Real estate markets are complex both in terms of structure and dynamics: they are both influenced by and influence almost all aspects of the economy and are equally vulnerable to the shocks experienced by the broader economy. Therefore, understanding the extent and nature of the impact of large-scale disruptive events such as natural disasters and economic financial downturns on the real estate market is crucial to policy makers and market stakeholders. In addition to anticipating and preparing for long-term effects, it has become imperative for stakeholders to monitor and manage the short-term effects as well due to the emergence of ‘PropTech’ and ‘platform real estate’. In this work, we explore the use of online, real-time dashboards which have been used extensively in the context of urban management, policymaking, citizen engagement and disaster response as an appropriate tool for the purpose of monitoring real estate markets. We describe the process of designing, building, and maintaining an operational dashboard for monitoring the residential real estate market in Australia during the COVID-19 pandemic in 2020. We detail the techniques and methods used in creating the dashboard and critically evaluate their feasibility and usefulness. Finally, we identify the major challenges in the process, such as the spatial and temporal availability and veracity of the real estate market data, and we identify possible avenues for consistent, high-quality data; methodology; and outputs for further research. Real estate is one of the most important sectors in the economic system. Because of their central role in the economy, real estate markets tend to be large, complex, and nonlinear systems that are not only influenced by a myriad of external factors but also influence them directly and indirectly . Due to Meanwhile, the pursuit to gather, analyse, visualise, and advise on the performance of large, nonlinear and complex urban systems has resulted in numerous online, real-time city dashboards . The accThis work aims to fill this gap by systematically documenting the process of conceptualising, designing, building, deploying, and maintaining an operational dashboard linking the spread of COVID-19 in Australia with corresponding changes in the residential real estate market. The paper begins by identifying the possible data sources that can provide a near-real-time insight into the status of the residential real estate market and describing the implementation of a data-processing pipeline for data collection. The paper explains how the collected datasets were cleaned, filtered, aggregated and visualised on a single-page, auto-refreshing, interactive and responsive dashboard built on the RShiny platform. This dashboard was then deployed online using a micro-services architecture. The paper discusses the novel insights that were derived from the dashboard and reflects on their utility. There are pitfalls associated with dashboards, such as oversimplification, isolation from the broader context, uncertainties and biases in the data and analysis . TherefoThe origin, evolution, purpose and application of city dashboards in the field of urban analytics along with the challenges encountered in creating, using, and maintaining them;The use of the experience, technologies, and techniques gained from city dashboards to monitor real estate markets; andThe events that affect the real estate market  and their impact on the real estate market, with a specific focus on the impact of the COVID-19 pandemic on markets around the world.The literature related to the use of real-time dashboards in the real estate market can be broadly classified into three topics: A brief history and overview of city dashboardsFrom the physical artifacts which gave a simplified status of complex machinery, dashboards have developed to become toolkits of urban planners, managers and policymakers to understand and manage the complex system of cities resulting in numerous city dashboards in the fields of research, industry and government. From the modest beginnings in CompStat in 1994, making city dashboards has rapidly developed in to a field with dedicated international standards in 2014  leading Operational dashboards, which inform the users about the status of the city;Analytical dashboards, which derive inferences and diagnoses the system; andStrategic dashboards, which predict future outcomes and provide guidance for decision-making .City dashboards can be large classified into three types based on their purpose: There can be numerous subtypes of these dashboards based on their purpose, audience, features, layouts, refresh frequency and more . DashboaCity dashboard development is an interdisciplinary field between urban planning, management, information technology and data science. It provides immense public value, such as improving the transparency and efficiency of the urban planning process and encouraging public engagement . NonetheUse of dashboards to monitor real estate marketThe information technology revolution, which digitised cities and led to an explosion of free and open data, fuelled the rise of city dashboards. A similar rapid and significant paradigm shift is due to occur in the real estate sector in this decade. In this context, Impact of disasters and disruptive events on the real estate marketLarge-scale disasters directly affect the real estate market by affecting liquidity, impacting fear and risk perception, increasing the cost of supply, and reducing demand. They also indirectly affect the market through changes in mobility, size/velocity/cycles of the overall economy and monetary or fiscal policy response to these changes. Although not extensive, there are prior studies that analyse and quantify the impact of such events on real estate markets. Research into flood-affected markets in United States  shows thEarly studies suggest on the ongoing COVID19 pandemic and its impact show that almost all aspects of everyone’s socio-economic life of have been affected . MoreoveIn a study of the real estate market of the Campania region of Italy, Spread and severity of COVID-19 in Australia,Performance of the property market,Broader socio-economic context andSentiment of the stakeholders and public.As shown by the literature survey in Section 2.0.3, disasters such as COVID19 affect the property market directly and indirectly through various factors. In order to build an operational dashboard, we set out to survey of data sources on four broad areas. The range of sources that were considered are detailed in Table Being the most significant event in 2020, the data sources regarding the spread of COVID-19 pandemic were abundant such as WHO, National and State government agencies, technology companies, news agencies and even volunteer run projects. For this research, we considered the Johns Hopkins University (JHU) School of Public Health’s dashboard and the associated data repository, the Australian Government’s website, and the websites of state governments as feasible data sources. For the overall Australian COVID-19 data, we selected the JHU’s repository since the data in the repository are derived from government sources, cleaned, stored in a format that is easy to access and updated daily. This repository provided us with the number of cases, fatalities, and recoveries for Australia at national and state level. More granular level of data, such as local government areas (LGA) or local health districts (LHD) were gathered from the websites of individual states.There were issues with the veracity of the data where the content and format were different and often changed with time between sources. For example, Victoria released data at LGA level while Queensland released them LHD level and New South Wales released both, while the rest of the states did not release data at such granularity. JHU data were published data as CSVs while other sources were in various formats such as HTML, PowerBI, Tableau etc. None of sources released granular geographic information on COVID19 cases to protect the privacy of the people involved.Although various property market monitors collect and disseminate up-to-date, near-real-time data on property sales and valuations across the country, these datasets are not openly accessible due to their significant commercial value. Out of the publicly available open data, we chose to use CoreLogic’s House Value Index and domain.com.au’s reports on residential property auctions. CoreLogic’s index is a patented and proprietary product which is updated daily. It covers Australia’s major cities and shows the capital growth in the value of residential properties combining data on property attributes and transactions along with data from government agencies. It acts as a benchmark for comparing market changes across the country. Domain.com reports the statistics on the result of residential property auctions across major cities in Australia every week such as total number, clearance rate, total value and median price. Although this dataset is updated weekly and is biased towards more expensive properties, it provides a way to monitor, track and understand the movements of the market with more granularity compared to a composite index. To understand the movements in the securitised property market, we used the daily value of Standard & Poor index on real estate funds (XRE) from Australian Stock Exchange.The State government agencies such as rental board, valuer general etc. release data on rental rates and property transactions regularly but they are often 2 to 6 months old and not suitable for monitoring the market in real-time. While the openly available data on Airbnb listings are updated infrequently, the proprietary and weekly AirDNA data is released as a tableau dashboard, discouraging further use. The availability of data across regions in Australia is inconsistent as well. For example, Cities such as Hobart and Darwin are covered in CoreLogic data but not on the Domain reports while the COVID-19 data are usually at the state or LGA level.We tried to quantify the impact of COVID-19 on the broader economy in two ways: the reduction in physical activity and the national changes in economic and financial activity. Lock-downs caused by the COVID-19 outbreak resulted in reductions in physical activity, measurable with data from both the transport authorities and private companies such as Google, Apple and Citymapper. The transport authority datasets posed similar limitations to those we encountered with the property data: updates were infrequent, especially exacerbated by the lock-downs. Since data from Google and Apple were released as portable documents (pdf) and proved challenging for use as data sources, the index provided by Citymapper was collected and used for this research. This index shows the transport activity within various cities across the world, estimated from the use of the mobile application. Although the data source was updated regularly, it was only available for two cities in Australia: Sydney and Melbourne. Like data from every other government agency, the economic data from the Reserve Bank of Australia (RBA) were updated quite infrequently. For example, the datasets on mortgages and spending were updated quarterly, making them unsuitable for use with this dashboard.The pandemic has affected the property market through consumer and investor sentiments such as fear, uncertainty, and risk perception. Social media was identified as one of the best data sources for quantifying these sentiments and Twitter was selected as it supports