aimed at developing a standardized measurement of the construct and at establishing the differences and the overlaps of the TAS-20 with pre-existing constructs such as those of personality, depression etc.The third unit comprises the studies of the “Post-TAS” era; their goal is to investigate the construct of alexithymia from the point of view of cognitive science and cognitive neuroscience as well as with behavioral and neurophysiological methods.The multifactorial definition of alexithymia construct proposed by the Toronto Group has established a watershed within the history of alexithymia. The development of a standardized and easy to use tool such as the self-reported TAS-20 has been a driving force for empirical research, especially in the cognitive and neuroscientific domain. This shift in disciplines co-occurred with a modification in the conceptualization of the construct. Specifically, the interpersonal dimension of alexithymia, from peripheral and collateral aspects of the construct, has become the main focus of research. Indeed, the corpus of early publications is represented by cluster #1, which is focused on the recognition of one's own subjective feelings and therefore on the success of insight-oriented psychoanalytical treatment. In contrast, the research post TAS-20, represented by publications inside cluster #3 (renamed by us “Emotion Information Processing) and #4 (“Autism Spectrum Disorder”), focuses on the recognition of external emotional stimuli. This is evident based on the many studies in clusters #3 studying the deficits of individuals with high alexithymia to recognize emotional facial expressions or emotional images. This shift becomes even more evident in cluster #4, where the condition of alexithymia is primarily associated with a deficit in empathy and theory of mind in people with Autism Spectrum Disorder.Social Cognitive & Affective Neuroscience, Frontiers in Human Neuroscience, Neuroscience & Biobehavioral Reviews). The evolution in time of the publications on alexithymia confirms a prediction made by Taylor and Bagby  the difficulty identifying feelings, (ii) the difficulty describing feelings, and (iii) the externally-oriented thinking, while (iv) impoverished fantasy life has been excluded for psychometric reasons. Secondly, the development of the Toronto Alexithymia Scale gave new impetus to the research on tools to assess alexithymia. Independently from their supportive or skeptical attitude toward the TAS-20, a number of researchers explored the potentialities and the limits of this scale, comparing it with instruments measuring related constructs such as depression, anxiety, personality or emotional intelligence. The availability of a highly standardized and easy to administer instrument to assess alexithymia allowed researchers to explore this condition in various experimental settings by the use of behavioral and neurophysiological techniques. Consequently, this line of research is not any more restricted to the field of psychodynamics and psychosomatics, but has been expanding to a much larger community. Indeed, cognitive science and neuroscience are becoming increasingly pivotal in the field. The more influential publications in cluster #3 and #4 testify to this trend: most of them employ neuroimaging techniques and other neurophysiological measures and address issues concerning the neural basis of emotional processing. The same trend is confirmed by Journal Co-citation Analysis, and in particular by the journals with the strongest recent citation bursts . The use of WoS generates a linguistic bias for a scientometric study since the majority of the journals indexed in WoS are in English; only a small percentage of journals in other languages are included in this database. By excluding the documents written in languages other than English, we probably amplified this bias. However, the language is not irrelevant for the impact of a study: especially in the last decades, with the exception of particular fields/topics, publications written in languages other than English have mostly only a national audience and become relevant for international research only when they are discussed by other publications in English. It is plausible that publications in languages other than English did not catch the attention of a large scientific community; in this case, they would still be invisible in the networks built using DCA and JCA which, by definition, capture only macroscopic trends in research.Secondly, the use of WoS as reference database also gives rise to a subtler bias related with the fact that psychoanalytic research–like the research in the field of humanities–is presented primarily in books, book chapters and journals that for the most part are not included in WoS or in other bibliometric databases. This applies especially to the past, but in part it still holds true today. Relying on the results we have achieved through our analysis, it seems that psychoanalysis gave a central contribution to the development of alexithymia only until the early'80s, which corresponds to the early years of the history of the construct. According to our scientometric study, it appears that later in time the psychoanalytic tradition gives up its interest in this construct. This is not the case. For example, McDougall –150 put The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.GG contributed to conceiving the study, created the dataset, conducted the analyses, and contributed to literature review and writing the article. AB contributed to the analyses and revising the paper. SD and LP conceived the study, contributed to the literature review, results interpretation, and writing the article. VA contributed to the study design and revising the article. GE conceived the study, obtained funding, and revised the paper. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.