November 6, 2022 Liz Borkowski, MPH 0Comment

Last week, the peer-reviewed journal Nature published a landmark article full of recommendations about how to end the COVID-19 public health threat. “A multinational Delphi consensus to end the COVID-19 public health threat” distills the expertise of 386 experts who engaged in a multi-month process based on existing COVID-19 research. The 41 consensus statements and 57 recommendations that emerged from the process could be a powerful tool for ending the pandemic — if governments acknowledge and act on them.

An Iterative Approach to Expert Consensus

The Delphi method gathers multiple rounds of input from experts in an iterative process that refines statements and/or recommendations with the goal of approaching consensus. In this case, four co-chairs launched the process: Jeffrey V. Lazarus, Diana Romero, Christopher J. Kopka, and Salim Abdool Karim identified 40 academic, health, nongovernmental organization, government, and policy experts from 25 countries and territories who had published and publicly engaged on COVID-19. That core group then proposed additional experts and convened a Delphi panel of 386 experts representing a diverse array of disciplines and nationalities.

The core group of 40 reviewed relevant literature published through January 2022 to draft initial statements in six domains: communication, health systems, vaccination, prevention, treatment and care, and pandemic inequities. The Delphi panelists then completed the first survey round, in which they registered their level of agreement with the statements (the options were agree, somewhat agree, somewhat disagree, disagree, or not qualified to respond) and had the opportunity to submit comments. Based on that feedback, core group members modified the statements and generated recommendations, to which the panelists responded in the second survey round. The core group convened to discuss the issues panelists raised in both survey rounds and then distributed the third and final survey, in which panelists registered their level of agreement and ranked the top half of recommendations in each of the six domains. Nearly all of the statements and recommendations ended up with at least 90% agreement.

Good Advice That Doesn’t Seem to Be Guiding Our Current Approach

The Nature article in which Jeffrey V. Lazarus and colleagues report on the Delphi process and its outcomes is an Open Access publication, so anyone can read the 41 statements and 57 recommendations (they’re listed in the tables). I’m going to highlight a few of the recommendations that I’d like to see U.S. government leaders adopt, because they don’t seem to be doing so currently:

Communication: Recommendation 1.4 states, “Institutions and individuals that wish to advance public trust should: (1) draw on evidence about how trust is created and restored; (2) provide training and professional development emphasizing skills and competencies that convey trustworthiness; and (3) develop, implement and assess communication strategies that are highly likely to create or restore trust.” I admit that agencies like CDC are facing an uphill battle here, because a lot of bad actors are actively working to sow disinformation and mistrust in government for their own personal gain. But it’s always going to be hard to trust an agency when its director emphasizes handwashing above interventions like masking that are far more important for airborne diseases.

Health Systems: Recommendation 2.1 states, “Governments should remove economic barriers to SARS-CoV-2 tests, personal protective equipment, treatments and care.” Widespread availability of free PCR tests and vaccinations were early pandemic success stories here, but distribution of rapid tests and high-quality masks never got as far as it should have — and now that Congress has failed to authorize additional funding, economic barriers to prevention and treatment have gotten much worse. “Healthcare organizations should support their workers’ physical, mental and social well-being” (Recommendation 2.4) is much harder to implement now that CDC no longer recommends masking in all healthcare facilities.

Vaccination: This is the one intervention that the Biden administration still seems happy to promote, although booster uptake is low and racial disparities in vaccination have narrowed but persisted. Our government could probably still do a better job of implementing Recommendations 3.2 — “In settings where individuals have lower levels of trust in government, vaccination efforts should engage trusted local leaders and organizations” — and 3.3., “To combat vaccine hesitancy, tailored messages that address the underlying bases of an individual’s concerns should be used in targeted public health communications.”

Prevention: Recommendation 4.1 urges that government support and incentivize structural prevention measures such as ventilation and air filtration, and Recommendation 4.6 specifies, “Prevention of SARS-CoV-2 transmission in the workplace, educational institutions and centres of commerce should remain a high priority, reflected in public health guidance and supported through multiple social measures and structural interventions (for example, remote work/schooling policies, ventilation, air filtration, facemask wearing).” The Biden administration has released ventilation guidance, and the American Rescue Plan Act provided funding that local education agencies could use to improve ventilation systems and purchase protective equipment. However, it’s unclear how many schools have improved their air quality, and public health experts who advised the Biden transition team (including my George Washington University Milken Institute School of Public Health colleague David Michaels) consider failure to prioritize systematic improvement of indoor air quality to be “perhaps the most important missed opportunity” in the U.S. pandemic response. They advise setting national indoor air quality standards and requiring buildings to post whether they meet those standards.

Treatment and care: “Governments should now prioritize early case detection so that health systems can facilitate earlier treatment and care,” states Recommendation 5.5. Rapid tests — no longer distributed free by the federal government, but still available free where local governments distribute them and reimbursable to those with health insurance — allow for quick results, but in many places there’s no system for sharing results with health officials. This makes local case counts less reliable and could delay detection of growing case numbers and implementation of measures like universal masking to reduce community transmission — although with its shift in focus from transmission levels to “community levels,” CDC hasn’t exactly encouraged the prompt implementation of such measures. And for those who do test positive, treatment is no longer free to many patients now that federal funding has expired.

Pandemic inequities: The expiration of federal funding has harmed our ability to comply domestically with Recommendation 6.2., “In addition to current vaccine equity efforts, governments and global health organizations should better coordinate to make COVID-19 tests and treatments affordable for all people in all countries.” High-income countries as a whole have performed abysmally on global vaccine equity, let alone equity regarding testing and treatment. And Recommendation 6.3., “Decision-making bodies (for example, governments, WHO committees) should meaningfully and transparently engage with a broad base of voices to inform their decisions,” made me think of the awful contrast between CDC’s stated commitment to considering the needs of disabled people and the agency’s repeated weakening of guidance that has further shut immunocompromised people out of the possibility of participating fully in their communities.

The Biden administration and Congress should acknowledge that the pandemic is far from over and implement all of these expert recommendations. With a multidisciplinary group of experts having done all the work to digest the evidence, there’s no excuse not to act on it.

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