Pandemics, pandemonium and panaceas: Scientific and technological uncertainty

Researchers at the Science Policy Research Unit (SPRU) have examined critical issues in the fight against COVID-19, including diagnostic technologies, vaccines and therapeutics, and response paradigms.

Pandemics

COVID-19 is perhaps the most significant science policy issue of our time. Whether it is diagnostic technologies, vaccines and therapeutics, or response paradigms, the issue at the heart of the COVID-19 response is the high level of scientific and technological uncertainty and how this shapes decision-making.

Yet, according to Dr Josh Moon, looking back to previous pandemics, and there have been quite a few in the not so distant past – SARS (2005) Swine Flu (2009); Ebola (2014) - the lessons are clear: Accountability is key. Despite efforts to bolster the International Health Regulations - the World Health Organization’s legally binding framework of rules, guidance and expectations for states in the event of a health emergency - there have been mixed results. And right now, the world is witnessing the effects of this in terms of preparedness and response to a global pandemic.

Globally, there has been significant apathy towards pandemic preparedness between outbreaks, punctuated by panic, pandemonium and throwing large amounts of resource at response when the epidemic hits. This leads to a lack of learning from previous outbreaks because institutions cannot depend on consistent funding to implement recommendations. COVID-19 stands as a case in point.

Nevertheless, from the perspective of the technical response, there have been significant improvements between COVID-19 and SARS. First of all, the identification of the virus was incredibly rapid, coming in a matter of weeks, not months. In addition to this, the rapid production of a diagnostic test and the sheer volume of data and clinical information sharing that has occurred during this outbreak demonstrates a clear improvement on previous outbreaks.

Pandemonium

However, one of the starkest things with COVID-19 is the varying levels of success different countries have had in dealing with the virus. This is something that Professor Michael Hopkins, with Dr Moon and colleagues from other organisations, has set out to examine by systematically comparing six countries and analysing the key aspects of these systems that could be rapidly replicated in other contexts. The project team is focused on identifying key elements of successful testing systems, including measures that facilitated preparedness and resilience before the crisis, and the rapid innovations that have helped countries to deal with a fast-evolving pandemic.

So far, results indicate great diversity in the accuracy of testing due to a whole range of issues from:

• Type of tests used, with lower respiratory samples more likely to provide positive test results than upper respiratory samples;
• The use of inadequate specimens, for example those not collected by a suitably trained professional and self-tests;
• And problems with sample collection, transportation or laboratory handling errors.

At the beginning of the pandemic, extensive use of mobile technology, including tracing apps, in conjunction with steps to ensure the protection of privacy was found to be more prevalent outside England. Even across the four nations of the UK there were marked differences, with the Scottish and Welsh governments endorsing their publics to use a COVID-19 symptom tracking app and Northern Ireland’s government developing and releasing a similar app quickly, whilst it took much longer for an app to be endorsed in England.

In evidence submitted to the House of Lords Science and Technology Committee inquiry on the Science of COVID, the researchers argue that there should be independent reviews of the practices established in other countries with the aim of providing a suite of mobile technologies for rapid use in England. These should provide individuals with access to an algorithm for self-diagnosis, health advice, and onward guidance for confirmatory testing, as well as rapid and automated alerting of contacts at risk of infection.

Despite positive steps in technical response, social lessons have not improved to the same degree. As with Ebola, WHO again fell under criticism for delays in declaring the COVID-19 pandemic. Secondly, the use of excessive quarantine measures - a near-impossible task and often implemented too late to have much of an effect – raises questions about the social responsibility of states.

Panacea…?

Dr Moon argues that responding to health emergencies and the WHO’s Review mechanism itself is necessarily political and needs to be recognised as such. Nowhere is this clearer than in the US. The politics of accountability and blame cannot be avoided. However, if organisations and nations are transparent and inclusive in the evidence-base and communicate and disseminate findings, response and future preparedness will improve.

Whilst many people think and hope that a vaccine will guarantee immunity from Covid-19, Dr Ohid Yaqub, who works on research policy and biomedical innovation, argues that there are huge technical, social, and political uncertainties involved in vaccines, right from the very moment they are conceived as a way to address a pandemic, all the way through development and roll-out.

One of the features of vaccine development to come to light amongst the broader public is the idea that there are different kinds and possibilities of vaccine. Vaccines that show high efficacy, vaccines that show low efficacy, vaccines that prevent infection, vaccines that can’t prevent infection but at least prevent serious symptoms developing, vaccines that are thermostable, vaccines that require cold chain refrigeration, vaccines that require one dose, vaccines that require three doses, vaccines that work differently in the young, old, obese, pregnant, and so on.

Let us just take two of these.

Somewhat counter-intuitively, low efficacy vaccines are harder to develop, because they require larger and longer trials to detect their efficacy. They take longer to arrive, and when they do arrive, the low efficacy means they might not have a transformative effect on the pandemic until it is rolled out far and wide. So, it might mean that the ‘test n trace’ system is not just a stop-gap until a vaccine arrives, it may well be needed for much longer than many might think. “Seen in this light”, says Dr Yaqub, “some of the hope imbued in a future vaccine is mere deflection from the fact the potential benefits of test and trace systems have not been fully tapped, and indeed how urgently a better test and trace system is needed.”

Vaccines that require cold chain refrigeration represent completely different challenges for countries without a network of delivery infrastructure in place. It can mean people having to travel further to where there is refrigeration in order to get vaccinated. This can mean that trust in vaccines, and motivation to get vaccinated need to be considerably stronger. A vaccine that requires multiple doses exacerbates this further.