conclusion for covid 19 research

• Research article
• Open access
• Published: 04 June 2021

Coronavirus disease (COVID-19) pandemic: an overview of systematic reviews

• Israel Júnior Borges do Nascimento 1 , 2 ,
• Dónal P. O’Mathúna 3 , 4 ,
• Thilo Caspar von Groote 5 ,
• Hebatullah Mohamed Abdulazeem 6 ,
• Ishanka Weerasekara 7 , 8 ,
• Ana Marusic 9 ,
• Livia Puljak   ORCID: orcid.org/0000-0002-8467-6061 10 ,
• Vinicius Tassoni Civile 11 ,
• Irena Zakarija-Grkovic 9 ,
• Tina Poklepovic Pericic 9 ,
• Alvaro Nagib Atallah 11 ,
• Santino Filoso 12 ,
• Nicola Luigi Bragazzi 13 &
• Milena Soriano Marcolino 1

On behalf of the International Network of Coronavirus Disease 2019 (InterNetCOVID-19)

BMC Infectious Diseases volume  21 , Article number:  525 ( 2021 ) Cite this article

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Navigating the rapidly growing body of scientific literature on the SARS-CoV-2 pandemic is challenging, and ongoing critical appraisal of this output is essential. We aimed to summarize and critically appraise systematic reviews of coronavirus disease (COVID-19) in humans that were available at the beginning of the pandemic.

Nine databases (Medline, EMBASE, Cochrane Library, CINAHL, Web of Sciences, PDQ-Evidence, WHO’s Global Research, LILACS, and Epistemonikos) were searched from December 1, 2019, to March 24, 2020. Systematic reviews analyzing primary studies of COVID-19 were included. Two authors independently undertook screening, selection, extraction (data on clinical symptoms, prevalence, pharmacological and non-pharmacological interventions, diagnostic test assessment, laboratory, and radiological findings), and quality assessment (AMSTAR 2). A meta-analysis was performed of the prevalence of clinical outcomes.

Eighteen systematic reviews were included; one was empty (did not identify any relevant study). Using AMSTAR 2, confidence in the results of all 18 reviews was rated as “critically low”. Identified symptoms of COVID-19 were (range values of point estimates): fever (82–95%), cough with or without sputum (58–72%), dyspnea (26–59%), myalgia or muscle fatigue (29–51%), sore throat (10–13%), headache (8–12%) and gastrointestinal complaints (5–9%). Severe symptoms were more common in men. Elevated C-reactive protein and lactate dehydrogenase, and slightly elevated aspartate and alanine aminotransferase, were commonly described. Thrombocytopenia and elevated levels of procalcitonin and cardiac troponin I were associated with severe disease. A frequent finding on chest imaging was uni- or bilateral multilobar ground-glass opacity. A single review investigated the impact of medication (chloroquine) but found no verifiable clinical data. All-cause mortality ranged from 0.3 to 13.9%.

Conclusions

In this overview of systematic reviews, we analyzed evidence from the first 18 systematic reviews that were published after the emergence of COVID-19. However, confidence in the results of all reviews was “critically low”. Thus, systematic reviews that were published early on in the pandemic were of questionable usefulness. Even during public health emergencies, studies and systematic reviews should adhere to established methodological standards.

Peer Review reports

The spread of the “Severe Acute Respiratory Coronavirus 2” (SARS-CoV-2), the causal agent of COVID-19, was characterized as a pandemic by the World Health Organization (WHO) in March 2020 and has triggered an international public health emergency [ 1 ]. The numbers of confirmed cases and deaths due to COVID-19 are rapidly escalating, counting in millions [ 2 ], causing massive economic strain, and escalating healthcare and public health expenses [ 3 , 4 ].

The research community has responded by publishing an impressive number of scientific reports related to COVID-19. The world was alerted to the new disease at the beginning of 2020 [ 1 ], and by mid-March 2020, more than 2000 articles had been published on COVID-19 in scholarly journals, with 25% of them containing original data [ 5 ]. The living map of COVID-19 evidence, curated by the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), contained more than 40,000 records by February 2021 [ 6 ]. More than 100,000 records on PubMed were labeled as “SARS-CoV-2 literature, sequence, and clinical content” by February 2021 [ 7 ].

Due to publication speed, the research community has voiced concerns regarding the quality and reproducibility of evidence produced during the COVID-19 pandemic, warning of the potential damaging approach of “publish first, retract later” [ 8 ]. It appears that these concerns are not unfounded, as it has been reported that COVID-19 articles were overrepresented in the pool of retracted articles in 2020 [ 9 ]. These concerns about inadequate evidence are of major importance because they can lead to poor clinical practice and inappropriate policies [ 10 ].

Systematic reviews are a cornerstone of today’s evidence-informed decision-making. By synthesizing all relevant evidence regarding a particular topic, systematic reviews reflect the current scientific knowledge. Systematic reviews are considered to be at the highest level in the hierarchy of evidence and should be used to make informed decisions. However, with high numbers of systematic reviews of different scope and methodological quality being published, overviews of multiple systematic reviews that assess their methodological quality are essential [ 11 , 12 , 13 ]. An overview of systematic reviews helps identify and organize the literature and highlights areas of priority in decision-making.

In this overview of systematic reviews, we aimed to summarize and critically appraise systematic reviews of coronavirus disease (COVID-19) in humans that were available at the beginning of the pandemic.

Methodology

Research question.

This overview’s primary objective was to summarize and critically appraise systematic reviews that assessed any type of primary clinical data from patients infected with SARS-CoV-2. Our research question was purposefully broad because we wanted to analyze as many systematic reviews as possible that were available early following the COVID-19 outbreak.

Study design

We conducted an overview of systematic reviews. The idea for this overview originated in a protocol for a systematic review submitted to PROSPERO (CRD42020170623), which indicated a plan to conduct an overview.

Overviews of systematic reviews use explicit and systematic methods for searching and identifying multiple systematic reviews addressing related research questions in the same field to extract and analyze evidence across important outcomes. Overviews of systematic reviews are in principle similar to systematic reviews of interventions, but the unit of analysis is a systematic review [ 14 , 15 , 16 ].

We used the overview methodology instead of other evidence synthesis methods to allow us to collate and appraise multiple systematic reviews on this topic, and to extract and analyze their results across relevant topics [ 17 ]. The overview and meta-analysis of systematic reviews allowed us to investigate the methodological quality of included studies, summarize results, and identify specific areas of available or limited evidence, thereby strengthening the current understanding of this novel disease and guiding future research [ 13 ].

A reporting guideline for overviews of reviews is currently under development, i.e., Preferred Reporting Items for Overviews of Reviews (PRIOR) [ 18 ]. As the PRIOR checklist is still not published, this study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 statement [ 19 ]. The methodology used in this review was adapted from the Cochrane Handbook for Systematic Reviews of Interventions and also followed established methodological considerations for analyzing existing systematic reviews [ 14 ].

Approval of a research ethics committee was not necessary as the study analyzed only publicly available articles.

Eligibility criteria

Systematic reviews were included if they analyzed primary data from patients infected with SARS-CoV-2 as confirmed by RT-PCR or another pre-specified diagnostic technique. Eligible reviews covered all topics related to COVID-19 including, but not limited to, those that reported clinical symptoms, diagnostic methods, therapeutic interventions, laboratory findings, or radiological results. Both full manuscripts and abbreviated versions, such as letters, were eligible.

No restrictions were imposed on the design of the primary studies included within the systematic reviews, the last search date, whether the review included meta-analyses or language. Reviews related to SARS-CoV-2 and other coronaviruses were eligible, but from those reviews, we analyzed only data related to SARS-CoV-2.

No consensus definition exists for a systematic review [ 20 ], and debates continue about the defining characteristics of a systematic review [ 21 ]. Cochrane’s guidance for overviews of reviews recommends setting pre-established criteria for making decisions around inclusion [ 14 ]. That is supported by a recent scoping review about guidance for overviews of systematic reviews [ 22 ].

Thus, for this study, we defined a systematic review as a research report which searched for primary research studies on a specific topic using an explicit search strategy, had a detailed description of the methods with explicit inclusion criteria provided, and provided a summary of the included studies either in narrative or quantitative format (such as a meta-analysis). Cochrane and non-Cochrane systematic reviews were considered eligible for inclusion, with or without meta-analysis, and regardless of the study design, language restriction and methodology of the included primary studies. To be eligible for inclusion, reviews had to be clearly analyzing data related to SARS-CoV-2 (associated or not with other viruses). We excluded narrative reviews without those characteristics as these are less likely to be replicable and are more prone to bias.

Scoping reviews and rapid reviews were eligible for inclusion in this overview if they met our pre-defined inclusion criteria noted above. We included reviews that addressed SARS-CoV-2 and other coronaviruses if they reported separate data regarding SARS-CoV-2.

Information sources

Nine databases were searched for eligible records published between December 1, 2019, and March 24, 2020: Cochrane Database of Systematic Reviews via Cochrane Library, PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Sciences, LILACS (Latin American and Caribbean Health Sciences Literature), PDQ-Evidence, WHO’s Global Research on Coronavirus Disease (COVID-19), and Epistemonikos.

The comprehensive search strategy for each database is provided in Additional file 1 and was designed and conducted in collaboration with an information specialist. All retrieved records were primarily processed in EndNote, where duplicates were removed, and records were then imported into the Covidence platform [ 23 ]. In addition to database searches, we screened reference lists of reviews included after screening records retrieved via databases.

Study selection

All searches, screening of titles and abstracts, and record selection, were performed independently by two investigators using the Covidence platform [ 23 ]. Articles deemed potentially eligible were retrieved for full-text screening carried out independently by two investigators. Discrepancies at all stages were resolved by consensus. During the screening, records published in languages other than English were translated by a native/fluent speaker.

Data collection process

We custom designed a data extraction table for this study, which was piloted by two authors independently. Data extraction was performed independently by two authors. Conflicts were resolved by consensus or by consulting a third researcher.

We extracted the following data: article identification data (authors’ name and journal of publication), search period, number of databases searched, population or settings considered, main results and outcomes observed, and number of participants. From Web of Science (Clarivate Analytics, Philadelphia, PA, USA), we extracted journal rank (quartile) and Journal Impact Factor (JIF).

We categorized the following as primary outcomes: all-cause mortality, need for and length of mechanical ventilation, length of hospitalization (in days), admission to intensive care unit (yes/no), and length of stay in the intensive care unit.

The following outcomes were categorized as exploratory: diagnostic methods used for detection of the virus, male to female ratio, clinical symptoms, pharmacological and non-pharmacological interventions, laboratory findings (full blood count, liver enzymes, C-reactive protein, d-dimer, albumin, lipid profile, serum electrolytes, blood vitamin levels, glucose levels, and any other important biomarkers), and radiological findings (using radiography, computed tomography, magnetic resonance imaging or ultrasound).

We also collected data on reporting guidelines and requirements for the publication of systematic reviews and meta-analyses from journal websites where included reviews were published.

Quality assessment in individual reviews

Two researchers independently assessed the reviews’ quality using the “A MeaSurement Tool to Assess Systematic Reviews 2 (AMSTAR 2)”. We acknowledge that the AMSTAR 2 was created as “a critical appraisal tool for systematic reviews that include randomized or non-randomized studies of healthcare interventions, or both” [ 24 ]. However, since AMSTAR 2 was designed for systematic reviews of intervention trials, and we included additional types of systematic reviews, we adjusted some AMSTAR 2 ratings and reported these in Additional file 2 .

Adherence to each item was rated as follows: yes, partial yes, no, or not applicable (such as when a meta-analysis was not conducted). The overall confidence in the results of the review is rated as “critically low”, “low”, “moderate” or “high”, according to the AMSTAR 2 guidance based on seven critical domains, which are items 2, 4, 7, 9, 11, 13, 15 as defined by AMSTAR 2 authors [ 24 ]. We reported our adherence ratings for transparency of our decision with accompanying explanations, for each item, in each included review.

One of the included systematic reviews was conducted by some members of this author team [ 25 ]. This review was initially assessed independently by two authors who were not co-authors of that review to prevent the risk of bias in assessing this study.

Synthesis of results

For data synthesis, we prepared a table summarizing each systematic review. Graphs illustrating the mortality rate and clinical symptoms were created. We then prepared a narrative summary of the methods, findings, study strengths, and limitations.

For analysis of the prevalence of clinical outcomes, we extracted data on the number of events and the total number of patients to perform proportional meta-analysis using RStudio© software, with the “meta” package (version 4.9–6), using the “metaprop” function for reviews that did not perform a meta-analysis, excluding case studies because of the absence of variance. For reviews that did not perform a meta-analysis, we presented pooled results of proportions with their respective confidence intervals (95%) by the inverse variance method with a random-effects model, using the DerSimonian-Laird estimator for τ 2 . We adjusted data using Freeman-Tukey double arcosen transformation. Confidence intervals were calculated using the Clopper-Pearson method for individual studies. We created forest plots using the RStudio© software, with the “metafor” package (version 2.1–0) and “forest” function.