granular, large-scale data collection in real-time. Although the twitter search API provides with much more targeted approach for collecting tweets, the API is limited in the total number of tweets it can return. The initial data collection also showed that the tweets focussing on just property and real-estate markets in Australia are extremely limited compared to more general tweets. For example, on between Dec 2019 and April 2020, there were only 2300 tweets relating just to property market while there were 175,000 tweets relating to COVID19. Keeping these in mind we switched to the streaming API which gives more comprehensive set of data. Moreover, it is also noted that using the streaming API with broad set of search terms gives a better pulse of the general market sentiment and thus a better comparison with COVID19 infection numbers especially in daily time intervals. An exhaustive list of 336 keywords was created by combining the variations of words ‘COVID-19’, ‘corona’, ‘property’, ‘real-estate’ and names of cities states across Australia. Tweets containing these terms  were collected and streamed into a database. An average of 56,000 tweets per day and a total of 11.6 million tweets were collected between April 2020 and Oct 2020. The trends in terms used in Google were also collected as a proxy for the relative importance of the property market and COVID-19 in the public discussion over time and in relation to each other. The daily trends for the search terms ‘COVID-19’ and ‘real estate’ were collected for Australia. This allows us to capture the broader contextual changes such as policies and rules in the country. It is important to note that data from Twitter has significant biases and noise in terms of the users, coverage and posts. Similarly, the proprietary Google Search trends data are comparative measures and need to be combined carefully with other absolute data.Some of the datasets collected were indices that were already processed and cleaned before publication; these did not need any further processing. The rest  needed a customised pipeline for collecting, cleaning and processing data before use. These datasets could be deemed to be ‘medium’ in size since they exhibit large amounts of variety and veracity but limited volume and velocity . These dA total of 22 indicators and summary statistics were produced from the collected data. These indicators, their geographic extent and the source from which they were derived are shown in Table Across the COVID19 related indicators, the summary statistics were plotted as text, the daily totals were plotted as a line chart showing the change over time, and LGA-level active case numbers were depicted as static or interactive maps. A line chart of the daily total cases at the national level was also created for comparison with other national indices. It is important to note that the map Fig.  is a comIn property market indicators, since domain research reports were not published in certain weeks, the gaps were linearly interpolated. Similar to the COVID-19 cases, the weekly number of auctions across Australia was created for comparison with other national indices. The performance indicators  and the house value index were depicted as line charts showing change since January 2020. The House Value Index from CoreLogic for major cities was also used as an indicator. Though the House Value Index does not change substantially daily, the marginal daily changes were averaged on a 20-day rolling window and annualised (assuming 250 trading days) for comparison with returns from the equity market. This shows the daily momentum of the market in terms of the value of houses across the major markets, similar to the stock market. For further understanding, broader socio-economic context indicators  were also created and depicted as line charts showing changes since January 2020. The collected ‘tweets’ were aggregated into an indicator showing the Twitter sentiment index . First, the collected tweets were converted to plain text and filtered to remove special characters and re-tweets. They were then tokenised to generate a list of words. These words were then classified as positive, negative, and neutral using the ‘Bing’ lexicon; summarised to give the number of words in each sentiment; and subsequently used to provide the Twitter sentiment index for that interval. This sentiment index was then shown as a diverging bar chart at 15 minute intervals for the last 7 days.The overall COVID-19 Property Dashboard was built by combining the above indicators using the ‘Shiny’ library. The library is part of the R statistical programming language and handles both the front and back ends of the dashboard.At the back end, datasets are queried from PostgreSQL, analysed in R and appropriate charts are generated before handing over to the front end. Since the query process is often the longest step, to optimise the performance of the dashboard, the queries are cached every hour. Similar to the data collection services, this ‘Shiny’ dashboard is also containerised and deployed in AWS ECS as an auto-scaling service which can increase or decrease its capacity in line with demand.https://covid19dashboard.be.unsw.edu.au. The data on the dashboard is updated every hour. The user interface of the dashboard has been made interactive using the ‘plotly’ library which lets the users interact with each chart separately where they can ‘zoom’ in and out of the charts temporally in an interactive manner. A snapshot of the dashboard is shown in Fig. At the front end, the dashboard is a one-page application available at The dashboard was released to the wider community on 24th April 2020 and has been in use since. It has been covered in news portals such as The Guardian, the Financial Standard etc. and was used by 14000 people across the world with the primary audience based in Australia and the United States. The dashboard was developed to help the government, industry and communities to understand the current impacts of COVID-19 on the Australian property market; it shows the volume and change of these phenomena in tandem and enables users to spot patterns in them. These potential inferences, patterns, and the overall utility of the dashboard are discussed in the next section.InsightsWith ‘data-driven science’ emerging as the fourth paradigm of GI science , this daWhen the indicators showing the weekly total value, clearance rate and median price of residential property auctions were plotted against the number of cases of COVID-19 in the corresponding states they show the impact of the pandemic on the market. It is observed that the number of auctions and the clearance rates reduce when there is an increase in the number of COVID-19 cases in the state, which may be due to the restriction of market activities during the lock downs that followed. This is highlighted in the closure of the auction market completely in Melbourne when Victoria experienced a second wave of infections in August 2020. On 22 April 2020, around the peak of the first wave of cases, the dashboard reported that the total volume of sales across Australia that week has been down $237 million compared to the previous year and the clearance rates dropped in all major cities. In contrast to this, the median prices have remained unaffected in 2020, which may be because of the numerous fiscal interventions implemented by the government such as reduction of interest rates, first home owner subsidies and other building incentives.The House Value Index indicator Fig.  shows thOut of all the indicators, Twitter sentiment analysis captures the sentiment of the public regarding the COVID-19 with most granularity. Although it is derived from a simplistic classification method, the 15-minute aggregate index reflects the general sentiment and captures reactions to current events and news fairly accurately. For example, Fig. The difference in the spread of the virus between the two major centres of population (Melbourne and Sydney) provides the best opportunity in Australia to see the impact of COVID-19 on these two markets; this can be best observed through the Citymapper Mobility Index shown in Fig. Usefulness of the dashboardThe primary aim of the dashboard is to enable the users to monitor the state of the property market and contrast the changes occurring in the market to the ongoing COVID19 pandemic. In this context, the dashboard has proven to be useful in understanding the general movement of the market along with the pandemic indicators. For example, Figs. Although this gives us a broad overview, to understand the relationship between these indicators and to develop comprehensive analytical models, a simple Pearson’s correlation analysis between them was conducted. Table We also need to consider the speed of the data and their suitability for use in a real estate market context where the definition of ‘real time’ could be widely different. For example, what would be considered ‘past data’ in social media such as twitter could be considered almost real time in real estate context where transactions can take often weeks to be completed. There is a need to reclassify or reframe what is real-time for real estate markets. From the experience of building this dashboard, we believe that for real estate markets, both spatial and temporal resolution play a significant role in determining the effectiveness of a dashboard. Besides scenarios dealing securitised commodities such as REITs, any data source or indicator with temporal granularity greater than weekly basis could be considered as real time. This understanding can help us avoid situations where higher granularity would require large increase in resources with marginal improvement in quality. The precision and accuracy of the indicators and analytical models in the dashboard need be designed based on the targeted user of the dashboard. For example, visual analytics comparing various data points may be sufficient for a reporting or monitoring use such as this dashboard but for a policy making use we may need much more detailed models and scenario building tools.Limitations and challengesAs discussed in Section Future workIn terms of events disrupting real estate markets, this dashboard focuses on just the COVID-19 pandemic. This could be broadened to make a more flexible monitoring dashboard that can provide insights during similar events in the future. The major portion of such work would be identifying and collecting appropriate data sources and creating indicators that could be substituted instead of COVID-19. One could also focus on rental markets using the data from rental transactions, bond lodgements and short-term leasing platforms such as Airbnb, StayZ and Homestay. Another direction is to develop analytical models using the relationship between the various indicators and the real estate market to quantify the impact in a timely manner. This task is not currently possible to the fullest potential because of the issues discussed earlier; however, it could be attempted again with more granular and reliable data sources. This—along with analytical models—can lead to the development of a predictive models to help estimate and debate the impact and effectiveness of policy decisions and risk reduction methods. With the given volume of information, the sentiment analysis section of the dashboard has great potential for further development as a study in its own right. The sentiment analysis could be improved with the use of advanced natural language processing techniques, and the analysis could be conducted in a