Top experts call for major new coalition on non-medical pandemic research

Doug Hendrie

3/07/2020 4:26:00 PM

The best successes against the ever-growing coronavirus pandemic have so far not come from drugs or vaccines, but from behavioural and social techniques.

Social distancing blocks
Social distancing has been one of the most effective efforts in the fight against coronavirus.

Countries that have done best in the fight against coronavirus are those that have asked their citizens to change behaviour by wearing masks, keeping 1.5 m apart, self-isolating and working from home.
But, surprisingly, almost no funding goes into finding how to test – and perfect – proven and emerging non-medical ways to combat COVID-19.
That means there is no definitive answer to seemingly simple questions that could slash the rate of virus transmission, such as whether face masks work better than face shields, or whether copper-coated door knobs could cut virus transmission, as they do for bacteria.
That evidence vacuum has at times led to conflicting advice, hampering pandemic control efforts. 
What is needed, according to top researchers, is an international coalition for behaviour and social preparedness for epidemics, focusing on non-medical methods of cutting viral transmission rates.
In a proposal seen by newsGP, the team of Australian, Canadian and UK researchers suggest the coalition could immediately begin work on urgent projects, such as field-testing whether copper-impregnated masks are better than standard masks and developing ways to improve uptake of contact-tracing apps such as COVIDSafe.
The calls have been backed by World Health Organization (WHO) COVID-19 adviser and UNSW Professor Marylouise McLaws, who told newsGP there is a great deal of knowledge lacking in this area.
‘There’s only so much money going around and it often goes to pharmaceutical prophylaxis, treatment and vaccines. This is a superb idea,’ she said.
Another supporter is top Australian infectious disease expert, ANU’s Professor Peter Collignon, who told newsGP the area of research is ‘really important’.
If funded, the coalition would complement the established Coalition for Epidemic Preparedness and Innovation (CEPI), which to date has reportedly spent around AUD$1.2 billion funding nine candidate vaccines.
Another backer of the new coalition is Professor Paul Glasziou from the Institute of Evidence-Based Healthcare at Bond University, who told newsGP such a coalition would focus research firepower on a ‘vital neglected issue’.
‘These non-medical interventions will always be our first line of defence against any new pandemic because we won’t have a vaccine,’ he said. ‘If another one hits, we’ll be in the same situation as we are now – because we don’t know what works.
‘During this pandemic we need to learn less disruptive and more effective ways to reduce the risks of transmission.  
‘This coalition is about how we can take all the tools we have used successfully to date and make them more effective and less disruptive to people’s lives. The only way we can do that is head-to-head comparative studies.
‘We need research and trials of behavioural, social, environmental and systems interventions, which are effectively the things that have been saving us at the moment.

‘Consider one simple question: should we wear face masks, or are face shields better? We simply don’t have any direct data on which one is better [at cutting virus transmission]. We only have theoretical reasons. But that’s informed guesswork, rather than a controlled test.’

Professor Paul Glasziou believes the proposed coalition would focus research firepower on the ‘vital neglected issue’ of non-drug interventions.

Non-drug interventions such as face masks are often only tested in an observational study or in a mechanistic way in a laboratory, and do not take into account how people actually use them, whether they use them properly, or how they rate against alternatives, according to Professor Glasziou.
‘We would be better off now if we had done these studies earlier and knew the answers to vital questions. We need to do it now, for this pandemic, but it would also work for any future flu or respiratory virus pandemic,’ he said.  
‘In many ways we missed the initial boat on this. We can’t afford to waste any more time.
‘This is incredibly frustrating, to be honest. People are thinking vaccines and drugs are the answer – and, yes, we do need those – but we also need a backup plan.
‘For instance, we have mechanistic evidence of the efficacy of face masks versus face shields, but no direct head-to-head evidence. We will end up at the end of this pandemic with that argument unresolved, and we could answer it in a month.’
The coalition proposal states that ‘world-leading experts with relevant experience in a wide range of disciplines and sectors need to be brought together,’ in the same way that CEPI was formed in 2017 as a partnership between public, private, philanthropic and civil sector organisations to develop vaccines the market was not supplying.
Professor Glasziou and the other early backers of the coalition believe effective suppression of the coronavirus epidemic will require evidence-based behavioural, social, environmental and systems changes, rather than placing all hopes into vaccines and medical treatment.
‘Unlike the vaccine response, there has been little work to rapidly develop and evaluate [these] interventions during the first wave of this, or indeed any, pandemic,’ the coalition proposal states.
‘[These] interventions have been central in the global response to COVID-19, allowing countries to “flatten the curve” and protect their citizens and healthcare systems.’ 
The proposed coalition is the brainchild of Professor Glasziou, Professor Susan Michie, Director of the Centre for Behaviour Change at the University College London, and Professor Jeremy Grimshaw of the University of Ottawa, who is an implementation research specialist.
Professor Collignon said the coalition could help find how to stop transmission of the virus most effectively.
‘There are questions still unresolved, such as the value of masks and face shields. We need research into whether which is better – it’s really useful information to know, but these studies are not done very often – if at all,’ he said.
‘Compared to a billion-dollar drug, infection control may not get the same attention, but it might be more effective and more cost-effective.’
Professor McLaws said the proposed coalition is an excellent way to attract more interest and funding to the area.
‘At the moment, infection prevention and control, and social-science approaches, is the orphan child of the science,’ she said. ‘It’s sad and an indictment, but infection control is always underfunded.
‘Vaccines and treatments are the desired outcome in medicine. They attract huge money and hope, compared to non-pharmaceutical and behaviour controls, which never attracts that.
‘But knowing human behaviour is very important. There is a lot we can learn about preventing spread by understanding human nature.’
Professor Glynn Kelly, Chair of the RACGP Specific Interests Disaster Management network, told newsGP the proposal is a ‘great initiative’.
‘We do have to look at behavioural aspects. We can’t expect that we can just put messages out and people will follow them,’ he said. 
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A.Prof Christopher David Hogan   7/07/2020 12:50:57 PM

I wish my colleagues well in their endeavours but I do not envy them their task.
There are multiple confounders in the use of PPE. I speak not only as a procedural GP but as a researcher & a member of emergency services trained in CBR (chemical, biological & radiation) protection protocols.
Many doctors are well trained in aseptic techniques to prevent contamination of their patients but poorly aware of the reverse techniques when their patients can contaminate them. Internationally, images & video of doctors in the field show multiple errors in the wearing & handling of masks, cross contamination of patients, errors in removing PPE etc.
Even when trained it is so easy to break protocol when busy, tired or distracted. During our training we found it useful to have a supervisor irreverently self titled as "Matron Ratchet" who was able to promote , encourage & direct safe handing techniques including PPE.