Managing overlapping systematic reviews

Some of the included systematic reviews that address the same or similar research questions may include the same primary studies in overviews. Including such overlapping reviews may introduce bias when outcome data from the same primary study are included in the analyses of an overview multiple times. Thus, in summaries of evidence, multiple-counting of the same outcome data will give data from some primary studies too much influence [ 14 ]. In this overview, we did not exclude overlapping systematic reviews because, according to Cochrane’s guidance, it may be appropriate to include all relevant reviews’ results if the purpose of the overview is to present and describe the current body of evidence on a topic [ 14 ]. To avoid any bias in summary estimates associated with overlapping reviews, we generated forest plots showing data from individual systematic reviews, but the results were not pooled because some primary studies were included in multiple reviews.

Our search retrieved 1063 publications, of which 175 were duplicates. Most publications were excluded after the title and abstract analysis ( n = 860). Among the 28 studies selected for full-text screening, 10 were excluded for the reasons described in Additional file 3 , and 18 were included in the final analysis (Fig. 1 ) [ 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ]. Reference list screening did not retrieve any additional systematic reviews.

PRISMA flow diagram

Characteristics of included reviews

Summary features of 18 systematic reviews are presented in Table 1 . They were published in 14 different journals. Only four of these journals had specific requirements for systematic reviews (with or without meta-analysis): European Journal of Internal Medicine, Journal of Clinical Medicine, Ultrasound in Obstetrics and Gynecology, and Clinical Research in Cardiology . Two journals reported that they published only invited reviews ( Journal of Medical Virology and Clinica Chimica Acta ). Three systematic reviews in our study were published as letters; one was labeled as a scoping review and another as a rapid review (Table 2 ).

All reviews were published in English, in first quartile (Q1) journals, with JIF ranging from 1.692 to 6.062. One review was empty, meaning that its search did not identify any relevant studies; i.e., no primary studies were included [ 36 ]. The remaining 17 reviews included 269 unique studies; the majority ( N = 211; 78%) were included in only a single review included in our study (range: 1 to 12). Primary studies included in the reviews were published between December 2019 and March 18, 2020, and comprised case reports, case series, cohorts, and other observational studies. We found only one review that included randomized clinical trials [ 38 ]. In the included reviews, systematic literature searches were performed from 2019 (entire year) up to March 9, 2020. Ten systematic reviews included meta-analyses. The list of primary studies found in the included systematic reviews is shown in Additional file 4 , as well as the number of reviews in which each primary study was included.

Population and study designs

Most of the reviews analyzed data from patients with COVID-19 who developed pneumonia, acute respiratory distress syndrome (ARDS), or any other correlated complication. One review aimed to evaluate the effectiveness of using surgical masks on preventing transmission of the virus [ 36 ], one review was focused on pediatric patients [ 34 ], and one review investigated COVID-19 in pregnant women [ 37 ]. Most reviews assessed clinical symptoms, laboratory findings, or radiological results.

Systematic review findings

The summary of findings from individual reviews is shown in Table 2 . Overall, all-cause mortality ranged from 0.3 to 13.9% (Fig. 2 ).

A meta-analysis of the prevalence of mortality

Clinical symptoms

Seven reviews described the main clinical manifestations of COVID-19 [ 26 , 28 , 29 , 34 , 35 , 39 , 41 ]. Three of them provided only a narrative discussion of symptoms [ 26 , 34 , 35 ]. In the reviews that performed a statistical analysis of the incidence of different clinical symptoms, symptoms in patients with COVID-19 were (range values of point estimates): fever (82–95%), cough with or without sputum (58–72%), dyspnea (26–59%), myalgia or muscle fatigue (29–51%), sore throat (10–13%), headache (8–12%), gastrointestinal disorders, such as diarrhea, nausea or vomiting (5.0–9.0%), and others (including, in one study only: dizziness 12.1%) (Figs. 3 , 4 , 5 , 6 , 7 , 8 and 9 ). Three reviews assessed cough with and without sputum together; only one review assessed sputum production itself (28.5%).

A meta-analysis of the prevalence of fever

A meta-analysis of the prevalence of cough

A meta-analysis of the prevalence of dyspnea

A meta-analysis of the prevalence of fatigue or myalgia

A meta-analysis of the prevalence of headache

A meta-analysis of the prevalence of gastrointestinal disorders

A meta-analysis of the prevalence of sore throat

Diagnostic aspects

Three reviews described methodologies, protocols, and tools used for establishing the diagnosis of COVID-19 [ 26 , 34 , 38 ]. The use of respiratory swabs (nasal or pharyngeal) or blood specimens to assess the presence of SARS-CoV-2 nucleic acid using RT-PCR assays was the most commonly used diagnostic method mentioned in the included studies. These diagnostic tests have been widely used, but their precise sensitivity and specificity remain unknown. One review included a Chinese study with clinical diagnosis with no confirmation of SARS-CoV-2 infection (patients were diagnosed with COVID-19 if they presented with at least two symptoms suggestive of COVID-19, together with laboratory and chest radiography abnormalities) [ 34 ].

Therapeutic possibilities

Pharmacological and non-pharmacological interventions (supportive therapies) used in treating patients with COVID-19 were reported in five reviews [ 25 , 27 , 34 , 35 , 38 ]. Antivirals used empirically for COVID-19 treatment were reported in seven reviews [ 25 , 27 , 34 , 35 , 37 , 38 , 41 ]; most commonly used were protease inhibitors (lopinavir, ritonavir, darunavir), nucleoside reverse transcriptase inhibitor (tenofovir), nucleotide analogs (remdesivir, galidesivir, ganciclovir), and neuraminidase inhibitors (oseltamivir). Umifenovir, a membrane fusion inhibitor, was investigated in two studies [ 25 , 35 ]. Possible supportive interventions analyzed were different types of oxygen supplementation and breathing support (invasive or non-invasive ventilation) [ 25 ]. The use of antibiotics, both empirically and to treat secondary pneumonia, was reported in six studies [ 25 , 26 , 27 , 34 , 35 , 38 ]. One review specifically assessed evidence on the efficacy and safety of the anti-malaria drug chloroquine [ 27 ]. It identified 23 ongoing trials investigating the potential of chloroquine as a therapeutic option for COVID-19, but no verifiable clinical outcomes data. The use of mesenchymal stem cells, antifungals, and glucocorticoids were described in four reviews [ 25 , 34 , 35 , 38 ].

Laboratory and radiological findings

Of the 18 reviews included in this overview, eight analyzed laboratory parameters in patients with COVID-19 [ 25 , 29 , 30 , 32 , 33 , 34 , 35 , 39 ]; elevated C-reactive protein levels, associated with lymphocytopenia, elevated lactate dehydrogenase, as well as slightly elevated aspartate and alanine aminotransferase (AST, ALT) were commonly described in those eight reviews. Lippi et al. assessed cardiac troponin I (cTnI) [ 25 ], procalcitonin [ 32 ], and platelet count [ 33 ] in COVID-19 patients. Elevated levels of procalcitonin [ 32 ] and cTnI [ 30 ] were more likely to be associated with a severe disease course (requiring intensive care unit admission and intubation). Furthermore, thrombocytopenia was frequently observed in patients with complicated COVID-19 infections [ 33 ].

Chest imaging (chest radiography and/or computed tomography) features were assessed in six reviews, all of which described a frequent pattern of local or bilateral multilobar ground-glass opacity [ 25 , 34 , 35 , 39 , 40 , 41 ]. Those six reviews showed that septal thickening, bronchiectasis, pleural and cardiac effusions, halo signs, and pneumothorax were observed in patients suffering from COVID-19.

Quality of evidence in individual systematic reviews

Table 3 shows the detailed results of the quality assessment of 18 systematic reviews, including the assessment of individual items and summary assessment. A detailed explanation for each decision in each review is available in Additional file 5 .

Using AMSTAR 2 criteria, confidence in the results of all 18 reviews was rated as “critically low” (Table 3 ). Common methodological drawbacks were: omission of prospective protocol submission or publication; use of inappropriate search strategy: lack of independent and dual literature screening and data-extraction (or methodology unclear); absence of an explanation for heterogeneity among the studies included; lack of reasons for study exclusion (or rationale unclear).

Risk of bias assessment, based on a reported methodological tool, and quality of evidence appraisal, in line with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method, were reported only in one review [ 25 ]. Five reviews presented a table summarizing bias, using various risk of bias tools [ 25 , 29 , 39 , 40 , 41 ]. One review analyzed “study quality” [ 37 ]. One review mentioned the risk of bias assessment in the methodology but did not provide any related analysis [ 28 ].

This overview of systematic reviews analyzed the first 18 systematic reviews published after the onset of the COVID-19 pandemic, up to March 24, 2020, with primary studies involving more than 60,000 patients. Using AMSTAR-2, we judged that our confidence in all those reviews was “critically low”. Ten reviews included meta-analyses. The reviews presented data on clinical manifestations, laboratory and radiological findings, and interventions. We found no systematic reviews on the utility of diagnostic tests.

Symptoms were reported in seven reviews; most of the patients had a fever, cough, dyspnea, myalgia or muscle fatigue, and gastrointestinal disorders such as diarrhea, nausea, or vomiting. Olfactory dysfunction (anosmia or dysosmia) has been described in patients infected with COVID-19 [ 43 ]; however, this was not reported in any of the reviews included in this overview. During the SARS outbreak in 2002, there were reports of impairment of the sense of smell associated with the disease [ 44 , 45 ].

The reported mortality rates ranged from 0.3 to 14% in the included reviews. Mortality estimates are influenced by the transmissibility rate (basic reproduction number), availability of diagnostic tools, notification policies, asymptomatic presentations of the disease, resources for disease prevention and control, and treatment facilities; variability in the mortality rate fits the pattern of emerging infectious diseases [ 46 ]. Furthermore, the reported cases did not consider asymptomatic cases, mild cases where individuals have not sought medical treatment, and the fact that many countries had limited access to diagnostic tests or have implemented testing policies later than the others. Considering the lack of reviews assessing diagnostic testing (sensitivity, specificity, and predictive values of RT-PCT or immunoglobulin tests), and the preponderance of studies that assessed only symptomatic individuals, considerable imprecision around the calculated mortality rates existed in the early stage of the COVID-19 pandemic.

Few reviews included treatment data. Those reviews described studies considered to be at a very low level of evidence: usually small, retrospective studies with very heterogeneous populations. Seven reviews analyzed laboratory parameters; those reviews could have been useful for clinicians who attend patients suspected of COVID-19 in emergency services worldwide, such as assessing which patients need to be reassessed more frequently.

All systematic reviews scored poorly on the AMSTAR 2 critical appraisal tool for systematic reviews. Most of the original studies included in the reviews were case series and case reports, impacting the quality of evidence. Such evidence has major implications for clinical practice and the use of these reviews in evidence-based practice and policy. Clinicians, patients, and policymakers can only have the highest confidence in systematic review findings if high-quality systematic review methodologies are employed. The urgent need for information during a pandemic does not justify poor quality reporting.

We acknowledge that there are numerous challenges associated with analyzing COVID-19 data during a pandemic [ 47 ]. High-quality evidence syntheses are needed for decision-making, but each type of evidence syntheses is associated with its inherent challenges.

The creation of classic systematic reviews requires considerable time and effort; with massive research output, they quickly become outdated, and preparing updated versions also requires considerable time. A recent study showed that updates of non-Cochrane systematic reviews are published a median of 5 years after the publication of the previous version [ 48 ].

Authors may register a review and then abandon it [ 49 ], but the existence of a public record that is not updated may lead other authors to believe that the review is still ongoing. A quarter of Cochrane review protocols remains unpublished as completed systematic reviews 8 years after protocol publication [ 50 ].

Rapid reviews can be used to summarize the evidence, but they involve methodological sacrifices and simplifications to produce information promptly, with inconsistent methodological approaches [ 51 ]. However, rapid reviews are justified in times of public health emergencies, and even Cochrane has resorted to publishing rapid reviews in response to the COVID-19 crisis [ 52 ]. Rapid reviews were eligible for inclusion in this overview, but only one of the 18 reviews included in this study was labeled as a rapid review.

Ideally, COVID-19 evidence would be continually summarized in a series of high-quality living systematic reviews, types of evidence synthesis defined as “ a systematic review which is continually updated, incorporating relevant new evidence as it becomes available ” [ 53 ]. However, conducting living systematic reviews requires considerable resources, calling into question the sustainability of such evidence synthesis over long periods [ 54 ].

Research reports about COVID-19 will contribute to research waste if they are poorly designed, poorly reported, or simply not necessary. In principle, systematic reviews should help reduce research waste as they usually provide recommendations for further research that is needed or may advise that sufficient evidence exists on a particular topic [ 55 ]. However, systematic reviews can also contribute to growing research waste when they are not needed, or poorly conducted and reported. Our present study clearly shows that most of the systematic reviews that were published early on in the COVID-19 pandemic could be categorized as research waste, as our confidence in their results is critically low.

Our study has some limitations. One is that for AMSTAR 2 assessment we relied on information available in publications; we did not attempt to contact study authors for clarifications or additional data. In three reviews, the methodological quality appraisal was challenging because they were published as letters, or labeled as rapid communications. As a result, various details about their review process were not included, leading to AMSTAR 2 questions being answered as “not reported”, resulting in low confidence scores. Full manuscripts might have provided additional information that could have led to higher confidence in the results. In other words, low scores could reflect incomplete reporting, not necessarily low-quality review methods. To make their review available more rapidly and more concisely, the authors may have omitted methodological details. A general issue during a crisis is that speed and completeness must be balanced. However, maintaining high standards requires proper resourcing and commitment to ensure that the users of systematic reviews can have high confidence in the results.