range of suburbs and regional markets to understand their dynamics.In this paper, we have explored the use of real-time dashboards in monitoring the impact of disruptive events on the real estate market through the case study of COVID-19 in Australia. We have discussed existing literature regarding the characteristics of the real estate market, the impact of disruptive events on it, and city dashboards and their usage in understanding the real estate market. To summarise, the real estate market—which has historically been a conservative, long-term investment market is changing into a faster, more speculative, and more responsive market due to developments in information technology and associated PropTech innovations. As large-scale disruptive events such as economic downturn and natural disasters are occurring more frequently due to the globalizing economy and climate change, there is a clear opportunity for applying the knowledge and expertise in urban planning and building city dashboards to the monitoring of real estate markets.We aimed to build a COVID-19 property dashboard to help real estate market stakeholders  to monitor and understand the behaviour of the Australian property market during the COVID-19 pandemic. We surveyed the sources of open, usable and comprehensive data concerning real estate markets in Australia and noted the opportunities presented by them. We also highlighted the gaps present in them along with problems in their veracity, spatio-temporal variance and inaccessible formats. Within these limitations, we collected data and designed indicators to track the spread of COVID-19, residential property auctions, house values, market sentiment and mobility across markets in Australia. These indicators were then compiled into a single-page, responsive, interactive dashboard that was implemented and deployed using a micro-services architecture.The paper has also discussed various insights we could derive from the dashboard by having all these indicators side by side. Some indicators  are correlated to the daily new cases of COVID-19 in their corresponding spatial units, while other indicators  have remained unaffected. The Twitter sentiment index and the mobility index served best in understanding the impact of COVID-19 in the short term, while Google Search trends were found to be useful in the long term. Although numerous relationships present between these indicators were confirmed visually through the dashboard, we found that they were weak when measured through Pearson’s correlation. One of outcomes from the data we observe is that the total auction values and number of COVID19 cases are not significantly correlated in Australia. Although this may appear counter intuitive, our research suggests that the property market in Australia largely avoided any meaningful impact from COVID19 in 2020. This could be attributed to an array of factors such as government interventions such as quantitative easing, home buyer/owner grants and interest rate changes, plasticity of property market in general, etc. There is need for further research regarding this including the data from 2021 & 2022 to identify and quantify the impact of these factors. There is also a need for better infrastructure, standards, and improved frequency of dissemination in real estate data for the sector to transform itself, similar to how urban management and planning transformed under the umbrella of smart cities and research into construction of tools and methodologies for better analytical models. Although, we still remain challenged in realising the real-time digital city discussed by , we have


A multicriteria decision analysis (MCDA) model was used to evaluate the benefits and risks of traditional Chinese medicine preparations of sinomenine alone or in combination with conventional drugs in the treatment of rheumatoid arthritis (RA) and to provide a basis for the rational clinical application of sinomenine.A study search was performed using six major databases, and Review Manager 5.3 was used for data analysis. Then, an MCDA model evaluation system was established for the treatment of RA with sinomenine preparations, and the benefit values, risk values, and total benefit-risk values of sinomenine preparations alone or in combination with conventional drugs were calculated using Hiview 3.2 software. Finally, Monte Carlo simulations were performed using Crystal Ball embedded in Excel software to calculate the 95% confidence intervals (95% CI), and the probability of the differences between the 2 drug regimens was determined to optimize the evaluation results.Forty-four randomized controlled trials (RCTs) were included. Quantitative assessment of the MCDA model showed that the sinomenine preparation alone offered less benefits than when combined with conventional drugs with a benefit difference of 20 . However, the risk of the combination was significantly lower with a risk difference of 13. The total value of the benefit-risk of sinomenine alone and in combination with conventional drugs was 46 and 53 at 60% and 40% of the benefit-risk ratio of the two dosing regimens, respectively, with a difference of 7 . The probability that the comprehensive score of the combined regimen is greater than that of sinomenine alone is 90.1%, and the evaluation was steady.The benefit-risk of the combined application regimen of sinomenine is greater than that of sinomenine alone. Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that affects approximately 0.5 ~ 1% of the population and is characterized by painful, swollen joints that can severely impair physical function and quality of life . In addiCaulis Sinomenii, which has anti-inflammatory, analgesic, and immunosuppressive effects and can inhibit the development of RA through multiple pathways and targets [Caulis Sinomenii was approved by the State Food and Drug Administration of China for treating RA almost 20 years ago [Caulis Sinomenii, has achieved efficacy in clinical practice. A randomized control trial of 80 patients showed that the efficacy of sinomenine in the treatment of RA was 82.6% compared to 70.8% for conventional drugs and that sinomenine was effective in improving joint symptoms and laboratory parameters in RA patients [Sinomenine is the main active constituent of the plant  targets , 5. Caulears ago . The Chipatients  and Liu patients  analysedTherefore, this study used a multicriteria decision analysis (MCDA) to standardize the scoring of various outcome indicators and evaluated the benefits and risks of sinomenine individually or in combination therapy for RA based on real-world RCT data. The benefits and risks of sinomenine in the treatment of RA are taken into account, the scores of each index can be evaluated more intuitively, and the advantages and disadvantages of the drug regimen can be judged from the comprehensive evaluation to help clinicians make a more favourable choice for patients.Caulis Sinomenii for RA using the CNKI , VIP , WanFang, Embase, PubMed, and Web of Science databases. Keywords, including rheumatoid arthritis, RA, Zhengqing Fengtongning, Sinomenine, RCT, and randomized literature retrieval time, were employed to search for studies published from database establishment to December 2021. The search strategy is shown in Table We searched randomized controlled trials (RCTs) of Chinese medicine preparations of Patients with a definite diagnosis of RA based on diagnostic criteria referring to the 1987 American College of Rheumatology criteria regardless of gender, age, race, or disease activity.Randomized controlled trial.The experimental group applied Chinese patent medicines containing sinomenine alone or in combination. The control group used conventional medicines, including nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs).Total effective rate, including morning stiffness, tender joint count (TJC), swollen joint count (SJC), rheumatoid factor (RF), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR); the adverse effects rate based on gastrointestinal reaction, leukocyte decline, liver function impairment, and skin lesions.Animal studies, review literature, literature for which full text was not available, and literature lacking outcome indicators or records of adverse reactions were excluded.To establish the decision tree of evaluation indices, the evaluation of outcome indices is divided into benefit and risk indices, and the expression of each index is presented in the form of an effects tree based on Hiview 3.2, as shown in Fig. The benefit and risk indicators of each study were merged using RevMan 5.3 software and are presented in the form of 95% confidence intervals (CIs), as shown in Table Given that the benefit and risk indicators are not measured similarly, comparing their performance in an MCDA requires transforming the data into preference scores. Therefore, based on the single-attribute utility function relationship, we set a 0–100 rating for each of these 13 indicators, For the benefit, a higher preference value indicates a higher gift, whereas the opposite is true for the risk. Some metrics are relatively more important than others, and we give them more weight by weighing them. The optimal value and the worst value for each indicator are specified in Table Due to the subjective nature of the weight assigned to each indicator, a sensitivity analysis is required to demonstrate the stability of its weight selection. If the weight changes by greater than 20%, the evaluation results will change. Then, the weighting of indicators is more reasonable, and the sensitivity established by the MCDA model is not high and more stable, and vice versa .As the benefit and risk values obtained by RevMan 5.3 are point estimates, Monte Carlo simulations were performed in Excel via Crystal Ball 11 to iteratively calculate the benefit and risk values and the 95% CI of the total benefit-risk values for the 2 groups  and to simulate the probability of differences between the 2 groups to optimize the MCDA evaluation results.A total of 1163 articles were retrieved for the first time. After removing duplicates and noncompliant studies, 44 studies were finally obtained –55, all A meta-analysis of 14 studies showed that the sinomenine preparation alone was effective in improving joint symptoms  and laboratory parameters  and had a lower incidence of adverse reactions than conventional drugs. However, a high incidence of skin damage was reported. The meta-analysis of 30 combined drugs showed that sinomenine alone could effectively improve patients' joint symptoms, laboratory indices, and the incidence of adverse reactions compared with the ordinary medicine group, but the incidence of allergic reactions was still greater than that in the conventional drug group (Table The benefit values of a sinomenine preparation alone and combined with ordinary medicine were 39 and 59, respectively. Thus, sinomenine combination therapy has a better effect on RA. However, sinomenine use alone is more effective in alleviating joint tenderness and joint swelling, as shown in Table The risk values of sinomenine alone and in combination were 56 and 43, respectively, demonstrating that the risk of sinomenine alone for RA is lower, especially in terms of damage to liver function. The incidence of adverse reactions to sinomenine alone is more advantageous, but both regimens scored 0 in skin damage reactions, indicating that sinomenine is not skin friendly (see Table The benefit-risk values for sinomenine alone and the combination were 46 and 53, respectively, and the benefit-risk for the combination