The co-operative, multiplayer game “Pandemic” is won by ‘researchers’ and ‘scientists’ while the other players work to slow the spread (“flatten the curve” and “zero covid”), buying time for the researchers to develop and test effective vaccines and/or treatments for the four epidemic diseases. Designed in 2008 (after the SARS outbreak) the game is instructive in its presentation of pandemics as “research emergencies”. As we have seen with COVID19, most of the transmission control measures buy time while we either improve treatment sufficiently or find effective vaccines to ameliorate the consequences of the illness. In the COVID-19 pandemic we have been fortunate that prior experience with other pandemic has meant many policy makers, researchers, scientists, and funders had prepared for just such a research emergency, and went to work very early on treatments and vaccines.
Playing Pandemic (Picture from CDC blog The Next Monopoly? What “Pandemic” teaches us about public health )
In February 2020, Peter Horby and colleagues in Oxford were watching the growth in COVID-19 cases in England. Having previously failed to complete clinical trials in the Ebola epidemic and in the initial Wuhan outbreak, Professor Horby was determined not to fail again. With emergency research funds promised from UKRI, he and colleague Martin Landry got to work. They wrote the trial protocol in two days, had ethics clearance in three days, and randomised the first patient at the John Radcliffe Hospital in Oxford within a fortnight. A month later over 1,000 patients, at 132 hospitals across the UK, had been randomised to the different treatment arms of the RECOVERY trial, and by June RECOVERY published important results that have saved over a million lives during the pandemic. A trial such as RECOVERY would normally take years from conception to completion was done in months. This was achieved by efficiency not shortcuts: they compressed many of the steps and avoided the usual waiting time between them – see the timeline below. Similar expedited project management was used to develop the vaccines in record time (I plan a separate blog on the vaccine processes).
What are the secrets to achieving of this staggering compression of the research timeline? Planning and preparedness were crucial. From previous epidemics such as the H1N1 influenza outbreak, UK funders knew that emergency research funds would be required to rapidly kickstart trials. Next, a clinical trials network already existed in many hospitals in the UK and could rapidly switch to enrolling COVID-19 patients – essential infrastructure for conducting trials. Further, to encourage patient enrolment, the Chief Medical Officers of England, Wales, Scotland, and Northern Ireland wrote to NHS clinicians saying that it was preferable to enrol patients in trials rather than use likely agents off-label. Finally, the expedited and single ethics review for multicentre studies was crucial to allowing the rapid commencement and scaling of enrolment – and again had been planned for years in advance. For other less prepared countries these proved to be a stumbling blocks in getting appropriate clinical trials going.
While these practical aspects to expedite clinical trials such as RECOVERY were vital, underpinning this success was envisaging the pandemic as a “research emergency”. Many other countries focused on access to untested treatments, wasting precious research time. For example, the USA spent almost $1 billion on emergency access to convalescent plasma, which randomise trials later found was ineffective for most patients. Maybe more government policy makers and funders could play the Pandemic game to get a better understanding of why research should be seen as an emergency in epidemics and pandemics. However, the lessons though have wider implications for research beyond pandemics. Other major health care issues could be more efficiently addressed by adapting the lessons from research in the pandemic.
Healthy Evidence 