Furthermore, we used adjusted AMSTAR 2 scoring, as the tool was designed for critical appraisal of reviews of interventions. Some reviews may have received lower scores than actually warranted in spite of these adjustments.

Another limitation of our study may be the inclusion of multiple overlapping reviews, as some included reviews included the same primary studies. According to the Cochrane Handbook, including overlapping reviews may be appropriate when the review’s aim is “ to present and describe the current body of systematic review evidence on a topic ” [ 12 ], which was our aim. To avoid bias with summarizing evidence from overlapping reviews, we presented the forest plots without summary estimates. The forest plots serve to inform readers about the effect sizes for outcomes that were reported in each review.

Several authors from this study have contributed to one of the reviews identified [ 25 ]. To reduce the risk of any bias, two authors who did not co-author the review in question initially assessed its quality and limitations.

Finally, we note that the systematic reviews included in our overview may have had issues that our analysis did not identify because we did not analyze their primary studies to verify the accuracy of the data and information they presented. We give two examples to substantiate this possibility. Lovato et al. wrote a commentary on the review of Sun et al. [ 41 ], in which they criticized the authors’ conclusion that sore throat is rare in COVID-19 patients [ 56 ]. Lovato et al. highlighted that multiple studies included in Sun et al. did not accurately describe participants’ clinical presentations, warning that only three studies clearly reported data on sore throat [ 56 ].

In another example, Leung [ 57 ] warned about the review of Li, L.Q. et al. [ 29 ]: “ it is possible that this statistic was computed using overlapped samples, therefore some patients were double counted ”. Li et al. responded to Leung that it is uncertain whether the data overlapped, as they used data from published articles and did not have access to the original data; they also reported that they requested original data and that they plan to re-do their analyses once they receive them; they also urged readers to treat the data with caution [ 58 ]. This points to the evolving nature of evidence during a crisis.

Our study’s strength is that this overview adds to the current knowledge by providing a comprehensive summary of all the evidence synthesis about COVID-19 available early after the onset of the pandemic. This overview followed strict methodological criteria, including a comprehensive and sensitive search strategy and a standard tool for methodological appraisal of systematic reviews.

In conclusion, in this overview of systematic reviews, we analyzed evidence from the first 18 systematic reviews that were published after the emergence of COVID-19. However, confidence in the results of all the reviews was “critically low”. Thus, systematic reviews that were published early on in the pandemic could be categorized as research waste. Even during public health emergencies, studies and systematic reviews should adhere to established methodological standards to provide patients, clinicians, and decision-makers trustworthy evidence.

Availability of data and materials

All data collected and analyzed within this study are available from the corresponding author on reasonable request.

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Acknowledgments

We thank Catherine Henderson DPhil from Swanscoe Communications for pro bono medical writing and editing support. We acknowledge support from the Covidence Team, specifically Anneliese Arno. We thank the whole International Network of Coronavirus Disease 2019 (InterNetCOVID-19) for their commitment and involvement. Members of the InterNetCOVID-19 are listed in Additional file 6 . We thank Pavel Cerny and Roger Crosthwaite for guiding the team supervisor (IJBN) on human resources management.

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Israel Júnior Borges do Nascimento & Milena Soriano Marcolino

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Israel Júnior Borges do Nascimento

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Dónal P. O’Mathúna

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IJBN conceived the research idea and worked as a project coordinator. DPOM, TCVG, HMA, IW, AM, LP, VTC, IZG, TPP, ANA, SF, NLB and MSM were involved in data curation, formal analysis, investigation, methodology, and initial draft writing. All authors revised the manuscript critically for the content. The author(s) read and approved the final manuscript.

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Supplementary Information

Additional file 1: appendix 1..

Search strategies used in the study.

Additional file 2: Appendix 2.

Adjusted scoring of AMSTAR 2 used in this study for systematic reviews of studies that did not analyze interventions.

Additional file 3: Appendix 3.

List of excluded studies, with reasons.

Additional file 4: Appendix 4.

Table of overlapping studies, containing the list of primary studies included, their visual overlap in individual systematic reviews, and the number in how many reviews each primary study was included.

Additional file 5: Appendix 5.

A detailed explanation of AMSTAR scoring for each item in each review.

Additional file 6: Appendix 6.

List of members and affiliates of International Network of Coronavirus Disease 2019 (InterNetCOVID-19).

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Borges do Nascimento, I.J., O’Mathúna, D.P., von Groote, T.C. et al. Coronavirus disease (COVID-19) pandemic: an overview of systematic reviews. BMC Infect Dis 21 , 525 (2021). https://doi.org/10.1186/s12879-021-06214-4

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Analysis of the COVID-19 pandemic: lessons towards a more effective response to public health emergencies

• Yibeltal Assefa   ORCID: orcid.org/0000-0003-2393-1492 1 ,
• Charles F. Gilks 1 ,
• Simon Reid 1 ,
• Remco van de Pas 2 ,
• Dereje Gedle Gete 1 &
• Wim Van Damme 2  

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The pandemic of Coronavirus Disease 2019 (COVID-19) is a timely reminder of the nature and impact of Public Health Emergencies of International Concern. As of 12 January 2022, there were over 314 million cases and over 5.5 million deaths notified since the start of the pandemic. The COVID-19 pandemic takes variable shapes and forms, in terms of cases and deaths, in different regions and countries of the world. The objective of this study is to analyse the variable expression of COVID-19 pandemic so that lessons can be learned towards an effective public health emergency response.

We conducted a mixed-methods study to understand the heterogeneity of cases and deaths due to the COVID-19 pandemic. Correlation analysis and scatter plot were employed for the quantitative data. We used Spearman’s correlation analysis to determine relationship strength between cases and deaths and socio-economic and health systems. We organized qualitative information from the literature and conducted a thematic analysis to recognize patterns of cases and deaths and explain the findings from the quantitative data.

We have found that regions and countries with high human development index have higher cases and deaths per million population due to COVID-19. This is due to international connectedness and mobility of their population related to trade and tourism, and their vulnerability related to older populations and higher rates of non-communicable diseases. We have also identified that the burden of the pandemic is also variable among high- and middle-income countries due to differences in the governance of the pandemic, fragmentation of health systems, and socio-economic inequities.

The COVID-19 pandemic demonstrates that every country remains vulnerable to public health emergencies. The aspiration towards a healthier and safer society requires that countries develop and implement a coherent and context-specific national strategy, improve governance of public health emergencies, build the capacity of their (public) health systems, minimize fragmentation, and tackle upstream structural issues, including socio-economic inequities. This is possible through a primary health care approach, which ensures provision of universal and equitable promotive, preventive and curative services, through whole-of-government and whole-of-society approaches.

The pandemic of Coronavirus Disease 2019 (COVID-19) is a timely reminder of the nature and impact of emerging infectious diseases that become Public Health Emergency of International Concern (PHEIC) [ 1 ]. The COVID-19 pandemic takes variable shapes and forms in how it affects communities in different regions and countries [ 2 , 3 ]. As of 12 January, 2022, there were over 314 million cases and over 5.5 million deaths notified around the globe since the start of the pandemic. The number of cases per million population ranged from 7410 in Africa to 131,730 in Europe while the number of deaths per million population ranged from 110 in Oceania to 2740 in South America. Case-fatality rates (CFRs) ranged from 0.3% in Oceania to 2.9% in South America [ 4 , 5 ]. Regions and countries with high human development index (HDI), which is a composite index of life expectancy, education, and per capita income indicators [ 6 ], are affected by COVID-19 more than regions with low HDI. North America and Europe together account for 55 and 51% of cases and deaths, respectively. Regions with high HDI are affected by COVID-19 despite their high universal health coverage index (UHCI) and Global Health Security index (GHSI) [ 7 ].

This seems to be a paradox (against the established knowledge that countries with weak (public) health systems capacity will have worse health outcomes) in that the countries with higher UHCI and GHSI have experienced higher burdens of COVID-19 [ 7 ]. The paradox can partially be explained by variations in testing algorithms, capacity for testing, and reporting across different countries. Countries with high HDI have health systems with a high testing capacity; the average testing rate per million population is less than 32, 000 in Africa and 160,000 in Asia while it is more than 800, 000 in HICs (Europe and North America). This enables HICs to identify more confirmed cases that will ostensibly increase the number of reported cases [ 3 ]. Nevertheless, these are insufficient to explain the stark differences between countries with high HDI and those with low HDI. Many countries with high HDI have a high testing rate and a higher proportion of symptomatic and severe cases, which are also associated with higher deaths and CFRs [ 7 ]. On the other hand, there are countries with high HDI that sustain a lower level of the epidemic than others with a similar high HDI. It is, therefore, vital to analyse the heterogeneity of the COVID-19 pandemic and explain why some countries with high HDI, UHCI and GHSI have the highest burden of COVID-19 while others are able to suppress their epidemics and mitigate its impacts.

The objective of this study was to analyse the COVID-19 pandemic and understand its variable expression with the intention to learn lessons for an effective and sustainable response to public health emergencies. We hypothesised that high levels of HDI, UHCI and GHSI are essential but not sufficient to prevent and control COVID-19.

We conducted an explanatory mixed-methods study to understand and explain the heterogeneity of the pandemic around the world. The study integrated quantitative and qualitative secondary data. The following steps were included in the research process: (i) collecting and analysing quantitative epidemiological data, (ii) conducting literature review of qualitative secondary data and (iii) evaluating countries’ pandemic responses to explain the variability in the COVID-19 epidemiological outcomes. The study then illuminated specific factors that were vital towards an effective and sustainable epidemic response.

We used the publicly available secondary data sources from Johns Hopkins University ( https://coronavirus.jhu.edu/data/new-cases ) for COVID-19 and UNDP 2020 HDI report ( http://hdr.undp.org/en/2019-report ) for HDI, demographic and epidemiologic variables. These are open data sources which are regularly updated and utilized by researchers, policy makers and funders. We performed a correlation analysis of the COVID-19 pandemic. We determined the association between COVID-19 cases, severity, deaths and CFRs at the 0.01 and 0.05 levels (2-tailed). We used Spearman’s correlation analysis, as there is no normal distribution of the variables [ 8 ].

The UHCI is calculated as the geometric mean of the coverage of essential services based on 17 tracer indicators from: (1) reproductive, maternal, newborn and child health; (2) infectious diseases; (3) non-communicable diseases; and, (4) service capacity and access and health security [ 9 ]. The GHSI is a composite measure to assess a country’s capability to prevent, detect, and respond to epidemics and pandemics [ 10 ].

We then conducted a document review to explain the epidemic patterns in different countries. Secondary data was obtained from peer-reviewed journals, reputable online news outlets, government reports and publications by public health-related associations, such as the WHO. To explain the variability of COVID-19 across countries, a list of 14 indicators was established to systematically assess country’s preparedness, actual pandemic response, and overall socioeconomic and demographic profile in the context of COVID-19. The indicators used in this study include: 1) Universal Health Coverage Index, 2) public health capacity, 3) Global Health Security Index, 4) International Health Regulation, 5) leadership, governance and coordination of response, 6) community mobilization and engagement, 7) communication, 8) testing, quarantines and social distancing, 9) medical services at primary health care facilities and hospitals, 10) multisectoral actions, 11) social protection services, 12) absolute and relative poverty status, 13) demography, and 14) burden of communicable and non-communicable diseases. These indicators are based on our previous studies and recommendation from the World Health Organization [ 3 , 4 ]. We conducted thematic analysis and synthesis to identify the factors that may explain the heterogeneity of the pandemic.

Heterogeneity of COVID-19 cases and deaths around the world: what can explain it?

Table  1 indicates that the pandemic of COVID-19 is heterogeneous around regions of the world. Figure  1 also shows that there is a strong and significant correlation between HDI and globalisation (with an increase in trade and tourism as proxy indicators) and a corresponding strong and significant correlation with COVID-19 burden.

Human development index and its correlates associated with COVID-19 in 189 countries*

Globalisation and pandemics interact in various ways, including through international trade and mobility, which can lead to multiple waves of infections [ 11 ]. In at least the first waves of the pandemic, countries with high import and export of consumer goods, food products and tourism have high number of cases, severe cases, deaths and CFRs. Countries with high HDI are at a higher risk of importing (and exporting) COVID-19 due to high mobility linked to trade and tourism, which are drivers of the economy. These may have led to multiple introductions of COVID-19 into these countries before border closures.

The COVID-19 pandemic was first identified in China, which is central to the global network of trade, from where it spread to all parts of the world, especially those countries with strong links with China [ 12 ]. The epidemic then spread to Europe. There is very strong regional dimension to manufacturing and trading, which could be facilitate the spread of the virus. China is the heart of ‘Factory Asia’; Italy is in the heart of ‘Factory Europe’; the United States is the heart of ‘Factory North America’; and Brazil is the heart of ‘Factory Latin America’ [ 13 ]. These are the countries most affected by COVID-19 during the first wave of the pandemic [ 2 , 3 , 14 ].