was sevenfold greater than that for sinomenine alone. The combined use scored is relatively evenly distributed in all areas, indicating that the regimen can alleviate the patient's condition via numerous mechanisms. Thus, the patient can benefit more. Regarding hepatic impairment and the incidence of adverse reactions, the score was higher for sinomenine alone. Considering that the patients had liver disease, perhaps sinomenine alone was more appropriate (Fig. When the relative benefit weight is 60%, the total benefit-risk for the combination of sinomenine is greater than that for sinomenine, as shown in Fig. The MCDA model provides a structured framework within which the aspects considered to be important to the overall aspects are assessed and graded, and specific judgements are made. The model is mainly comprised of three steps: determine the main influencing factors, evaluate the evidence for each factor, and ensure that the results of the MCDA model are meaningful. In this study, the hypothesis was artificially graded twice, and the relative weight of relevant outcome indicators was obtained. Although the constituent ratios and established weights are subjective, the assumptions underlying their use are clear. Theoretical and clinical perspectives work together to determine what represents value and facilitate drug decisions. MCDA is also widely used in the benefit-risk assessment of drugs. For example, MCDA is used to identify the most suitable treatment for patients with NVAF  and to pCaulis linoleum has been utilized to treat RA for more than 1,000 years as recorded in a compendium of material media. Many recent studies have shown that it has a significant effect on RA [RA is a chronic inflammatory autoimmune disease influenced by both genetic and environmental factors . As therct on RA , 61, andThese features are observed in the RCTs included in this study. Whether used alone or in combination, it has better efficacy than conventional drugs in improving patient signs and laboratory indicators, especially in combination. Monte Carlo simulation showed that sinomenine combined with conventional drugs was 100% better than sinomenine alone and more effective in reducing morning stiffness time and RF. This finding indicates that the combination of sinomenine with conventional drugs may achieve better clinical efficacy and is more favourable for alleviating patients' conditions, providing a reliable theoretical basis for clinical medicine.Due to the chronic increase of RA patients and the need for long-term medication, the risk of drugs is at the center of the attention of clinicians and patients. Traditional DMARD conventional drugs work slowly, and many months are needed to reach the effect of the control condition; however, the cumulative effect of long-term medication can lead to various complications, such as gastrointestinal reactions, liver and kidney function, and bone marrow toxicity. Studies have demonstrated that small doses of MTX could also lead to gastrointestinal tract, infection, lung diseases, and other adverse reactions . SimilarOur study showed a series of unfavourable reactions to sinomenine. Skin damage was reported most frequently. The merged data showed that both were below the minimum criteria we set, so both regimens scored 0. However, from the perspective of the included RCT, its adverse reactions and system damage were less than those of conventional Western medicine drugs either alone or in combination. Among them, the incidence of adverse reactions of a single application was lower, and the scores of multiple adverse reactions were better than those of a combined regimen. Therefore, patients with poor tolerance in clinical application may choose to use sinomenine alone to obtain more benefits.Sinomenine has both benefits and risks in the treatment of RA. Therefore, comprehensive consideration should be paid to the application of sinomenine in the treatment of RA, and multiple factors should jointly determine the medication regimen to improve drug compliance. Although numerous studies have analysed the effectiveness and safety of sinomenine, these studies have neglected to unify the benefit and risk evaluation and failed to comprehensively evaluate its overall utility for RA patients, which is one-sided to some extent. Based on the MCDA model and Monte Carlo simulation, this study further verified the theoretical differences in benefits and risks between the two treatment regimens. In the analysis of this study, the weights of benefit and risk were set at 60% and 40%, respectively. The reason for this allocation is that compared to side effects, limb deformities, joint swelling and pain have more far-reaching and serious consequences for patients. Moreover, sensitivity analysis showed that our allocation was reasonable. When performing the sensitivity analysis, we observed a significant change in the results when the benefit weight was decreased to 40%, indicating that the weight assigned was reasonable according to the previous statement. The final results demonstrate that the two treatment regimens differ in their benefit and risk scores. Specifically, sinomenine in combination with conventional drugs offered more benefits in the treatment of RA compared with sinomenine alone. However, the combination regimen exhibited higher risk scores than sinomenine alone, which may be related to the inherent risk of combining drugs. Combining the benefits and risks, the combination of sinomenine with conventional drugs has a higher score, and the combination regimen is more recommended than sinomenine alone for clinical applications.A total of 44 literatures were included in this study. According to the risk assessment results, there is a certain deviation risk, and the main risk factors are blind design and selection allocation hiding. It is difficult to avoid the bias caused by the lack of rigor in the research program. Only high-quality research program design can alleviate this situation, but there is still room for improvement in the blind design of such studies. Secondly, sinomenine is only applied in the Chinese market at present, so the studies we included were all in Chinese, which may also lead to the deviation of the results. The studies we included ranged from 1999 to 2021, and there may be some bias between individual studies. To sum up, we still need to design rigorous research schemes and higher quality studies to further verify the correctness of our research.In summary, the combination regimen may be more beneficial to patients than sinomenine alone. The incidence of adverse reactions for sinomenine alone is lower than that noted for the combination regimen, and sinomenine alone may be more appropriate for patients with poor health status or allergies. This study is based on the MCDA model that provides a clear method of assigning weights, and the above conclusions were obtained after several iterations of simulations. This information is expected to serve as a reference for clinical practice.


Social capital is a well-known health determinant with both relational and geographic aspects. It can help mitigate adverse events and has been shown to impact behaviors and responses during the COVID-19 pandemic. Mental health has declined during the COVID-19 pandemic, and social capital, may serve to buffer those declines.Building from this, we assessed whether pre-pandemic social capital and contemporaneous social policy, which included indicators of social trust, civic participation, and presence of mask mandates, affected pandemic mental health, measured as the percent of the population experiencing symptoms of depression and anxiety at the state level.Generalized social trust and state mask mandates were significantly associated with lower levels of depression and anxiety. Conversely, states with greater civic engagement prior to the pandemic experienced more anxiety and depression.Findings suggest that existing social capital, particularly social trust, may protect against anxiety and depression and contribute to community resilience during times of adversity. States should invest in policies and programs that increase social trust. Social capital is a multilevel health determinant incorporating aspects of individual social networks, participation in civic life, and contextual factors related to the social and economic organization of neighborhoods, organizations, or communities, together which facilitate coordinated actions to improve society . Social The social capital in one's environment, whether that be within a person's community or workplace, impacts health, independent of individual measures of social capital; furthermore, this relationship holds across a variety of settings, study designs or health outcomes . Put anoSzreter and Woolcock  make theAs well, there is increasing recognition that social capital is a key factor in mitigating the impacts of adverse events . Mental MH) was the percent of persons in a state reporting symptoms of anxiety or depression on the Centers for Disease Control's Pulse Survey during the period ending February 15, 2021  was measured as the percentage of the population that “trust all or most of their neighbors”. This is a primary measure frequently used to compare social trust internationally (civic) was an index aggregating eight individual measures . This index is standardized so its mean is zero and the standard deviation equals one. A third indicator of social capital was whether the state had a mask mandate  (mask) in effect as of February 26, 2021 , percentage of the state's population over age 65 (pop65), and percentage of the state's population that is Black or African American (black). State unemployment rates were obtained from the Federal Reserve Economic Database and used to calculate the difference between the unemployment rate (Δunemp) in February 2021 compared to January 2020 (preMH) by using age-adjusted percentage of adults reporting 14 or more days of poor mental health per month in the state in 2018 (covidper), as reported by the Center for Disease Control Data Tracker, concurrent with the measure of anxiety , to a high of 45.1% (Oregon), with a median value of 38.7% . Scores Regression results, utilizing robust standard errors, are presented in The findings offer support for our hypothesis that higher levels of social capital will translate to mental health protection (lower levels of anxiety and depression). While social trust and masking policies seemed to confer some protection for mental health, the findings for civic participation are more nuanced. To ascertain the robustness of these results, numerous versions of models nested in Equation (1). were investigated. The results of this exercise point to the consistency of the coefficient estimates and significance for both social trust and the mask mandate. Within these models, while the civic participation coefficient experienced greater variability, it remained positive and generally significant at the 10% level.The findings provide a first look into states' social capital and how that social capital may confer mental health protection during the COVID-19 pandemic. We found that states with higher levels of social trust pre-pandemic tended to also have fewer persons experiencing symptoms of anxiety and depression, suggesting that their neighborly relations and sense of community may mitigate these symptoms. As expected, state mask mandates were associated with lower percentages of persons reporting anxiety and depression and could indicate that citizens feel less anxiety knowing the