During the COVID-19 pandemic, numerous attempts to conduct randomized trials of public health and social measures (PHSM) faced significant obstacles, according to a review of trials proposed and initiated at the Centre for Epidemic Interventions Research (CEIR). The review, which examined the first four years of the pandemic, revealed that of 18 proposed trials, only five were completed, one was ongoing, and one halted after recruitment began, with the remaining 11 trials not implemented. These findings highlight critical challenges in generating evidence for effective public health interventions during crises.
Legal and Ethical Barriers
One of the primary barriers identified was the stringent informed consent requirements stipulated by the Norwegian Health Research Act. The law's interpretation necessitates informed consent from every individual within a group or cluster, even in cluster randomized trials (CRTs), before they can be exposed to an intervention. This requirement is more restrictive than guidelines from the Council for International Organizations of Medical Sciences (CIOMS), which allow waivers or modifications of informed consent in CRTs where obtaining individual consent is virtually impossible. This legal constraint significantly impeded the feasibility of conducting population-based trials.
Political and Practical Obstacles
Beyond legal hurdles, the researchers encountered reluctance from relevant authorities to carry out trials due to political or practical considerations. For example, a proposed trial of school reopening was rejected by the Norwegian government, which believed it would be unacceptable to the public. Similarly, a suggestion to arrange mass gatherings for young people randomized to rapid test screening was met with concern from municipal authorities, who feared it could worsen the COVID-19 situation given the relatively high incidence of the disease in Norway at the time. These instances underscore the challenges of balancing scientific rigor with political feasibility and public perception during a pandemic.
Timing and Methodological Issues
Timing also proved to be a critical factor. The unpredictable shifts in disease incidence and continuously changing recommendations and regulations from authorities created additional barriers. A trial of close contact testing, for instance, became impractical when it was implemented as a national recommendation. Methodological challenges further complicated trial implementation. The expected effect sizes of PHSM may be small, requiring large participant numbers. Some interventions are not easily amenable to randomization, necessitating alternative evaluation methods like the stepped wedge design, which staggers intervention implementation over time. However, the stepped wedge design also has limitations, particularly in infectious outbreaks with fluctuating case incidence.
Lessons from Ebola and Future Preparedness
The challenges encountered during the COVID-19 pandemic echo those from the 2014–2016 Ebola outbreak, highlighting the need for better research preparedness. Key lessons include the necessity for rapidly adaptable core protocols, streamlined ethical approval processes, inclusive stakeholder engagement, and greater international collaboration. The World Health Organization (WHO) has initiated efforts to measure the effectiveness and impact of PHSM during health emergencies, proposing study protocols for rapid implementation during future crises. The Pandemic EVIDENCE Collaboration also aims to develop 'oven-ready' research protocols for rapid deployment in early pandemic phases.
Revisions to Health Research Act
Discussions are ongoing in Norway regarding how to facilitate more randomized trials of policy interventions. The informed consent requirement in the Health Research Act is under review, considering competing principles: the need for individual informed consent, waivers for low-risk interventions, and exemptions when governmental bodies mandate interventions without consent in non-research settings. These considerations also touch upon the concept of community consent, where gatekeepers protect the interests of organizations or communities in cluster randomized trials, though this is generally not considered a substitute for individual informed consent.
Conclusions
The review concludes that strengthening the evidence base for PHSM in pandemics requires political and public understanding and support for population-based randomized trials, along with a revision of the Health Research Act to address the challenges encountered during the COVID-19 pandemic.