It is also important to note that two-third of the countries currently reporting more than a million cases are middle-income countries (MICs), which are not only major emerging market economies but also regional political powers, including the BRICS countries (Brazil, Russia, India and South Africa) [ 3 , 15 ]. These countries participate in the global economy, with business travellers and tourists. They also have good domestic transportation networks that facilitate the internal spread of the virus. The strategies that helped these countries to become emerging markets also put them at greater risk for importing and spreading COVID-19 due to their connectivity to the rest of the world.

In addition, countries with high HDI may be more significantly impacted by COVID-19 due to the higher proportion of the elderly and higher rates of non-communicable diseases. Figure 1 shows that there is a strong and significant correlation between HDI and demographic transition (high proportion of old-age population) and epidemiologic transition (high proportion of the population with non-communicable diseases). Countries with a higher proportion of people older than 65 years and NCDs (compared to communicable diseases) have higher burden of COVID-19 [ 16 , 17 , 18 , 19 , 20 ]. Evidence has consistently shown a higher risk of severe COVID-19 in older individuals and those with underlying health conditions [ 21 , 22 , 23 , 24 , 25 ]. CFR is age-dependent; it is highest in persons aged ≥85 years (10 to 27%), followed by those among persons aged 65–84 years (3 to 11%), and those among persons aged 55-64 years (1 to 3%) [ 26 ].

On the other hand, regions and countries with low HDI have, to date, experienced less severe epidemics. For instance, as of January 12, 2022, the African region has recorded about 10.3 million cases and 233,000 deaths– far lower than other regions of the world (Table 1 ) [ 27 ]. These might be due to lower testing rates in Africa, where only 6.5% of the population has been tested for the virus [ 14 , 28 ], and a greater proportion of infections may remain asymptomatic [ 29 ]. Indeed, the results from sero-surveys in Africa show that more than 80% of people infected with the virus were asymptomatic compared to an estimated 40-50% asymptomatic infections in HICs [ 30 , 31 ]. Moreover, there is a weak vital registration system in the region indicating that reports might be underestimating and underreporting the disease burden [ 32 ]. However, does this fully explain the differences observed between Africa and Europe or the Americas?

Other possible factors that may explain the lower rates of cases and deaths in Africa include: (1) Africa is less internationally connected than other regions; (2) the imposition of early strict lockdowns in many African countries, at a time when case numbers were relatively small, limited the number of imported cases further [ 2 , 33 , 34 ]; (3) relatively poor road network has also limited the transmission of the virus to and in rural areas [ 35 ]; (4) a significant proportion of the population resides in rural areas while those in urban areas spend a lot of their time mostly outdoors; (5) only about 3% of Africans are over the age of 65 (so only a small proportion are at risk of severe COVID-19) [ 36 ]; (6) lower prevalence of NCDs, as disease burden in Africa comes from infectious causes, including coronaviruses, which may also have cross-immunity that may reduce the risk of developing symptomatic cases [ 37 ]; and (7) relative high temperature (a major source of vitamin D which influences COVID-19 infection and mortality) in the region may limit the spread of the virus [ 38 , 39 ]. We argue that a combination of all these factors might explain the lower COVID-19 burden in Africa.

The early and timely efforts by African leaders should not be underestimated. The African Union, African CDC, and WHO convened an emergency meeting of all African ministers of health to establish an African taskforce to develop and implement a coordinated continent-wide strategy focusing on: laboratory; surveillance; infection prevention and control; clinical treatment of people with severe COVID-19; risk communication; and supply chain management [ 40 ]. In April 2021, African Union and Africa CDC launched the Partnerships for African Vaccine Manufacturing (PAVM), framework to expanding Africa’s vaccine manufacturing capacity for health security [ 41 ].

Heterogeneity of the pandemic among countries with high HDI: what can explain it?

Figures 2 and 3 illustrate the variability of cases and deaths due to the COVID-19 pandemic across high-income countries (HICs). Contrary to the overall positive correlation between high HDI and cases, deaths and fatality rates due to COVID-19, there are outlier HICs, which have been able to control the epidemic. Several HICs, such as New Zealand, Australia, South Korea, Japan, Denmark, Iceland, and Norway, managed to contain their epidemics (Figs. 2 and 3 ) [ 15 , 42 , 43 ]. It is important to note that most of these countries (especially the island states) have far less cross-border mobility than other HICs.

Scatter plot of COVID-19 cases per million population in countries with high human development index (> 0.70)

Scatter plot of COVID-19 deaths per million population in countries with high human development index (> 0.70)

HICs that have been successful at controlling their epidemics have similar characteristics, which are related to governance of the response [ 44 ], synergy between UHC and GHS, and existing relative socio-economic equity in the country. Governance and leadership is a crucial factor to explain the heterogeneity of the epidemic among countries with high HDI [ 45 ]. There has been substantial variation in the nature and timing of the public health responses implemented [ 46 ]. Adaptable and agile governments seem better able to respond to their epidemics [ 47 , 48 ]. Countries that have fared the best are the ones with good governance and public support [ 49 ]. Countries with an absence of coherent leadership and social trust have worse outcomes than countries with collective action, whether in a democracy or autocracy, and rapid mobilisation of resources [ 50 ]. The erosion of trust in the United States government has hurt the country’s ability to respond to the COVID-19 crisis [ 51 , 52 ]. The editors of the New England Journal of Medicine argued that the COVID-19 crisis has produced a test of leadership; but, the leaders in the United States had failed that test [ 47 ].

COVID-19 has exposed the fragility of health systems, not only in the public health and primary care, but also in acute and long-term care systems [ 49 ]. Fragmentation of health systems, defined here to mean inadequate synergy and/ or integration between GHS and UHC, is typical of countries most affected by the COVID-19 pandemic. Even though GHS and UHC agendas are convergent and interdependent, they tend to have different policies and practices [ 53 ]. The United States has the highest index for GHS preparedness; however, it has reported the world’s highest number of COVID-19 cases and deaths due to its greatly fragmented health system [ 54 , 55 ]. Countries with health systems and policies that are able to integrate International Health Regulations (IHR) core capacities with primary health care (PHC) services have been effective at mitigating the effects of COVID-19 [ 50 , 53 ]. Australia has been able to control its COVID-19 epidemic through a comprehensive primary care response, including protection of vulnerable people, provision of treatment and support services to affected people, continuity of regular healthcare services, protection and support of PHC workers and primary care services, and provision of mental health services to the community and the primary healthcare workforce [ 56 ]. Strict implementation of public health and social intervention together with UHC systems have ensured swift control of the epidemics in Singapore, South Korea, and Thailand [ 57 ].

The heterogeneity of cases and deaths, due to COVID-19, is also explained by differences in levels of socio-economic inequalities, which increase susceptibility to acquiring the infection and disease progression as well as worsening of health outcomes [ 58 ]. COVID-19 has been a stress test for public services and social protection systems. There is a higher burden of COVID-19 in Black, Asian and Minority Ethnic individuals due to socio-economic inequities in HICs [ 59 , 60 ]. Poor people are more likely to live in overcrowded accommodation, are more likely to have unstable work conditions and incomes, have comorbidities associated with poverty and precarious living conditions, and reduced access to health care [ 59 ].

The epidemiology of COVID-19 is also variable across MICs, with HDI between 0.70 and 0.85, around the world. Overall, the epidemic in MICs is exacerbated by the rapid demographic and epidemiologic transitions as well as high prevalence of obesity. While India and Brazil witnessed rapidly increasing rates of cases and deaths, China, Thailand, Vietnam have experienced a relatively lower disease burden [ 15 ]. This heterogeneity may be attributed to a number of factors, including governance, communication and service delivery. Thailand, China and Vietnam have implemented a national harmonized strategic response with decentralized implementation through provincial and district authorities [ 61 ]. Thailand increased its testing capacity from two to over 200 certified facilities that could process between 10,000 to 100,000 tests per day; moreover, over a million village health volunteers in Thailand supported primary health services [ 62 , 63 ]. China’s swift and decisive actions enabled the country to contain its epidemic though there was an initial delay in detecting the disease. China has been able to contain its epidemic through community-based measures, very high public cooperation and social mobilization, strategic lockdown and isolation, multi-sector action [ 64 ]. Overall, multi-level governance (effective and decisive leadership and accountability) of the response, together with coordination of public health and socio-economic services, and high levels of citizen adherence to personal protection, have enabled these countries to successfully contain their epidemics [ 61 , 65 , 66 ].

On the other hand, the Brazilian leadership was denounced for its failure to establish a national surveillance network early in the pandemic. In March 2020, the health minister was reported to have stated that mass testing was a waste of public funding, and to have advised against it [ 67 ]. This was considered as a sign of a collapse of public health leadership, characterized by ignorance, neoliberal authoritarianism [ 68 ]. There were also gaps in the public health capacity in different municipalities, which varied greatly, with a considerable number of Brazilian regions receiving less funding from the federal government due to political tension [ 69 ]. The epidemic has a disproportionate adverse burden on states and municipalities with high socio-economic vulnerability, exacerbated by the deep social and economic inequalities in Brazil [ 70 ].

India is another middle-income country with a high burden of COVID-19. It was one of the countries to institute strict measures in the early phase of the pandemic [ 71 , 72 ]. However, the government eased restrictions after the claim that India had beaten the pandemic, which lead to a rapid increase in disease incidence. Indeed, on 12 January 2022, India reported 36 million cumulative cases and almost 485,000 total deaths [ 15 ]. The second wave of the epidemic in India exposed weaknesses in governance and inadequacies in the country’s health and other social systems [ 73 ]. The nature of the Indian federation, which is highly centripetal, has prevented state and local governments from tailoring a policy response to suit local needs. A centralized one-size-fits-all strategy has been imposed despite high variations in resources, health systems capacity, and COVID-19 epidemics across states [ 74 ]. There were also loose social distancing and mask wearing, mass political rallies and religious events [ 75 ]. Rapid community transmission driven by high population density and multigenerational households has been a feature of the current wave in India [ 76 ]. In addition, several new variants of the virus, including the UK (B.1.1.7), the South Africa (20H/501Y or B.1.351), and Brazil (P.1), alongside a newly identified Indian variant (B.1.617), are circulating in India and have been implicated as factors in the second wave of the pandemic [ 75 , 76 ].

Heterogeneity of case-fatality rates around the world: what can explain it?

The pandemic is characterized by variable CFRs across regions and countries that are negatively associated with HDI (Fig.  1 ). The results presented in Fig.  4 show that the proportion of elderly population and rate of obesity are important factors which are positively associated with CFR. On the other hand, UHC, IHR capacity and other indicators of health systems capacity (health workforce density and hospital beds) are negatively associated with the CFR (Figs. 1 and 4 ).

Correlates of COVID-19 cases, deaths and case-fatality rates in 189 countries

The evidence from several research indicates that heterogeneity can be explained by several factors, including differences in age-pyramid, socio-economic status, access to health services, or rates of undiagnosed infections. Differences in age-pyramid may explain some of the observed variation in epidemic severity and CFR between countries [ 77 ]. CFRs across countries look similar when taking age into account [ 78 ]. The elderly and other vulnerable populations in Africa and Asia are at a similar risk as populations in Europe and Americas [ 79 ]. Data from European countries suggest that as high as 57% of all deaths have happened in care homes and many deaths in the US have also occurred in nursing homes. On the other hand, in countries such as Mexico and India, individuals < 65 years contributed the majority of deaths [ 80 ].

Nevertheless, CFR also depends on the quality of hospital care, which can be used to judge the health system capacity, including the availability of healthcare workers, resources, and facilities, which affects outcomes [ 81 ]. The CFR can increase if there is a surge of infected patients, which adds to the strain on the health system [ 82 ]. COVID-19 fatality rates are affected by numerous health systems factors, including bed capacity, existence and capacity of intensive care unit (ICU), and critical care resources (such as oxygen and dexamethasone) in a hospital. Regions and countries with high HDI have a greater number of acute care facilities, ICU, and hospital bed capacities compared to lower HDI regions and countries [ 83 ]. Differences in health systems capacity could explain why North America and Europe, which have experienced much greater number of cases and deaths per million population, reported lower CFRs than the Southern American and the African regions, partly also due to limited testing capacity in these regions (Table 1 ) [ 84 , 85 , 86 ]. The higher CFR in Southern America can be explained by the relatively lower health systems surge capacity that could not adequately respond to the huge demand for health services [ 69 , 86 ]. The COVID-19 pandemic has highlighted existing health systems’ weaknesses, which are not able to effectively prepare for and respond to PHEs [ 87 ]. The high CFRs in the region are also exacerbated by the high social inequalities [ 69 ].

On the other hand, countries in Asia recorded lower CFRs (~ 1.4%) despite sharing many common risk factors (including overcrowding and poverty, weak health system capacity etc) with Africa. The Asian region shares many similar protective factors to the African region. They have been able to minimize their CFR by suppressing the transmission of the virus and flattening the epidemic curve of COVID-19 cases and deaths. Nevertheless, the epidemic in India is likely to be different because it has exceeded the health system capacity to respond and provide basic medical care and medical supplies such as oxygen [ 88 ]. Overall, many Asian countries were able to withstand the transmission of the virus and its effect due to swift action by governments in the early days of the pandemic despite the frequency of travel between China and neighbouring countries such as Hong Kong, Taiwan and Singapore [ 89 ]. This has helped them to contain the pandemic to ensure case numbers remain within their health systems capacity. These countries have benefited from their experience in the past in the prevention and control of epidemics [ 90 ].