state is actively trying to prevent virus spread. Our findings fit with research by Brodeur and colleagues who found greater decreases in mobility in high-trust counties after stay-at-home orders were implemented .States with higher levels of pre-pandemic civic participation reported greater symptoms of anxiety and depression during the pandemic, although this finding should be taken with a note of caution since it was only significant at the 10% level. While somewhat counterintuitive, it could be a reflection of how the pandemic has limited social interaction, leading to elevated occurrences of anxiety and depression among the residents in those states and fits with other research in this area . Our finThis is important as both COVID-19 and mental health concerns persist. Overall, there was wide variation in social trust across states with a 35% difference between states with a little and a lot of social trust. Civic participation also varies, but appears to be lower in the South and Southwest. Such differences between states, indicate that both social trust and civic participation are changeable, though more research is needed into the specific policies and social supports that results in higher social trust or greater civic participation.Our findings support the importance of existing area level social capital as a health protective factor mitigating adversities associated with the COVID-19 pandemic –29. In pThis research has some limitations. One limitation of the research is that the data are cross sectional and cannot establish causality, albeit two of the independent variables are captured from an earlier time point compared to the dependent variable. We only measured three aspects of social capital and assumed that the social capital variables were relatively static during the pandemic; however, some research has found declining trust over the course of the pandemic . NeverthThe datasets presented in this study are publicly available and can be found in online repositories. The names of the repository/repositories can be found in the article/KD designed the study. NW analyzed data. KD wrote the initial draft of the manuscript. Both authors identified data sources, interpreted the analysis, edited subsequent drafts of the paper and have read, and approve the final 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The COVID-19 pandemic has made visible inequalities as exemplified by unequal access to COVID-19 vaccine across and within countries; inequalities that are also apparent in rates of testing, disease, hospitalization and death from COVID-19 along class, ethnic and racial lines. For a global pandemic such as the COVID-19 to be effectively addressed, there is a need to reflect on the entrenched and structural inequalities within and between countries. While many countries in the global north have acquired more vaccines than they may need, in the global south many have very limited access. While countries in the global north had largely vaccinated their populations by 2022, those in the global south may not even complete vaccinating 70% of their population to enable them reach the so-called herd immunity by 2024. Even in the global north where vaccines are available, ethnic, racialized and poor working classes are disproportionately affected in terms of disproportionately low rates of infection and death. This paper explores the socio-economic and political structural factors that have created and maintain these disparities. In particular we sketch the role of neoliberal developments in deregulating and financializing the system, vaccine hoarding, patent protection and how this contributes to maintaining and widening disparities in access to COVID-19 vaccine and medication. With more than 200 million known cases of COVID-19 and nearly 5 million deaths around the world as of September 2021 , World Bank and USA Department of Treasury, that the neoliberal operations of the free market and a reduction of state involvement in welfare needed to be extended to countries in Africa and Latin America Hurt, . In otheNeoliberalism according to Davis , thus re.COVID-19 represents an opportunity to evaluate our individual and collective priorities and envision an alternative future. Many people demonstrated “new hope” for change to what they saw as a politically impotent, unequal and ultimately flawed social system: their subjective dreams revolved around communal solidarity, a greener planet and a fairer society.…In addition to the shift where communities in many parts of the world have mobilized, the lockdown or the new normal of working from home, schooling from home and reduced transport including air travel has, as argued by some, already lowered carbon emission and may improve health  to waive certain Trade-Related Aspects of Intellectual Property Rights (TRIPS) provisions. However, the member states of the WTO failed to arrive at the required consensus to move forward with the proposed waiver, while the European Union, the United States, the United Kingdom, and other developed countries opposed the waiver request Tran, . AccordiMeanwhile, COVID-19 vaccines Global Access Facility COVAX, a vaccine-sharing scheme, was created to ensure that vaccines would reach all people everywhere. COVAX is led by the World Health Organization, Gavi  and the Coalition for Epidemic Preparedness Innovations (a foundation that finances research into vaccines for pandemics), and aims to ensure that all participating countries have access to inoculations. All countries in Africa have signed up to the scheme, which now has 190 members. Of these, 92 fall into the low- and middle-income group.COVAX seeks to maximize the chances of successfully developing COVID-19 vaccines and manufacture them in the quantities needed to end the supply and distribution crisis. Thus, one motivation is humanitarian, but another is to prevent the emergence of new variants resistant to the available vaccines. According to COVAX, the target of distributing two billion doses by the end of 2021 will not be realized. Instead, COVAX expects to supply 1.4 billion doses of the vaccine in 2021, which is a shortfall of nearly a third (Diba et al., While the COVAX initiative did not get enough support from high income countries, billions of taxpayers' money from the same countries have been spent to help big pharmaceutical companies like AstraZeneca, Moderna and Pfizer BioNTech develop and produce vaccines. These as well as others, are the same companies that refuse to share their research, knowledge and technology with low income countries which means that other pharmaceutical companies, and especially those in low income countries with smaller budgets, cannot access the advances in science to step up their own vaccine production.The issue of profit-making by private companies and the impact on healthcare and, ultimately inequalities in health outcomes, is demonstrated by the attempt to manufacture easy to handle and improved ventilators in the USA (Sanger et al., It appears that the shortfalls noted above are a matter of the institutional power structures. Looking at the issues of vaccine nationalism and patent protection by companies in the rich global north, the problem lies in the political and economic structures and the ways the neoliberal capitalist system has been changing over time. As argued by Sell  financiaAs noted earlier, Monbiot  argues tOne aspect discussed by Pagano  is the gFinancialized capitalism is a pattern of accumulation in which profits accrue primarily through financial channels rather than through trade and commodity production. Financial markets, motives, institutions, and elites have increasingly come to dominate the global political economy, affecting everything from production and consumption, to regulation and health….Some of the challenges arising from financialized capitalism include, according to Sell , capitalThe capitalist transformation described above, informs the perspective presented by Kelly  regardinAnother source of power for the giant tech companies is that they quietly buy up many companies, with most of the acquisitions going unreported and unannounced. This, as reported by De Vynck and Zakrzewski , makes iThis paper is part of the research topic on the lessons learned from the COVID-19 pandemic so far that could help in building a fairer, healthier, inclusive and sustainable society. We have noted that there are positive trends as a result of the COVID-19 pandemic where communities in many areas have mobilized to support neighbors, healthcare workers and those who have been displaced. Governments have also taken action to support workers who lose their jobs and displaced communities in what Briggs et al.  calls suHowever, although states may use the pandemic to improve some conditions for the working class, the quest for profitability forces firms to continuously reduce their labor costs, which as Sell  argues, While studying the financialized interests of capital does not necessarily hold interest for medical sociologists, the evidence of this pandemic suggests that we cannot afford not to pay attention.Both authors have contributed to the work and approved it for publication.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


One of the major environmental determinants in IBD pathogenesis is diet.5 Several dietary factors have been explored and linked to the pathogenesis of IBD such as vitamin D intake.5–7 Obesity, on the other hand, has been recognized as a major health problem with a concerning surge in prevalence, especially in Western countries. Obesity is known to be associated with an inflammatory state and its link to IBD has been the subject of ongoing basic and clinical research over the last several years.9 Obese persons with IBD may have a higher rate of disease relapse, resistance to medical therapy, and the need for IBD-related surgery.11Inflammatory bowel disease (IBD) is a chronic immune-related disorder that affects gastrointestinal tract. As the disease is non-curable, patients need a lifelong treatment with a typical disease course of remissions and relapses.12 compared rates of obesity, IBD, with the geographic markers of lactase digestion status, average population-weighted national latitude, and national yearly sunshine exposure in 47 countries across the globe. The main findings shown were the global modest to moderate correlations of Crohn’s disease (CD) and ulcerative colitis (UC) incidence with geographic markers. The correlation between obesity and IBD (both CD and UC) was globally moderate, but it was poor for Europe and Asia. As the obesity pandemic is more pronounced in Western countries, it is not clear why the correlation was poor in Europe.In an interesting review, Szilagyi et alThe correlation of CD incidence with lactase non-persistence (LNP) in Europe and the correlation of CD and UC incidence with latitude in Asia remained moderate to strong. When the prevalence data on IBD were assessed, the outcomes with the geographical markers were similar globally but less clear in Europe and Asia, where UC prevalence remains moderately associated with LNP and strongly associated with latitude in Asia. It is difficult to know what this exactly means or the implications of these findings.While the study is interesting, it is limited by the availability and accuracy of epidemiological data from different countries. The results of the study are dependent on several assumptions and calculations that might be difficult to interpret. The accuracy of these calculations needs to be validated in future studies.


Elements associated with an increased risk factor for the contagion of COVID-19 in shelters include the turnover and overcrowding of people, time spent in communal areas, daily supply needs, water availability, and sanitation levels. The “Report on the Effects of the COVID-19 Pandemic on Migrants and Refugees,” shows that factors such as the shortage of food, supplies, water, sanitizing materials, spaces for healthy distancing, financial resources for rent and essential services, and the lack of medical or psychological care complicated providing care for migrants and applicants seeking international protection.We describe shelter operations regarding the detection and follow-up of suspected and confirmed COVID-19 cases showing mild symptoms among the migrant population housed in the border cities under study.We conducted semi-structured, in-depth interviews with study subjects  from 22 migrant shelters, and 30 with key informants. We studied the cities of Tijuana , Nogales (Sonora), Ciudad Juárez (Chihuahua), Piedras Negras (Coahuila), and Heroica Matamoros (Tamaulipas). The research was based on a qualitative methodological design with an ethnographic approach. The information collected was transcribed and systematized into two tables or analytical templates, one for interviews with study subjects, and another for interviews with key actors.Overall, seventy-eight registered shelters provided accommodation services for migrants in the five cities the study focused on: thirty-seven in Tijuana, five in Nogales, twenty-two in Ciudad Juárez, eight in Piedras Negras, and five plus a camp  in Matamoros. The major concentration of shelters was in Tijuana (47.4%) and Ciudad Juárez (28.2%). At the beginning of the pandemic, only a few shelter facilities met quarantine and isolation guidelines, such as having separate bathrooms and sufficient space to isolate the “asymptomatic” and “confirmed” from close “contacts”. The lack of isolation space and the inability to support the monitoring of patients with COVID-19 posed a challenge for those housed in shelters, forcing many shelters to close or continue operating behind closed doors to avoid becoming a source of infection during the pandemic.Contrary to speculation, during the onset of the pandemic northern border migrant shelters did not become sources of COVID-19 infection. According to the data analyzed from 78 shelters only seven had confirmed cases, and the classification of “outbreak” was applied only in two facilities. Contagion control or containment was successful as the result of following a preventive containment logic, including the isolation of all suspected but unconfirmed cases, without a clear understanding of the human and financial resources required to maintain isolation areas. However, shelters in the study implemented protocols for epidemiological surveillance, control, and prevention with elements that interfered with monitoring spaces, and processes that caused oversights that resulted in underestimating the number of cases.Due to travel restrictions imposed to prevent and contain coronavirus infections it was impossible to stay on-site in the cities studied, except for Tijuana, or carry-out recordings of migrants' views in shelters. On 14 April 2020, the World Health Organization , have transformed this region into a transit region, the last great containment filter for national, international, and extra-continental migratory corridors into the United States, and as a waiting territory , 3.This situation was exacerbated in the context of the SARS-CoV-2 pandemic by the establishment of health policies such as Section 265 of U.S. Code Title 42, authorizing U.S. border authorities to expeditiously expel undocumented migrants wishing to enter the United States by land to their last country of transit, rather than their country of origin, even if they had expressed a desire to request asylum , and the fact that these spaces were designed as temporary shelters but had to serve migrants needing long stays and a rotating population such as deportees .On 30 March 2020, Mexico declared a health emergency due to the coronavirus, immediately followed by imposing “stay-at-home” orders that turned temporary migrant shelters into spaces for shelter, voluntary isolation, and quarantine of people on the move along the northern border without a place to “stay home.”Elements that increase the risk factors for contagion by COVID-19 in shelters include the turnover and overcrowding of people, gathering in communal areas, the need for daily supplies, water service availability, and sanitation. In addition, since April 2020, states on the northern border, mainly Baja California and Chihuahua, having the main border cities, stand out nationwide by their high rates of contagion and deaths from COVID-19. During the 1st weeks of the health emergency, migrant shelters in this region were associated as possible sources of infection, outbreaks, and contexts where prevention, control, and surveillance of the epidemic had become unmanageable. Was this association verified in the early months of the pandemic?Operating Plan for the Care of the Migrant Population during COVID-19, in an environment of public health policies focused on coping with the pandemic, at least from January to September 2020 failed to consider the needs of this population  published the This Plan prioritized the role of the SESA and the Health Jurisdictions, centralized coordination of “comprehensive care” including medical care ; mental health; epidemiological surveillance and laboratories; health promotion; reproductive health and protection) for migrants in conjunction with various agencies in the health sector, the INM , NGOs /ACs (Civil Associations), and local governments, including migrant houses and shelters. Given the common problems faced by migrant houses and shelters pose the following questions: what were the regional challenges of implementing epidemiological surveillance and control guidelines as described in the Plan? How was the follow-up of COVID-19 cases detected in these shelters conducted? Was contagion successfully contained? Using a qualitative approach, we sought to measure the incidence and spread of contagion in the empirical case of migrant shelters in this region. We answered the question above using qualitative research with an ethnographic approach that included conducting 48 semi-structured in-depth interviews with shelter staff and key informants between July and December 2020, in the cities of Tijuana , Nogales (Sonora), Ciudad Juárez (Chihuahua), Piedras Negras (Coahuila), and Heroica Matamoros (Tamaulipas).The main finding is that the shelters did not become sources of contagion, we found only seven out of 78 shelters had confirmed COVID cases, detected through PCR, and only two registered outbreaks. Nonetheless, certain factors may have influenced the epidemiological surveillance process and resulted in underestimating positive COVID-19 cases at these locations.This article presents some of the findings of a research project titled “United States-Mexico Border Health Conditions” financed by the US-Mexico Border Health Commission and El Colegio de la Frontera Norte in Tijuana. The overall objective was to analyze the response to the spread of COVID-19 virus infections from a public health perspective among migrant shelters in cities on the northern border of Mexico. The research was based on a qualitative methodological design using an ethnographic approach. Data collection took place between July and December 2020.The cities on the Mexican northern border chosen to be included in the research met the following qualitative criteria.A border city from each Mexican state that has a border with the United States, ~ 3,000 km long, in order to record the particularities of the states' socio-political context. Efforts were made to select the most populous city and the main border crossing point for each state.Cities that are immersed in the main mass migratory flows of people tend to use migrant shelters. Includes cities that serve as a port of return for deported migrants and/or asylum seekers in the United States under the MPP (Migrant Protection Protocols), and/or with the largest number of people on the waiting lists for requesting asylum in the U.S., and/or most involved in the transit of undocumented migrants seeking to cross the U.S. border.Key cities that bear a presence of a shelter network that provides accommodation services for migrants. We prioritized cities where the network is comprised of shelters with different trajectories  under the aegis of institutions , to record the heterogeneity characterized in the shelter landscape and its patterns along Mexico's northern border. We included major cities having health filter shelters set up for epidemiological surveillance and prevention during the pandemic.The eligibility criteria resulted in the following cities being included in this study: Tijuana , Nogales (Sonora), Ciudad Juárez (Chihuahua), Piedras Negras (Coahuila), and Heroica Matamoros (Tamaulipas).The study subjects in this research took refuge in shelters, asylums, foster homes, and, in general, institutions with or without a civil society charter that granted humanitarian support by providing accommodations to a population fully or partly composed of migrants with varying profiles along the five cities on Mexico's northern border.The key informants were institutional actors who, within the framework of the pandemic, intervened in migrant shelters, provided health care in these spaces, and/or participated in the development of strategies to mitigate infection and follow-up on suspected or confirmed COVID- 19 cases detected in shelters.Key informants also included parties holding a holistic view of the study focus who were able to describe the practices, patterns, needs, challenges, facilities, and resources related to the response of shelters to the pandemic. Key informants were mainly identified during the research process, through the narratives and networks of the study subjects consulted.Migrants housed in the northern border shelters were not interviewed for two main reasons. First, the impossibility of physically going to these spaces complicated contact with this population. Second, when the field data collection phase was conducted between July and December 2020, a time when migrants in shelters saw their migratory and life projects negatively affected by the adoption of public health policies designed to stop the spread of contagion in Mexico and the United States.As a first step, a list was drawn up with the contacts of active shelters for migrants in the cities under study. These shelters were mapped based on previous academic research that had identified these spaces in the region; the websites and/or social networks of migrant shelters in the cities under study; the lists of institutions that provide humanitarian assistance along the migratory routes drawn up by organizations that support populations on the move. The list was also enhanced by information gathered through interviews with study subjects and key actors.The research instrument was a semi-structured, in-depth interview conducted in 40 cases by telephone, in five cases through virtual platforms, and in three cases with face-to-face interviews. Out of a total of 48 interviews, 19 were conducted with study subjects  from 22 migrant shelters, and 30 with key informants. A brief questionnaire was also administered in 74 of the 78 shelters to survey each institution's profile and ensure that it was operational during the time of the research.Shelter classification was based on the methodology by Albicker and Velazco  which caThe interview guide for study subjects was divided into thematic axes with 57 guiding questions, broken down as follows: the interviewee profile, shelter profile, migratory context where the shelter operates, participation in institutional networks, and efforts to coordinate health care in the shelter and respond to the pandemic. Other axes included the shelter's first response to the pandemic, prevention measures, epidemiological control, surveillance undertaken, monitoring of suspected cases, confirmed cases, contacts detected, outlook, and intervention proposals.The interview guide for key actors included thirty-five guiding questions divided into the following thematic axes: interviewee profile, institution profile, the migratory context where the institution operates, information on the reaction of migrant shelters to the pandemic, interventions by the institution to support shelters in the context of the pandemic, inter-institutional coordination, and outreach for the health care of the migrant population during COVID-19, prospects and intervention proposals.The information gathered was transcribed and systematized into two tables or analytical templates, one for interviews with study subjects and another for interviews with key actors. The information obtained was organized in the tables into several homologous analytical categories. The findings presented in this document are mainly drawn from an analysis of the categories of “epidemiological monitoring of suspected COVID-19 cases detected in shelters” and “epidemiological surveillance and prevention in shelters.” These categories, contained in both templates, were used to analyze the material gathered through the other instruments.The following findings emerged:- Increase in emergency shelters to meet the demand for accommodation of the recent large, extraordinary flows, especially of people seeking international protection, refer to - Heterogeneity of institutions in charge, many types of institutions, and heterogeneity within the same type  and Catholic .