There are a number of issues with the use of the CFR to compare the management of the pandemic between countries and regions [ 91 ], as it does not depict the true picture of the mortality burden of the pandemic. A major challenge with accurate calculation of the CFR is the denominator on number of identified cases, as asymptomatic infections and patients with mild symptoms are frequently left untested, and therefore omitted from CFR calculations. Testing might not be widely available, and proactive contact tracing and containment might not be employed, resulting in a smaller denominator, and skewing to a higher CFR [ 82 ]. It is, therefore, far more relevant to estimate infection fatality rate (IFR), the proportion of all infected individuals who have died due to the infection [ 91 ], which is central to understanding the public health impact of the pandemic and the required policies for its prevention and control [ 92 ].

Estimates of prevalence based on sero-surveys, which includes asymptomatic and mildly symptomatic infections, can be used to estimate IFR [ 93 ]. In a systematic review of 17 studies, seroprevalence rates ranged from 0.22% in Brazil to 53% in Argentina [ 94 ]. The review also identified that the seroprevalence estimate was higher than the cumulative reported case incidence, by a factor between 1.5 times in Germany to 717 times in Iran, in all but two studies (0.56 times in Brazil and 0.88 times in Denmark) [ 94 , 95 ]. The difference between seroprevalence and cumulative reported cases might be due to asymptomatic cases, atypical or pauci-symptomatic cases, or the lack of access to and uptake of testing [ 94 ]. There is only a modest gap between the estimated number of infections from seroprevalence surveys and the cumulative reported cases in regions with relatively thorough symptom-based testing. Much of the gap between reported cases and seroprevalence is likely to be due to undiagnosed symptomatic or asymptomatic infections [ 94 ].

Collateral effects of the COVID-19 pandemic

It is important to note that the pandemic has significant collateral effects on the provision of essential health services, in addition to the direct health effects [ 96 ]. Disruptions in the provision of essential health services, due to COVID-19, were reported by nearly all countries, though it is more so in lower-income than higher-income countries [ 97 , 98 ]. The biggest impact reported is on provision of day-to-day primary care to prevent and manage some of the most common health problems [ 99 ].

The causes of disruptions in service delivery were a mix of demand and supply factors [ 100 ]. Countries reported that just over one-third of services were disrupted due to health workforce-related reasons (the most common causes of service disruptions), supply chains, community mistrust and fears of becoming infected, and financial challenge s[ 101 ]. Cognizant of the disruptive effects of the pandemic, countries have reorganized their health system.

Countries with better response to COVID-19 have mobilized, trained and reallocated their health workforce in addition to hiring new staff, using volunteers and medical trainees and mobilizing retirees [ 102 ]. Several strategies have also been implemented to mitigate disruptions in service delivery and utilization, including: triaging to identify the most urgent patient needs, and postponing elective medical procedures; switching to alternative models of care, such as providing more home-based care and telemedicine [ 101 ].

This study identifies that the COVID-19 pandemic, in terms f cases and deaths, is heterogeneous around the world. This variability is explained by differences in vulnerability, preparedness, and response. It confirms that a high level of HDI, UHCI and GHSI are essential but not sufficient to control epidemics [ 103 ]. An effective response to public health emergencies requires a joint and reinforcing implementation of UHC, health emergency and disease control priorities [ 104 , 105 ], as well as good governance and social protection systems [ 106 ]. Important lessons have been learned to cope better with the COVID-19 pandemic and future emerging or re-emerging pandemics. Countries should strengthen health systems, minimize fragmentation of public health, primary care and secondary care, and improve coordination with other sectors. The pandemic has exposed the health effects of longstanding social inequities, which should be addressed through policies and actions to tackle vulnerability in living and working conditions [ 106 ].

The shift in the pandemic epicentre from high-income to MICs was observed in the second global wave of the pandemic. This is due to in part to the large-scale provision of vaccines in HICs [ 15 ] as well as the limitations in the response in LMICs, including inadequate testing, quarantine and isolation, contact tracing, and social distancing. The second wave of the pandemic in low- and middle-income countries spread more rapidly than the first wave and affected younger and healthier populations due to factors, including poor government decision making, citizen behaviour, and the emergence of highly transmissible SARS-CoV-2 variants [ 107 ]. It has become catastrophic in some MICs to prematurely relax key public health measures, such as mask wearing, physical distancing, and hand hygiene [ 108 ].

There is consensus that global vaccination is essential to ending the pandemic. Universal and equitable vaccine delivery, implemented with high volume, speed and quality, is vital for an effective and sustainable response to the current pandemic and future public health emergencies. There is, however, ongoing concern regarding access to COVID-19 vaccines in low-income countries [ 109 ]. Moreover, there is shortage of essential supplies, including oxygen, which has had a major impact on the prevention and control of the pandemic. It is, therefore, vital to transform (through good governance and financing mechanisms) the ACT-A platform to deliver vaccines, therapeutics, diagnostics, and other essential supplies [ 109 , 110 ]. The global health community has the responsibility to address these inequalities so that we can collectively end the pandemic [ 107 ].

The Omicron variant has a huge role in the current wave around the world despite high vaccine coverage [ 111 ]. Omicron appears to spread rapidly around the world ever since it was identified in November 2021 [ 112 ]. It becomes obvious that vaccination alone is inadequate for controlling the infection. This has changed our understanding of the COVID-19 pandemic endgame. The emergence of new variants of concern and their spread around the world has highlighted the importance of combination prevention, including high vaccination coverage in combination with other public health prevention measures [ 112 ].

Overall, the COVID-19 pandemic and the response to it emphasise valuable lessons towards an effective and sustainable response to public health emergencies. We argue that the PHC approach captures the different preparedness and response strategies required towards ensuring health security and UHC [ 113 ]. The PHC approach enables countries to progressively realize universal access to good-quality health services (including essential public health functions) and equity, empower people and communities, strengthen multi-sectoral policy and action for health, and enhance good governance [ 114 ]. These are essential in the prevention and control of public health emergencies, to suppress transmission, and reduce morbidity and mortality [ 115 ]. Access to high-quality primary care is at the foundation of any strong health system [ 116 ], which will, in turn, have effect on containing the epidemic, and reducing mortality and CFR [ 117 ]. Australia is a good example in this regard because it has implemented a comprehensive PHC approach in combination with border restrictions to ensure health system capacity is not exceeded [ 56 ]. The PHC approach will enable countries to develop and implement a context-specific health strategy, enhance governance, strengthen their (public) health systems, minimize segmentation and fragmentation, and tackle upstream structural issues, including discrimination and socio-economic inequities [ 118 ]. This is the type of public health approach (comprehensive, equity-focused and participatory) that will be effective and sustainable to tackle public health emergencies in the twenty-first century [ 119 , 120 ]. In addition, it is vital to transform the global and regional health systems, with a strong IHR and an empowered WHO at the apex [ 121 ]. We contend that this is the way towards a healthier and safer country, region and world.

The COVID-19 pandemic demonstrates that the world remains vulnerable to public health emergencies with significant health and other socio-economic impacts. The pandemic takes variable shapes and forms across regions and countries around the world. The pandemic has impacted countries with inadequate governance of the epidemic, fragmentation of their health systems and higher socio-economic inequities more than others. We argue that adequate response to public health emergencies requires that countries develop and implement a context-specific national strategy, enhance governance of public health emergency, build the capacity of their health systems, minimize fragmentation, and tackle socio-economic inequities. This is possible through a PHC approach that provides universal access to good-quality health services through empowered communities and multi-sectoral policy and action for health development. The pandemic has affected every corner of the world; it has demonstrated that “no country is safe unless other countries are safe”. This should be a call for a strong global health system based on the values of justice and capabilities for health.

Availability of data and materials

Data are available in a public, open access repository: Johns Hopkins University: https://coronavirus.jhu.edu/data/new-cases , and UNDP: http://hdr.undp.org/en/2019-report ; WHO: https://www.who.int/publications/m/item/weekly-epidemiological-update%2D%2D-22-december-2020

Abbreviations

Coronavirus Disease 2019

Case-fatality rates

Human development index

Universal health coverage index

Global Health Security index

High-income countries

Middle-income countries

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Assefa, Y., Gilks, C.F., Reid, S. et al. Analysis of the COVID-19 pandemic: lessons towards a more effective response to public health emergencies. Global Health 18 , 10 (2022). https://doi.org/10.1186/s12992-022-00805-9

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• http://orcid.org/0000-0003-1512-4471 Emily Long 1 ,
• Susan Patterson 1 ,
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• http://orcid.org/0000-0001-7342-4566 Raquel Bosó Pérez 1 ,
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• Correspondence to Dr Emily Long, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow G3 7HR, UK; emily.long{at}glasgow.ac.uk

This essay examines key aspects of social relationships that were disrupted by the COVID-19 pandemic. It focuses explicitly on relational mechanisms of health and brings together theory and emerging evidence on the effects of the COVID-19 pandemic to make recommendations for future public health policy and recovery. We first provide an overview of the pandemic in the UK context, outlining the nature of the public health response. We then introduce four distinct domains of social relationships: social networks, social support, social interaction and intimacy, highlighting the mechanisms through which the pandemic and associated public health response drastically altered social interactions in each domain. Throughout the essay, the lens of health inequalities, and perspective of relationships as interconnecting elements in a broader system, is used to explore the varying impact of these disruptions. The essay concludes by providing recommendations for longer term recovery ensuring that the social relational cost of COVID-19 is adequately considered in efforts to rebuild.

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https://doi.org/10.1136/jech-2021-216690

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Introduction

Infectious disease pandemics, including SARS and COVID-19, demand intrapersonal behaviour change and present highly complex challenges for public health. 1 A pandemic of an airborne infection, spread easily through social contact, assails human relationships by drastically altering the ways through which humans interact. In this essay, we draw on theories of social relationships to examine specific ways in which relational mechanisms key to health and well-being were disrupted by the COVID-19 pandemic. Relational mechanisms refer to the processes between people that lead to change in health outcomes.

At the time of writing, the future surrounding COVID-19 was uncertain. Vaccine programmes were being rolled out in countries that could afford them, but new and more contagious variants of the virus were also being discovered. The recovery journey looked long, with continued disruption to social relationships. The social cost of COVID-19 was only just beginning to emerge, but the mental health impact was already considerable, 2 3 and the inequality of the health burden stark. 4 Knowledge of the epidemiology of COVID-19 accrued rapidly, but evidence of the most effective policy responses remained uncertain.

The initial response to COVID-19 in the UK was reactive and aimed at reducing mortality, with little time to consider the social implications, including for interpersonal and community relationships. The terminology of ‘social distancing’ quickly became entrenched both in public and policy discourse. This equation of physical distance with social distance was regrettable, since only physical proximity causes viral transmission, whereas many forms of social proximity (eg, conversations while walking outdoors) are minimal risk, and are crucial to maintaining relationships supportive of health and well-being.

The aim of this essay is to explore four key relational mechanisms that were impacted by the pandemic and associated restrictions: social networks, social support, social interaction and intimacy. We use relational theories and emerging research on the effects of the COVID-19 pandemic response to make three key recommendations: one regarding public health responses; and two regarding social recovery. Our understanding of these mechanisms stems from a ‘systems’ perspective which casts social relationships as interdependent elements within a connected whole. 5

Social networks

Social networks characterise the individuals and social connections that compose a system (such as a workplace, community or society). Social relationships range from spouses and partners, to coworkers, friends and acquaintances. They vary across many dimensions, including, for example, frequency of contact and emotional closeness. Social networks can be understood both in terms of the individuals and relationships that compose the network, as well as the overall network structure (eg, how many of your friends know each other).

Social networks show a tendency towards homophily, or a phenomenon of associating with individuals who are similar to self. 6 This is particularly true for ‘core’ network ties (eg, close friends), while more distant, sometimes called ‘weak’ ties tend to show more diversity. During the height of COVID-19 restrictions, face-to-face interactions were often reduced to core network members, such as partners, family members or, potentially, live-in roommates; some ‘weak’ ties were lost, and interactions became more limited to those closest. Given that peripheral, weaker social ties provide a diversity of resources, opinions and support, 7 COVID-19 likely resulted in networks that were smaller and more homogenous.

Such changes were not inevitable nor necessarily enduring, since social networks are also adaptive and responsive to change, in that a disruption to usual ways of interacting can be replaced by new ways of engaging (eg, Zoom). Yet, important inequalities exist, wherein networks and individual relationships within networks are not equally able to adapt to such changes. For example, individuals with a large number of newly established relationships (eg, university students) may have struggled to transfer these relationships online, resulting in lost contacts and a heightened risk of social isolation. This is consistent with research suggesting that young adults were the most likely to report a worsening of relationships during COVID-19, whereas older adults were the least likely to report a change. 8

Lastly, social connections give rise to emergent properties of social systems, 9 where a community-level phenomenon develops that cannot be attributed to any one member or portion of the network. For example, local area-based networks emerged due to geographic restrictions (eg, stay-at-home orders), resulting in increases in neighbourly support and local volunteering. 10 In fact, research suggests that relationships with neighbours displayed the largest net gain in ratings of relationship quality compared with a range of relationship types (eg, partner, colleague, friend). 8 Much of this was built from spontaneous individual interactions within local communities, which together contributed to the ‘community spirit’ that many experienced. 11 COVID-19 restrictions thus impacted the personal social networks and the structure of the larger networks within the society.

Social support

Social support, referring to the psychological and material resources provided through social interaction, is a critical mechanism through which social relationships benefit health. In fact, social support has been shown to be one of the most important resilience factors in the aftermath of stressful events. 12 In the context of COVID-19, the usual ways in which individuals interact and obtain social support have been severely disrupted.

One such disruption has been to opportunities for spontaneous social interactions. For example, conversations with colleagues in a break room offer an opportunity for socialising beyond one’s core social network, and these peripheral conversations can provide a form of social support. 13 14 A chance conversation may lead to advice helpful to coping with situations or seeking formal help. Thus, the absence of these spontaneous interactions may mean the reduction of indirect support-seeking opportunities. While direct support-seeking behaviour is more effective at eliciting support, it also requires significantly more effort and may be perceived as forceful and burdensome. 15 The shift to homeworking and closure of community venues reduced the number of opportunities for these spontaneous interactions to occur, and has, second, focused them locally. Consequently, individuals whose core networks are located elsewhere, or who live in communities where spontaneous interaction is less likely, have less opportunity to benefit from spontaneous in-person supportive interactions.

However, alongside this disruption, new opportunities to interact and obtain social support have arisen. The surge in community social support during the initial lockdown mirrored that often seen in response to adverse events (eg, natural disasters 16 ). COVID-19 restrictions that confined individuals to their local area also compelled them to focus their in-person efforts locally. Commentators on the initial lockdown in the UK remarked on extraordinary acts of generosity between individuals who belonged to the same community but were unknown to each other. However, research on adverse events also tells us that such community support is not necessarily maintained in the longer term. 16

Meanwhile, online forms of social support are not bound by geography, thus enabling interactions and social support to be received from a wider network of people. Formal online social support spaces (eg, support groups) existed well before COVID-19, but have vastly increased since. While online interactions can increase perceived social support, it is unclear whether remote communication technologies provide an effective substitute from in-person interaction during periods of social distancing. 17 18 It makes intuitive sense that the usefulness of online social support will vary by the type of support offered, degree of social interaction and ‘online communication skills’ of those taking part. Youth workers, for instance, have struggled to keep vulnerable youth engaged in online youth clubs, 19 despite others finding a positive association between amount of digital technology used by individuals during lockdown and perceived social support. 20 Other research has found that more frequent face-to-face contact and phone/video contact both related to lower levels of depression during the time period of March to August 2020, but the negative effect of a lack of contact was greater for those with higher levels of usual sociability. 21 Relatedly, important inequalities in social support exist, such that individuals who occupy more socially disadvantaged positions in society (eg, low socioeconomic status, older people) tend to have less access to social support, 22 potentially exacerbated by COVID-19.

Social and interactional norms

Interactional norms are key relational mechanisms which build trust, belonging and identity within and across groups in a system. Individuals in groups and societies apply meaning by ‘approving, arranging and redefining’ symbols of interaction. 23 A handshake, for instance, is a powerful symbol of trust and equality. Depending on context, not shaking hands may symbolise a failure to extend friendship, or a failure to reach agreement. The norms governing these symbols represent shared values and identity; and mutual understanding of these symbols enables individuals to achieve orderly interactions, establish supportive relationship accountability and connect socially. 24 25

Physical distancing measures to contain the spread of COVID-19 radically altered these norms of interaction, particularly those used to convey trust, affinity, empathy and respect (eg, hugging, physical comforting). 26 As epidemic waves rose and fell, the work to negotiate these norms required intense cognitive effort; previously taken-for-granted interactions were re-examined, factoring in current restriction levels, own and (assumed) others’ vulnerability and tolerance of risk. This created awkwardness, and uncertainty, for example, around how to bring closure to an in-person interaction or convey warmth. The instability in scripted ways of interacting created particular strain for individuals who already struggled to encode and decode interactions with others (eg, those who are deaf or have autism spectrum disorder); difficulties often intensified by mask wearing. 27

Large social gatherings—for example, weddings, school assemblies, sporting events—also present key opportunities for affirming and assimilating interactional norms, building cohesion and shared identity and facilitating cooperation across social groups. 28 Online ‘equivalents’ do not easily support ‘social-bonding’ activities such as singing and dancing, and rarely enable chance/spontaneous one-on-one conversations with peripheral/weaker network ties (see the Social networks section) which can help strengthen bonds across a larger network. The loss of large gatherings to celebrate rites of passage (eg, bar mitzvah, weddings) has additional relational costs since these events are performed by and for communities to reinforce belonging, and to assist in transitioning to new phases of life. 29 The loss of interaction with diverse others via community and large group gatherings also reduces intergroup contact, which may then tend towards more prejudiced outgroup attitudes. While online interaction can go some way to mimicking these interaction norms, there are key differences. A sense of anonymity, and lack of in-person emotional cues, tends to support norms of polarisation and aggression in expressing differences of opinion online. And while online platforms have potential to provide intergroup contact, the tendency of much social media to form homogeneous ‘echo chambers’ can serve to further reduce intergroup contact. 30 31

Intimacy relates to the feeling of emotional connection and closeness with other human beings. Emotional connection, through romantic, friendship or familial relationships, fulfils a basic human need 32 and strongly benefits health, including reduced stress levels, improved mental health, lowered blood pressure and reduced risk of heart disease. 32 33 Intimacy can be fostered through familiarity, feeling understood and feeling accepted by close others. 34

Intimacy via companionship and closeness is fundamental to mental well-being. Positively, the COVID-19 pandemic has offered opportunities for individuals to (re)connect and (re)strengthen close relationships within their household via quality time together, following closure of many usual external social activities. Research suggests that the first full UK lockdown period led to a net gain in the quality of steady relationships at a population level, 35 but amplified existing inequalities in relationship quality. 35 36 For some in single-person households, the absence of a companion became more conspicuous, leading to feelings of loneliness and lower mental well-being. 37 38 Additional pandemic-related relational strain 39 40 resulted, for some, in the initiation or intensification of domestic abuse. 41 42

Physical touch is another key aspect of intimacy, a fundamental human need crucial in maintaining and developing intimacy within close relationships. 34 Restrictions on social interactions severely restricted the number and range of people with whom physical affection was possible. The reduction in opportunity to give and receive affectionate physical touch was not experienced equally. Many of those living alone found themselves completely without physical contact for extended periods. The deprivation of physical touch is evidenced to take a heavy emotional toll. 43 Even in future, once physical expressions of affection can resume, new levels of anxiety over germs may introduce hesitancy into previously fluent blending of physical and verbal intimate social connections. 44

The pandemic also led to shifts in practices and norms around sexual relationship building and maintenance, as individuals adapted and sought alternative ways of enacting sexual intimacy. This too is important, given that intimate sexual activity has known benefits for health. 45 46 Given that social restrictions hinged on reducing household mixing, possibilities for partnered sexual activity were primarily guided by living arrangements. While those in cohabiting relationships could potentially continue as before, those who were single or in non-cohabiting relationships generally had restricted opportunities to maintain their sexual relationships. Pornography consumption and digital partners were reported to increase since lockdown. 47 However, online interactions are qualitatively different from in-person interactions and do not provide the same opportunities for physical intimacy.

Recommendations and conclusions

In the sections above we have outlined the ways in which COVID-19 has impacted social relationships, showing how relational mechanisms key to health have been undermined. While some of the damage might well self-repair after the pandemic, there are opportunities inherent in deliberative efforts to build back in ways that facilitate greater resilience in social and community relationships. We conclude by making three recommendations: one regarding public health responses to the pandemic; and two regarding social recovery.

Recommendation 1: explicitly count the relational cost of public health policies to control the pandemic

Effective handling of a pandemic recognises that social, economic and health concerns are intricately interwoven. It is clear that future research and policy attention must focus on the social consequences. As described above, policies which restrict physical mixing across households carry heavy and unequal relational costs. These include for individuals (eg, loss of intimate touch), dyads (eg, loss of warmth, comfort), networks (eg, restricted access to support) and communities (eg, loss of cohesion and identity). Such costs—and their unequal impact—should not be ignored in short-term efforts to control an epidemic. Some public health responses—restrictions on international holiday travel and highly efficient test and trace systems—have relatively small relational costs and should be prioritised. At a national level, an earlier move to proportionate restrictions, and investment in effective test and trace systems, may help prevent escalation of spread to the point where a national lockdown or tight restrictions became an inevitability. Where policies with relational costs are unavoidable, close attention should be paid to the unequal relational impact for those whose personal circumstances differ from normative assumptions of two adult families. This includes consideration of whether expectations are fair (eg, for those who live alone), whether restrictions on social events are equitable across age group, religious/ethnic groupings and social class, and also to ensure that the language promoted by such policies (eg, households; families) is not exclusionary. 48 49 Forethought to unequal impacts on social relationships should thus be integral to the work of epidemic preparedness teams.

Recommendation 2: intelligently balance online and offline ways of relating

A key ingredient for well-being is ‘getting together’ in a physical sense. This is fundamental to a human need for intimate touch, physical comfort, reinforcing interactional norms and providing practical support. Emerging evidence suggests that online ways of relating cannot simply replace physical interactions. But online interaction has many benefits and for some it offers connections that did not exist previously. In particular, online platforms provide new forms of support for those unable to access offline services because of mobility issues (eg, older people) or because they are geographically isolated from their support community (eg, lesbian, gay, bisexual, transgender and queer (LGBTQ) youth). Ultimately, multiple forms of online and offline social interactions are required to meet the needs of varying groups of people (eg, LGBTQ, older people). Future research and practice should aim to establish ways of using offline and online support in complementary and even synergistic ways, rather than veering between them as social restrictions expand and contract. Intelligent balancing of online and offline ways of relating also pertains to future policies on home and flexible working. A decision to switch to wholesale or obligatory homeworking should consider the risk to relational ‘group properties’ of the workplace community and their impact on employees’ well-being, focusing in particular on unequal impacts (eg, new vs established employees). Intelligent blending of online and in-person working is required to achieve flexibility while also nurturing supportive networks at work. Intelligent balance also implies strategies to build digital literacy and minimise digital exclusion, as well as coproducing solutions with intended beneficiaries.

Recommendation 3: build stronger and sustainable localised communities

In balancing offline and online ways of interacting, there is opportunity to capitalise on the potential for more localised, coherent communities due to scaled-down travel, homeworking and local focus that will ideally continue after restrictions end. There are potential economic benefits after the pandemic, such as increased trade as home workers use local resources (eg, coffee shops), but also relational benefits from stronger relationships around the orbit of the home and neighbourhood. Experience from previous crises shows that community volunteer efforts generated early on will wane over time in the absence of deliberate work to maintain them. Adequately funded partnerships between local government, third sector and community groups are required to sustain community assets that began as a direct response to the pandemic. Such partnerships could work to secure green spaces and indoor (non-commercial) meeting spaces that promote community interaction. Green spaces in particular provide a triple benefit in encouraging physical activity and mental health, as well as facilitating social bonding. 50 In building local communities, small community networks—that allow for diversity and break down ingroup/outgroup views—may be more helpful than the concept of ‘support bubbles’, which are exclusionary and less sustainable in the longer term. Rigorously designed intervention and evaluation—taking a systems approach—will be crucial in ensuring scale-up and sustainability.

The dramatic change to social interaction necessitated by efforts to control the spread of COVID-19 created stark challenges but also opportunities. Our essay highlights opportunities for learning, both to ensure the equity and humanity of physical restrictions, and to sustain the salutogenic effects of social relationships going forward. The starting point for capitalising on this learning is recognition of the disruption to relational mechanisms as a key part of the socioeconomic and health impact of the pandemic. In recovery planning, a general rule is that what is good for decreasing health inequalities (such as expanding social protection and public services and pursuing green inclusive growth strategies) 4 will also benefit relationships and safeguard relational mechanisms for future generations. Putting this into action will require political will.

Ethics statements

Patient consent for publication.

Not required.

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• ↵ (ONS), O.f.N.S., Domestic abuse during the coronavirus (COVID-19) pandemic, England and Wales . Available: https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/domesticabuseduringthecoronaviruscovid19pandemicenglandandwales/november2020
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Twitter @karenmaxSPHSU, @Mark_McCann, @Rwilsonlowe, @KMitchinGlasgow

Contributors EL and KM led on the manuscript conceptualisation, review and editing. SP, KM, CB, RBP, RL, MM, JR, KS and RW-L contributed to drafting and revising the article. All authors assisted in revising the final draft.

Funding The research reported in this publication was supported by the Medical Research Council (MC_UU_00022/1, MC_UU_00022/3) and the Chief Scientist Office (SPHSU11, SPHSU14). EL is also supported by MRC Skills Development Fellowship Award (MR/S015078/1). KS and MM are also supported by a Medical Research Council Strategic Award (MC_PC_13027).

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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Introduction - Pandemic Preparedness | Lessons From COVID-19

Introduction.