- Different models and degrees of care. Some shelters offered basic care , and other shelters offered expansive services . These shelters provided comprehensive care to integrate the migrant population into the city (such as Tijuana and Ciudad Juárez's integration centers and certain Migrant Houses).- Assorted sizes and maximum capacities: small (family) shelters with fewer than 50 people, such as El Puente in Tijuana, and massive shelters for nearly 500 people such as San Juan Bosco in Nogales, or 1,000 or more such as Pan de Vida in Ciudad Juárez and those repurposed by the government on the premises of former maquiladoras.- Shelters' adaptation to new user profiles due to the increase of displaced unaccompanied Children and Adolescents (CA), single women and women with children, and families with CA.- The pandemic reinforced the tendency to eliminate the maximum length of stay in the regulations and the maximum time was adapted to the migratory process for each person for whom accommodation was provided.- Implementation of confinement policy in shelters that became a “co-responsible domestic shelter” space for people on the move, that is, those without a fixed address in the northern Mexican border region.- Heavy dependence on shelters run by non-governmental institutions offering cross-border solidarity.- Epidemiological filter shelters were set up as a result of the pandemic. In both the city of Tijuana and Ciudad Juárez, the International Organization for Migration (IOM) Filter Hotel was adopted. In Ciudad Juárez, two filter spaces operated by a religious non-profit (the San Matías Shelter System and the Espíritu Santo Shelter) were adopted.During the early weeks of the health emergency, the epidemiological containment and prevention measures adopted in the shelters resulted from informal consultations and inquiries between responsible parties and local health authorities. As of 19–20 March 2020, federal level and Health Jurisdictions required shelters to implement quarantine measures, the refusal of entry to new migrants, volunteers, and members of organizations supporting these institutions, and the “decongestion” of spaces by relocating residents. This was the general trend in the initial response to the pandemic by shelters located on the northern border of Mexico.Operating Plan for the Care of the Migrant Population during COVID-19 whose main purpose was to “establish effective coordination and liaison for comprehensive health care for the migrant population during COVID-19”  and the detection of symptoms. They offered guidelines on how to clean up shelters and adopt prevention measures  and provided supplies for prevention and personal protection.When a case with symptoms related to SARS-CoV-2 virus infection was detected in a shelter in the cities under study, the protocol described in the plan called to immediately notify the city's health jurisdictions for each individual case. The jurisdictions would be responsible for implementing actions and mechanisms to verify the event, surveillance, and laboratory, and ensure the care and follow-up of suspected and confirmed cases and contacts based on their surveillance, control, and epidemiological prevention criteria.However, the standardized protocol proposed by SESA merely “provided guidelines” for actions and decisions for shelter administrators and personnel in the Health Jurisdictions. In reality, the assigning of the follow-up process by the actors involved led to different, circumstantial, specific care routes, and follow-up practices for each suspected case detected in the shelters in each city.The factors discussed above led to high uncertainty and improvisation around actions implemented with each circumstance. This was exacerbated during the 1st months of the pandemic when the official guidelines were barely disseminated, which in turn affected compliance with control criteria and epidemiological surveillance.Operating Plan for the Care of the Migrant Population , and included the administration of a combination of instruments, including the “respiratory triage,” and the search for cases with fever. If a person fits the operational definition of a suspected case, an epidemiological study of a suspected case of viral respiratory disease was conducted, and contact tracing began. In addition, assessment could include the collection of a sample for the administration of a rapid test and/or the collection of a sample for a PCR laboratory test. Appropriate isolation measures were subsequently determined. In all the cities under study, the health authorities' evaluation policy regarding a case with symptoms at a migrant shelter only focused on the administration of a diagnostic test in limited cases.The PCR, the prerogative of the Jurisdictions, tended to be administered to just a small fraction of suspected cases with obvious respiratory symptoms. This may have led to the underreporting of infections at migrant shelters in the official statistics of the Jurisdictions, which are based on positive PCR results.One problem from the start of the pandemic and creating enormous concern among responsible parties for the shelters was the need to have an isolated or quarantine area for suspected and confirmed COVID-19 cases, those with mild symptoms, and contacts detected among the migrant population housed in these shelters.Isolation is required from the time between the detection of a case with symptoms and the confirmation of the event by health authorities at the shelter. When a PCR test was administered, the person remained isolated until the laboratory results were received (from 2 to 4 days depending on the distance from the laboratory). Once the laboratory confirmed a person had tested positive or had been in contact with someone who had , isolation was extended for 2 weeks. This measure was applied to all suspected cases, even when they had not been given a rapid test or laboratory diagnosis.At the beginning of the pandemic, very few shelters in the study had a designated isolation area meeting necessary requirements such as having separate bathrooms and sufficient space to ensure that “asymptomatic” and “confirmed” cases would not be lumped together with “contacts” .Having a space for isolation depended on a combination of factors such as the availability of space, and the human and financial resources to ensure isolation and provide medical/clinical follow-up to those who needed it, in addition to the resources for the total daily support of the person in quarantine for at least 2 weeks.The lack of this space, coupled with the impossibility of supporting the process of monitoring COVID-19 cases, forced many shelters to make the decision to close or continue operating behind closed doors to minimize the possibility of becoming a source of infection during the pandemic.To continue operating and accepting new migrants, some shelters, such as the Casa del Deportado de Tijuana and La Roca de Nogales shelter turned one of their dormitories into an isolation space that could be used in an emergency.Shelters equipped with a space for the isolation of suspected and confirmed asymptomatic cases, or those with mild symptoms—which do not require secondary care  —were characterized by the following:—Certain Migrant Shelters had areas for isolation with a large backyards.—Shelters supported by international organizations and/or the government have an isolation area for all suspected cases: “it is a small space. Only the doctors who are there go there all the time with all the necessary equipment and take in food, and from the time they are suspected cases to the time when they take the test, they are not allowed to leave” .—Other shelters with large areas were set up.Most organizations found it impossible to deal with this problem autonomously and immediately. In the 1st weeks of the health contingency, the OIM activated the Program to Strengthen Shelters   to meet Although some shelters did not fully resolve the need for confinement and containment of contagion given events of a severe outbreak in the establishment, as was mentioned by some of the responsible parties we consulted, the IOM canopies managed to allay widespread fear and uncertainty about how to proceed, providing a solution for the initial isolation of confirmed and suspected cases detected in shelters.In Tijuana and Ciudad Juárez, the creation of filter shelters such as the IOM Filter-Hotels or the San Matías and the Espiritu Santo prevented an outbreak of COVID-19 cases in the shelter network. Moreover, in each city under study, care referral routes were established for each case with symptoms detected in the shelters, which included their immediate transfer to other establishments equipped with specific isolation spaces, in some cases from the time of the assessment phase. In each city, these spaces consisted of several types of shelters not necessarily exclusively intended for the migrant population, or the shelter population, such as Voluntary Isolation Centers (CAV), mobile clinics, COVID-19 Units at General Hospitals, and COVID-19 Centers set up by the Ministry of Health, often in collaboration with other actors such as Doctors Without Borders and the private sector.Exercising epidemiological control through isolation posed a challenge for most shelters, which generally had limited, unreliable support, due to the demand for efforts and resources required for monitoring, even if they had a suitable space for doing so. But it was also a challenge for those housed at the shelter.For migrants, isolation meant separation from friends and family, with the displacement of the entire family nuclei. It meant being away from places with a flow of vital information. As noted by a doctor from the Ciudad Juárez jurisdiction: “often if people at the shelters […] have an appointment with the MPP, they do not want to be isolated, because what if they call them about the MPP when they are in isolation?”In addition, the need for quarantine and isolation created pressure on the shelters that housed migrants, especially in the areas controlled by the government or with a larger population, such as the Ciudad Juárez Migratory Integration Center and the Matamoros Camp, which housed ~2,500 migrants at the start of the pandemic, most of them families seeking asylum in the United States. In some cases, the pressure led to protests, sit-ins, riots, plots, and uprisings, as noted by key respondents.In Nogales, eleven migrants were isolated in an area of the DIF  Municipality that had resulted from a contagion outbreak in a shelter that continued to operate as one of the few accommodation options available to migrants in the city. The key actors interviewed reported difficulty in maintaining and sustaining isolation for 2 weeks due to the lack of government budget funds specifically designated to serve this population. The cost of a portion of the supplies was partly covered by the personal salaries of municipal officials and support from a local civil society organization “Panchito y Su Cristina,” supported by the American NGO, Voices from the Border. In addition, it was not possible to have personnel permanently monitor the area or confinement of migrants nor to separate lab-confirmed cases and their contacts. Nonetheless, in all of the cities, the isolation measure was applied to all suspected cases that were detected at the shelters, even when they had not been administered a rapid test or had a laboratory diagnosis.During the early months of the pandemic, the implementation of the protocol for epidemiological monitoring of migrants with suspected and confirmed COVID-19 acquired a connotation of uncertainty and improvisation that negatively influenced the way the criteria for surveillance, prevention, and control of the epidemic were implemented.We found heterogeneity in the data figures from the actor interviews in shelters in the cities under study used to estimate the degree of infection. The issue of epidemiological surveillance of the virus among the shelter population was also complicated by the lack of a reliable official record.The health authorities' event evaluation policy applied in the cities under study included the administration of a PCR (Polymerase Chain Reaction) test for a few cases in migrants showing obvious or severe respiratory symptoms. According to estimates by the Health Jurisdictions, by December 2020, PCR tests confirmed 40 cases recorded at the shelters, an estimate matching the figures shared by the jurisdictions' staff. The estimate above excludes the city of Tijuana because their jurisdiction did not share its figures. The