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On December 31, 2019, the World Health Organization (WHO) contacted China about media reports of a cluster of viral pneumonias in Wuhan, later attributed to a coronavirus, now named SARS-CoV-2 . By January 30, 2020, scarcely a month later, WHO declared the virus to be a public health emergency of international concern (PHEIC)—the highest alarm the organization can sound. Thirty days more and the pandemic was well underway; the coronavirus had spread to more than seventy countries and territories on six continents, and there were roughly ninety thousand confirmed cases worldwide of COVID-19, the disease caused by the coronavirus.

The COVID-19 pandemic is far from over and could yet evolve in unanticipated ways, but one of its most important lessons is already clear: preparation and early execution are essential in detecting, containing, and rapidly responding to and mitigating the spread of potentially dangerous emerging infectious diseases. The ability to marshal early action depends on nations and global institutions being prepared for the worst-case scenario of a severe pandemic and ready to execute on that preparedness The COVID-19 pandemic is far from over and could yet evolve in unanticipated ways, but one of its most important lessons is already clear: preparation and early execution are essential in detecting, containing, and rapidly responding to and mitigating the spread of potentially dangerous emerging infectious diseases. The ability to marshal early action depends on nations and global institutions being prepared for the worst-case scenario of a severe pandemic and ready to execute on that preparedness before that worst-case outcome is certain.

The rapid spread of the coronavirus and its devastating death toll and economic harm have revealed a failure of global and U.S. domestic preparedness and implementation, a lack of cooperation and coordination across nations, a breakdown of compliance with established norms and international agreements, and a patchwork of partial and mishandled responses. This pandemic has demonstrated the difficulty of responding effectively to emerging outbreaks in a context of growing geopolitical rivalry abroad and intense political partisanship at home.

Pandemic preparedness is a global public good. Infectious disease threats know no borders, and dangerous pathogens that circulate unabated anywhere are a risk everywhere. As the pandemic continues to unfold across the United States and world, the consequences of inadequate preparation and implementation are abundantly clear. Despite decades of various commissions highlighting the threat of global pandemics and international planning for their inevitability, neither the United States nor the broader international system were ready to execute those plans and respond to a severe pandemic. The result is the worst global catastrophe since World War II.

The lessons of this pandemic could go unheeded once life returns to a semblance of normalcy and COVID-19 ceases to menace nations around the globe. The United States and the world risk repeating many of the same mistakes that exacerbated this crisis, most prominently the failure to prioritize global health security, to invest in the essential domestic and international institutions and infrastructure required to achieve it, and to act quickly in executing a coherent response at both the national and the global level.

The goal of this report is to curtail that possibility by identifying what went wrong in the early national and international responses to the coronavirus pandemic and by providing a road map for the United States and the multilateral system to better prepare and execute in future waves of the current pandemic and when the next pandemic threat inevitably emerges. This report endeavors to preempt the next global health challenge before it becomes a disaster.

A Rapid Spread, a Grim Toll, and an Economic Disaster

On January 23, 2020, China’s government began to undertake drastic measures against the coronavirus, imposing a lockdown on Wuhan, a city of ten million people, aggressively testing, and forcibly rounding up potential carriers in makeshift quarantine centers. 1 In the subsequent days and weeks, the Chinese government extended containment to most of the country, sealing off cities and villages and mobilizing tens of thousands of health workers to contain and treat the disease. By the time those interventions began, however, the disease had already spread well beyond the country’s borders.

SARS-CoV-2 is a highly transmissible emerging infectious disease for which no highly effective treatments or vaccines currently exist and against which people have no preexisting immunity. Some nations have been successful so far in containing its spread through public health measures such as testing, contact tracing, and isolation of confirmed and suspected cases. Those nations have managed to keep the number of cases and deaths within their territories low.

More than one hundred countries implemented either a full or a partial shutdown in an effort to contain the spread of the virus and reduce pressure on their health systems. Although these measures to enforce physical distancing slowed the pace of infection, the societal and economic consequences in many nations have been grim. The supply chain for personal protective equipment (PPE), testing kits, and medical equipment such as oxygen treatment equipment and ventilators remains under immense pressure to meet global demand.

If international cooperation in response to COVID-19 has been occurring at the top levels of government, evidence of it has been scant, though technical areas such as data sharing have witnessed some notable successes. Countries have mostly gone their own ways, closing borders and often hoarding medical equipment. More than a dozen nations are competing in a biotechnology arms race to find a vaccine. A proposed international arrangement to ensure timely equitable access to the products of that biomedical innovation has yet to attract the necessary support from many vaccine-manufacturing nations, and many governments are now racing to cut deals with pharmaceutical firms and secure their own supplies.

As of August 31, 2020, the pandemic had infected at least twenty-five million people worldwide and killed at least 850,000 (both likely gross undercounts), including at least six million reported cases and 183,000 deaths in the United States. Meanwhile, the world economy had collapsed into a slump rivaling or surpassing the Great Depression, with unemployment rates averaging 8.4 percent in high-income economies. In the second quarter of 2020, the U.S gross domestic product (GDP) fell 9.5 percent, the largest quarterly decline in the nation’s history. 2

Already in May 2020, the Asia Development Bank estimated that the pandemic would cost the world $5.8 to 8.8 trillion, reducing global GDP in 2020 by 6.4 to 9.7 percent. The ultimate financial cost could be far higher. 3

The United States is among the countries most affected by the coronavirus, with about 24 percent of global cases (as of August 31) but just 4 percent of the world’s population. While many countries in Europe and Asia succeeded in driving down the rate of transmission in spring 2020, the United States experienced new spikes in infections in the summer because the absence of a national strategy left it to individual U.S. states to go their own way on reopening their economies. In the hardest-hit areas, U.S. hospitals with limited spare beds and intensive care unit capacity have struggled to accommodate the surge in COVID-19 patients. Resource-starved local and state public health departments have been unable to keep up with the staggering demand for case identification, contract tracing, and isolation required to contain the coronavirus’s spread.

A Failure to Heed Warnings

• Institute of Medicine, Microbial Threats to Health (1992)
• National Intelligence Estimate, The Global Infectious Disease Threat and Its Implications ...

This failing was not for any lack of warning of the dangers of pandemics. Indeed, many had sounded the alarm over the years. For nearly three decades, countless epidemiologists, public health specialists, intelligence community professionals, national security officials, and think tank experts have underscored the inevitability of a global pandemic of an emerging infectious disease. Starting with the Bill Clinton administration, successive administrations, including the current one, have included pandemic preparedness and response in their national security strategies. The U.S. government, foreign counterparts, and international agencies commissioned multiple scenarios and tabletop exercises that anticipated with uncanny accuracy the trajectory that a major outbreak could take, the complex national and global challenges it would create, and the glaring gaps and limitations in national and international capacity it would reveal.

The global health security community was almost uniformly in agreement that the most significant natural threat to population health and global security would be a respiratory virus—either a novel strain of influenza or a coronavirus that jumped from animals to humans. 4 Yet, for all this foresight and planning, national and international institutions alike have failed to rise to the occasion.

• National Intelligence Estimate, The Global Infectious Disease Threat and Its Implications for the United States (2000)
• Launch of the U.S. Global Health Security Initiative (2001)
• Institute of Medicine, Microbial Threats to Health: Emergence, Detection, and Response (2003)
• Revision of the International Health Regulations (2005)
• World Health Organization, Global Influenza Preparedness Plan (2005)
• Homeland Security Council, National Strategy for Pandemic Influenza (2005)
• U.S. Department of Health and Human Services, National Health Security Strategy of the United States of America (2009)
• U.S. Director of National Intelligence, Worldwide Threat Assessments (2009–2019)
• World Health Organization, Report of Review Committee on the Functioning of the International Health Regulations (2005) in Relation to Pandemic (H1N1) 2009 (2011)
• Pandemic and All-Hazards Preparedness Reauthorization Act of 2013
• Launch of the Global Health Security Agenda (2014)
• Blue Ribbon Study Panel on Biodefense (now Bipartisan Commission on Biodefense) (2015)
• National Security Strategy (2017)
• National Biodefense Strategy (2018)
• Crimson Contagion Simulation (2019)
• Global Preparedness Monitoring Board, A Work at Risk: Annual Report on Global Preparedness for Health Emergencies (2019)
• CSIS Commission, Ending the Cycle of Crisis and Complacency in U.S. Global Health Security (2019)
• U.S. National Health Security Strategy, 2019–2022 (2019)
• Global Health Security Index (2019)

Further Reading

Health-Systems Strengthening in the Age of COVID-19

By Angela E. Micah , Katherine Leach-Kemon , Joseph L Dieleman August 25, 2020

What Is the World Doing to Create a COVID-19 Vaccine?

By Claire Felter Aug 26, 2020

What Does the World Health Organization Do?

By CFR.org Editors Jun 1, 2020

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Research Article

The challenges arising from the COVID-19 pandemic and the way people deal with them. A qualitative longitudinal study

Contributed equally to this work with: Dominika Maison, Diana Jaworska, Dominika Adamczyk, Daria Affeltowicz

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

Affiliation Faculty of Psychology, University of Warsaw, Warsaw, Poland

Roles Formal analysis, Investigation, Writing – original draft, Writing – review & editing

Roles Conceptualization, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Roles Conceptualization, Formal analysis, Investigation, Methodology

• Dominika Maison, 
• Diana Jaworska, 
• Dominika Adamczyk, 
• Daria Affeltowicz

• Published: October 11, 2021
• https://doi.org/10.1371/journal.pone.0258133
• Peer Review
• Reader Comments

The conducted qualitative research was aimed at capturing the biggest challenges related to the beginning of the COVID-19 pandemic. The interviews were carried out in March-June (five stages of the research) and in October (the 6 th stage of the research). A total of 115 in-depth individual interviews were conducted online with 20 respondents, in 6 stages. The results of the analysis showed that for all respondents the greatest challenges and the source of the greatest suffering were: a) limitation of direct contact with people; b) restrictions on movement and travel; c) necessary changes in active lifestyle; d) boredom and monotony; and e) uncertainty about the future.

Citation: Maison D, Jaworska D, Adamczyk D, Affeltowicz D (2021) The challenges arising from the COVID-19 pandemic and the way people deal with them. A qualitative longitudinal study. PLoS ONE 16(10): e0258133. https://doi.org/10.1371/journal.pone.0258133

Editor: Shah Md Atiqul Haq, Shahjalal University of Science and Technology, BANGLADESH

Received: April 6, 2021; Accepted: September 18, 2021; Published: October 11, 2021

Copyright: © 2021 Maison et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files ( S1 Dataset ).

Funding: This work was supported by the Faculty of Psychology, University of Warsaw, Poland from the funds awarded by the Ministry of Science and Higher Education in the form of a subsidy for the maintenance and development of research potential in 2020 (501-D125-01-1250000). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The coronavirus disease (COVID-19), discovered in December 2019 in China, has reached the level of a pandemic and, till June 2021, it has affected more than 171 million people worldwide and caused more than 3.5 million deaths all over the world [ 1 ]. The COVID-19 pandemic as a major health crisis has caught the attention of many researchers, which has led to the creation of a broad quantitative picture of human behavior during the coronavirus outbreak [ 2 – 4 ]. What has been established so far is, among others, the psychological symptoms that can occur as a result of lockdown [ 2 ], and the most common coping strategies [ 5 ]. However, what we still miss is an in-depth understanding of the changes in the ways of coping with challenges over different stages of the pandemic. In the following study, we used a longitudinal qualitative method to investigate the challenges during the different waves of the coronavirus pandemic as well as the coping mechanisms accompanying them.

In Poland, the first patient was diagnosed with COVID-19 on the 4 th March 2020. Since then, the number of confirmed cases has grown to more than 2.8 million and the number of deaths to more than 73,000 (June 2021) [ 1 ]. From mid-March 2020, the Polish government, similarly to many other countries, began to introduce a number of restrictions to limit the spread of the virus. These restrictions had been changing from week to week, causing diverse reactions in people [ 6 ]. It needs to be noted that the reactions to such a dynamic situation cannot be covered by a single study. Therefore, in our study we used qualitative longitudinal research in order to monitor changes in people’s emotions, attitudes, and behavior. So far, few longitudinal studies have been carried out that investigated the various issues related to the COVID-19 pandemic; however, all of them were quantitative [ 7 – 10 ]. The qualitative approach (and especially the use of enabling and projective techniques) allows for an in-depth exploration of respondents’ reactions that goes beyond respondents’ declarations and captures what they are less aware of or even unconscious of. This study consisted of six stages of interviews that were conducted at key moments for the development of the pandemic situation in Poland. The first stage of the study was carried out at the moment of the most severe lockdown and the biggest restrictions (March 2020) and was focused on exploration how did people react to the new uncertain situation. The second stage of the study was conducted at the time when restrictions were extended and the obligation to cover the mouth and nose everywhere outside the household were introduced (middle of April 2020) and was focused at the way how did people deal with the lack of family gatherings over Easter. The third stage of the study was conducted at the moment of announcing the four stages of lifting the restrictions (April 2020) and was focused on people’s reaction to an emerging vision of getting back to normalcy. The fourth stage of the study was carried out, after the introduction of the second stage of lifting the restrictions: shopping malls, hotels, and cultural institutions were gradually being opened (May 2020). The fifth stage of the study was conducted after all four stages of restriction lifting were in place (June 2020). Only the obligation to cover the mouth and nose in public spaces, an order to maintain social distance, as well as the functioning of public places under a sanitary regime were still in effect. During those 5 stages coping strategies with the changes in restrictions were explored. The sixth and last stage of the study was a return to the respondents after a longer break, at the turn of October and November 2020, when the number of coronavirus cases in Poland began to increase rapidly and the media declared “the second wave of the pandemic”. It was the moment when the restrictions were gradually being reintroduced. A full description of the changes occurring in Poland at the time of the study can be found in S1 Table .