Directorate of Care for Migrants for the Municipality of Tijuana reported two cases were confirmed by PCR tests in the shelters.In addition, during the 1st months of the pandemic shelters had limited access to rapid tests and there were no official records of rapid tests administered in migrant shelters in the cities studied. Thus, tracing the route of PCR tests or rapid tests that were applied did not yield a reliable record of infections in the shelters and both routes seemed to lead to an underestimate of infections.In regards to the scope of the contagion in Tijuana and Matamoros, there was not a marked difference in the figures provided by the actors responsible for receiving migrants. In Piedras Negras, no cases were registered in these spaces by any actor interviewed since the shelters stopped working under the city council's order. In Ciudad Juárez, where the state tends to centralize the coordination of the humanitarian sector and strengthen the link between shelters and the Health Jurisdiction, figures provided by the actors interviewed tended to be similar to official figures.The Health Jurisdiction estimates considered cases that had tested positive with the PCR test. The numbers declared by other actors came from information based on rapid tests administered directly or indirectly by them and could include cases that tested positive with the rapid test, and/or isolated cases, and/or cases identified as positive as a result of an observation of symptoms assessment.The difficulty of having reliable information on the spread of infection in shelters could also be due to political factors, and the inaccurate, non-transparent handling of data between different actors, levels, and areas of government.Reflecting on the following account by a doctor from the Health Jurisdiction (face-to-face interview on 26 October 2020), one can assume that in Tijuana, transferring migrants with suspected COVID-19 between various COVID-19 care centers may also have complicated the estimates:“There were positive cases, but there were no serious cases we had to hospitalize. They were just patients we had to transfer at the time we had to refer them to the General Hospital. Once they had recovered at Zonkeys  Hospital or the COVID-19 Shelter, they were usually transferred from the General Hospital to Zonkeys and from Zonkeys to the COVID-19 shelters; there was only one case of hospitalization.” Thus, contrary to speculation during the first weeks of the pandemic, migrant shelters on the northern border did not become sources of COVID-19 infection, since from the seventy-eight shelters analyzed, only seven had confirmed cases, and only two received the classification of “outbreaks”.Infections were recorded tendentially at the shelters housing most migrants,  where monitoring was undertaken by staff doctors or specialized medical personnel from the government health sector (such as the CIM in Ciudad Juárez and the Filter Hotels—OIM). Based on the interviews, the people who were isolated came from groups of returnees from the United States and asylum seekers under the MPP. Only two cases of isolated migrants in the cities studied were referred to General Hospitals due to major complications, and both successfully recovered. In most cases where migrants had been isolated were eventually reincorporated into the community and their shelter after a fortnight, when they did not present symptoms after testing negative, but they did not always administer a confirmatory PCR test.Another factor that may have contributed to the underestimation of the official data on people infected by COVID-19 in shelters is due to certain institutions using a different protocol, follow-up, or care route than that established in the guidelines for suspected cases.Key informants reported that shelters with internal medical personnel and isolation spaces preferred to treat and manage cases with mild symptoms discreetly, isolating them in their facilities without sharing information with health authorities. At the same time, Civil Society Organizations that provided health care in the shelters declared that they were the first and only contact in the event of suspected cases at certain institutions and preferred not to interact with health authorities. The director at one of these organizations commented: “ I know the Jurisdiction is trying to do its job, but the simple fact that they wear a uniform prevents them from having access to the shelters […] the population doesn't trust them [...] and neither do the shelters, especially those that are illegal or clandestine, and are reluctant to let them in.”Fear of the imposition of quarantine or other repercussions may have also discouraged institutions from accessing and notifying suspected cases of the Health Jurisdiction. Notification of a suspected case among migrants or workers and volunteers could imply a quarantine for the entire institution, with the obligation to assume responsibility for the entire sheltered population, which posed an enormous challenge for shelters whose survival depended on a combination of limited and uncertain resources.A final factor that may have led to the underestimation of infections in the shelters is linked to a trend observed among housed migrants to not disclose the onset of COVID-19 symptoms to the shelter or camp staff. Actors who provided services in the Ciudad Juárez CIM and the Matamoros camp observed this attitude and associated it with the fear of being kept in an isolation space, which would exacerbate the loss of control of their projects which were already profoundly disrupted by health and immigration policies adopted in Mexico and the United States during the pandemic.Moreover, migrants may have been discouraged from reporting symptoms given a perceived lack of clarity and transparency in protocol compliance. The sensitive nature of the protocol for monitoring suspected cases and its implementation created uncertainty about what lay in store for migrants in the event they became a “suspected COVID-19 case.”In the past 5 years, cities on the Mexican northern border have received extraordinary flows of foreign and Mexican migrants in transit to and from the United States, with even more complex and diversified profiles and needs including people from various countries , an increase in the presence of children and adolescents, women traveling alone with their children, and more families displaced by violence within Mexico. At the same time, the implementation of security, immigration, and health policies by the U.S. and Mexico transformed this border into the last filter to contain these flows , 13–20.This situation called on the humanitarian system that is active on the northern border of Mexico to provide care for this population on the move, stuck on the move, or in a condition of “forced mobility,” as it has been classified by several analysts , 16.One of the pillars of this humanitarian system is the range of options offering accommodation to migrants who are highly susceptible to the recent sudden, drastic changes in the migratory dynamics of this border region and fluctuations in the demand for housing , 22.Recently, the array of shelters in this region assumed the appearance of a heterogeneous, fragmented body in terms of the type of structures, responsible institutions, and operating models. At the same time, they shared problems that, during the first few months of the pandemic, challenged the control and containment of contagion in these spaces, as well as the application of epidemiological surveillance protocols and case monitoring.We attempted to measure the incidence and spread of contagion using a qualitative approach in five cities on the northern Mexican border. We also analyzed the phases of the epidemiological monitoring process for suspected COVID-19 cases detected in these spaces which are, detection, assessment of the event, and isolation. In each phase, we highlighted the factors  that influenced the appropriation of epidemiological surveillance protocols in these spaces. We found that the difficulty of having reliable information on the spread of infection in shelters could also be due to political factors and the inaccurate, non-transparent handling of data between different actors, levels, and areas of government.Contrary to speculation, during the early weeks of the pandemic migrant shelters in the northern border did not become sources of COVID-19 infection, given that in a total of seventy-eight shelters in the five cities studied, only seven showed confirmed cases, and two shelters received the classification of “outbreaks.” Thus, contagion control or containment was successful.A total of 81% of the 42 cases confirmed through PCR tests given by health authorities were concentrated in Ciudad Juárez. From this figure, 52% were detected in the Integration Centers for Migrants and 33% in the OIM Filter Hotels. These shelters continued to operate and accept new migrants but also had permanent staff and professional medical health care which became a tool to detect infection.In addition, the implementation of strategies for control and containment materialized such as non-profit shelters operating behind closed doors and accepting new admissions, the implementation of epidemiological filter shelters by religious non-profits and international organizations in Tijuana and Ciudad Juarez, and the adoption of a preventive isolation policy. A preventive containment logic was detected which included the isolation of all suspected, even unconfirmed, cases of COVID-19 among migrants. At the same time, a lack of transparency and clear agreements was observed regarding the human and financial resources required to maintain isolation spaces, which were often improvised .However, the manner in which study contexts appropriated epidemiological surveillance and control protocols incorporated elements that hampered surveillance in these spaces and led to an underestimation of the phenomenon. A comparison of the information provided by the health authorities with that of the shelters and key local non-governmental actors with more contact with the field revealed higher underestimation rates in the cities of Tijuana, Nogales, and Matamoros. The factors that contributed to this underestimation were:Circumstantiality of protocols in each city under study during this initial stage of the pandemic. There was a lack of clarity about assistance routes, what happened to the migrant when they became a suspected case, and what happened to the shelter when a suspected case was detected.Migrants' and shelters' fear of quarantine and isolation.The incipient relationship between the health sector and shelters materialized in the shelters' fear of being sanctioned or “controlled” by health authorities.Limited availability of human resources and medical-health personnel in shelters, exacerbated by safe distance and shelter-in-place policies during the pandemic.Limited availability and administration of PCR tests when Jurisdictions exceeded their intervention capacity.The factors mentioned above along with their association with social, political, economic, and administrative spheres reveal the criticality that emerged from observing the planned standardized surveillance protocols in this heterogeneous overview of shelters. During the early months of the pandemic, shelters in the cities studied managed to contain the contagion while serving as spaces to shelter in place, quarantine, and offer access to some form of medical care in the event of contagion given an institutional environment that was closed to the population on the move. However, this study did not record the opinions of migrants at the shelters and it remains a pending task.The travel restrictions imposed by coronavirus infection prevention and containment measures made it impossible to engage in an on-site stay in the cities in the study, with the exception of Tijuana. As a result of these limitations, this study was an ethnography “at a physical distance” that drew information from telephone interviews, virtual platform interviews with study subjects and key informants, and from a critical hemerographic review of local newspaper articles on the subject. We also accessed documents published by academia, and local and international non-governmental organizations focusing on the issue of care at migrant shelters for the population on the move along Mexico's northern border during the health contingency. Finally, we also reviewed official documents and communication that established care guidelines for these spaces during the pandemic.The datasets generated for this study are available on reasonable request to the corresponding author.The studies involving human participants were reviewed and approved by the Ethics Committee of the United States-Mexico Border Health Commission. Subjects provided their informed consent to participate in this study.MR and RC-P: article proposal and review. VC: fieldwork and first and final draft document preparation. AL: document review and editing for Frontiers. MR, RC-P, and AL: final draft preparation. All authors contributed to the article and approved the submitted version.