The following study is the first qualitative longitudinal study investigating how people cope with the challenges arising from the COVID-19 pandemic at its different stages. The study, although conducted in Poland, shows the universal psychological relations between the challenges posed by the pandemic (and, even more, the restrictions resulting from the pandemic, which were very similar across different countries, not only European) and the ways of dealing with them.

Literature review

The COVID-19 pandemic has led to a global health crisis with severe economic [ 11 ], social [ 3 ], and psychological consequences [ 4 ]. Despite the fact that there were multiple crises in recent years, such as natural disasters, economic crises, and even epidemics, the coronavirus pandemic is the first in 100 years to severely affect the entire world. The economic effects of the COVID-19 pandemic concern an impending global recession caused by the lockdown of non-essential industries and the disruption of production and supply chains [ 11 ]. Social consequences may be visible in many areas, such as the rise in family violence [ 3 ], the ineffectiveness of remote education, and increased food insecurity among impoverished families due to school closures [ 12 ]. According to some experts, the psychological consequences of COVID-19 are the ones that may persist for the longest and lead to a global mental health crisis [ 13 ]. The coronavirus outbreak is generating increased depressive symptoms, stress, anxiety, insomnia, denial, fear, and anger all over the world [ 2 , 14 ]. The economic, social, and psychological problems that people are currently facing are the consequences of novel challenges that have been posed by the pandemic.

The coronavirus outbreak is a novel, uncharted situation that has shaken the world and completely changed the everyday lives of many individuals. Due to the social distancing policy, many people have switched to remote work—in Poland, almost 75% of white-collar workers were fully or partially working from home from mid-March until the end of May 2020 [ 15 ]. School closures and remote learning imposed a new obligation on parents of supervising education, especially with younger children [ 16 ]. What is more, the government order of self-isolation forced people to spend almost all their time at home and limit or completely abandon human encounters. In addition, the deteriorating economic situation was the cause of financial hardship for many people. All these difficulties and challenges arose in the aura of a new, contagious disease with unexplored, long-lasting health effects and not fully known infectivity and lethality [ 17 ]. Dealing with the situation was not facilitated by the phenomenon of global misinformation, called by some experts as the “infodemic”, which may be defined as an overabundance of information that makes it difficult for people to find trustworthy sources and reliable guidance [ 18 ]. Studies have shown that people have multiple ways of reacting to a crisis: from radical and even violent practices, towards individual solutions and depression [ 19 ]. Not only the challenges arising from the COVID-19 pandemic but also the ways of reacting to it and coping with it are issues of paramount importance that are worth investigating.

The reactions to unusual crisis situations may be dependent on dispositional factors, such as trait anxiety or perceived control [ 20 , 21 ]. A study on reactions to Hurricane Hugo has shown that people with higher trait anxiety are more likely to develop posttraumatic symptoms following a natural disaster [ 20 ]. Moreover, lack of perceived control was shown to be positively related to the level of distress during an earthquake in Turkey [ 21 ]. According to some researchers, the COVID-19 crisis and natural disasters have much in common, as the emotions and behavior they cause are based on the same primal human emotion—fear [ 22 ]. Both pandemics and natural disasters disrupt people’s everyday lives and may have severe economic, social and psychological consequences [ 23 ]. However, despite many similarities to natural disasters, COVID-19 is a unique situation—only in 2020, the current pandemic has taken more lives than the world’s combined natural disasters in any of the past twenty years [ 24 ]. It needs to be noted that natural disasters may pose different challenges than health crises and for this reason, they may provoke disparate reactions [ 25 ]. Research on the reactions to former epidemics has shown that avoidance and safety behaviors, such as avoiding going out, visiting crowded places, and visiting hospitals, are widespread at such times [ 26 ]. When it comes to the ways of dealing with the current COVID-19 pandemic, a substantial part of the quantitative research on this issue focuses on coping mechanisms. Studies have shown that the most prevalent coping strategies are highly problem-focused [ 5 ]. Most people tend to listen to expert advice and behave calmly and appropriately in the face of the coronavirus outbreak [ 5 ]. Problem-focused coping is particularly characteristic of healthcare professionals. A study on Chinese nurses has shown that the closer the problem is to the person and the more fear it evokes, the more problem-focused coping strategy is used to deal with it [ 27 ]. On the other hand, a negative coping style that entails risky or aggressive behaviors, such as drug or alcohol use, is also used to deal with the challenges arising from the COVID-19 pandemic [ 28 ]. The factors that are correlated with negative coping include coronavirus anxiety, impairment, and suicidal ideation [ 28 ]. It is worth emphasizing that social support is a very important component of dealing with crises [ 29 ].

Scientists have attempted to systematize the reactions to difficult and unusual situations. One such concept is the “3 Cs” model created by Reich [ 30 ]. It accounts for the general rules of resilience in situations of stress caused by crises, such as natural disasters. The 3 Cs stand for: control (a belief that personal resources can be accessed to achieve valued goals), coherence (the human desire to make meaning of the world), and connectedness (the need for human contact and support) [ 30 ]. Polizzi and colleagues [ 22 ] reviewed this model from the perspective of the current COVID-19 pandemic. The authors claim that natural disasters and COVID-19 pandemic have much in common and therefore, the principles of resilience in natural disaster situations can also be used in the situation of the current pandemic [ 22 ]. They propose a set of coping behaviors that could be useful in times of the coronavirus outbreak, which include control (e.g., planning activities for each day, getting adequate sleep, limiting exposure to the news, and helping others), coherence (e.g., mindfulness and developing a coherent narrative on the event), and connectedness (e.g., establishing new relationships and caring for existing social bonds) [ 22 ].

Current study

The issue of the challenges arising from the current COVID-19 pandemic and the ways of coping with them is complex and many feelings accompanying these experiences may be unconscious and difficult to verbalize. Therefore, in order to explore and understand it deeply, qualitative methodology was applied. Although there were few qualitative studies on the reaction to the pandemic [e.g., 31 – 33 ], they did not capture the perception of the challenges and their changes that arise as the pandemic develops. Since the situation with the COVID-19 pandemic is very dynamic, the reactions to the various restrictions, orders or bans are evolving. Therefore, it was decided to conduct a qualitative longitudinal study with multiple interviews with the same respondents [ 34 ].

The study investigates the challenges arising from the current pandemic and the way people deal with them. The main aim of the project was to capture people’s reactions to the unusual and unexpected situation of the COVID-19 pandemic. Therefore, the project was largely exploratory in nature. Interviews with the participants at different stages of the epidemic allowed us to see a wide spectrum of problems and ways of dealing with them. The conducted study had three main research questions:

• What are the biggest challenges connected to the COVID-19 pandemic and the resulting restrictions?
• How are people dealing with the pandemic challenges?
• What are the ways of coping with the restrictions resulting from a pandemic change as it continues and develops (perspective of first 6 months)?

The study was approved by the institutional review board of the Faculty of Psychology University of Warsaw, Poland. All participants were provided written and oral information about the study, which included that participation was voluntary, that it was possible to withdraw without any consequences at any time, and the precautions that would be taken to protect data confidentiality. Informed consent was obtained from all participants. To ensure confidentiality, quotes are presented only with gender, age, and family status.

The study was based on qualitative methodology: individual in-depth interviews, s which are the appropriate to approach a new and unknown and multithreaded topic which, at the beginning of 2020, was the COVID-19 pandemic. Due to the need to observe respondents’ reactions to the dynamically changing situation of the COVID-19 pandemic, longitudinal study was used where the moderator met on-line with the same respondent several times, at specific time intervals. A longitudinal study was used to capture the changes in opinions, emotions, and behaviors of the respondents resulting from the changes in the external circumstances (qualitative in-depth interview tracking–[ 34 ]).

The study took place from the end of March to October 2020. Due to the epidemiological situation in the country interviews took place online, using the Google Meets online video platform. The audio was recorded and then transcribed. Before taking part in the project, the respondents were informed about the purpose of the study, its course, and the fact that participation in the project is voluntary, and that they will be able to withdraw from participation at any time. The respondents were not paid for taking part in the project.

Participants.

In total, 115 interviews were conducted with 20 participants (6 interviews with the majority of respondents). Two participants (number 11 and 19, S2 Table ) dropped out of the last two interviews, and one (number 6) dropped out of the last interview. The study was based on a purposive sample and the respondents differed in gender, age, education, family status, and work situation (see S2 Table ). In addition to demographic criteria intended to ensure that the sample was as diverse as possible, an additional criterion was to have a permanent Internet connection and a computer capable of online video interviewing. Study participants were recruited using the snowball method. They were distant acquaintances of acquaintances of individuals involved in the study. None of the moderators knew their interviewees personally.

A total of 10 men and 10 women participated in the study; their age range was: 25–55; the majority had higher education (17 respondents), they were people with different professions and work status, and different family status (singles, couples without children, and families with children). Such diversity of respondents allowed us to obtain information from different life perspectives. A full description of characteristics of study participants can be found in S2 Table .

Each interview took 2 hours on average, which gives around 240 hours of interviews. Subsequent interviews with the same respondents conducted at different intervals resulted from the dynamics of the development of the pandemic and the restrictions introduced in Poland by the government.

The interviews scenario took a semi-structured form. This allowed interviewers freely modify the questions and topics depending on the dynamics of the conversation and adapt the subject matter of the interviews not only to the research purposes but also to the needs of a given respondent. The interview guides were modified from week to week, taking into account the development of the epidemiological situation, while at the same time maintaining certain constant parts that were repeated in each interview. The main parts of the interview topic guide consisted of: (a) experiences from the time of previous interviews: thoughts, feeling, fears, and hopes; (b) everyday life—organization of the day, work, free time, shopping, and eating, etc.; (c) changes—what had changed in the life of the respondent from the time of the last interview; (d) ways of coping with the situation; and (e) media—reception of information appearing in the media. Additionally, in each interview there were specific parts, such as the reactions to the beginning of the pandemic in the first interview or the reaction to the specific restrictions that were introduced.

The interviews were conducted by 5 female interviewers with experience in moderating qualitative interviews, all with a psychological background. After each series of interviews, all the members of the research teams took part in debriefing sessions, which consisted of discussing the information obtained from each respondent, exchanging general conclusions, deciding about the topics for the following interview stage, and adjusting them to the pandemic situation in the country.

Data analysis.

All the interviews were transcribed in Polish by the moderators and then double-checked (each moderator transcribed the interviews of another moderator, and then the interviewer checked the accuracy of the transcription). The whole process of analysis was conducted on the material in Polish (the native language of the authors of the study and respondents). The final page count of the transcript is approximately 1800 pages of text. The results presented below are only a portion of the total data collected during the interviews. While there are about 250 pages of the transcription directly related to the topic of the article, due to the fact that the interview was partly free-form, some themes merge with others and it is not possible to determine the exact number of pages devoted exclusively to analysis related to the topic of the article. Full dataset can be found in S1 Dataset .

Data was then processed into thematic analysis, which is defined as a method of developing qualitative data consisting of the identification, analysis, and description of the thematic areas [ 35 ]. In this type of analysis, a thematic unit is treated as an element related to the research problem that includes an important aspect of data. An important advantage of thematic analysis is its flexibility, which allows for the adoption of the most appropriate research strategy to the phenomenon under analysis. An inductive approach was used to avoid conceptual tunnel vision. Extracting themes from the raw data using an inductive approach precludes the researcher from imposing a predetermined outcome.

As a first step, each moderator reviewed the transcripts of the interviews they had conducted. Each transcript was thematically coded individually from this point during the second and the third reading. In the next step, one of the researchers reviewed the codes extracted by the other members of the research team. Then she made initial interpretations by generating themes that captured the essence of the previously identified codes. The researcher created a list of common themes present in all of the interviews. In the next step, the extracted themes were discussed again with all the moderators conducting the coding in order to achieve consistency. This collaborative process was repeated several times during the analysis. Here, further superordinate (challenges of COVID-19 pandemic) and subordinate (ways of dealing with challenges) themes were created, often by collapsing others together, and each theme listed under a superordinate and subordinate category was checked to ensure they were accurately represented. Through this process of repeated analysis and discussion of emerging themes, it was possible to agree on the final themes that are described below.

Main challenges of the COVID-19 pandemic.

Challenge 1 –limitation of direct contact with people . The first major challenge of the pandemic was that direct contact with other people was significantly reduced. The lockdown forced many people to work from home and limit contact not only with friends but also with close family (parents, children, and siblings). Limiting contact with other people was a big challenge for most of our respondents, especially those who were living alone and for those who previously led an active social life. Depending on their earlier lifestyle profile, for some, the bigger problem was the limitation of contact with the family, for others with friends, and for still others with co-workers.

I think that because I can’t meet up with anyone and that I’m not in a relationship , I miss having sex , and I think it will become even more difficult because it will be increasingly hard to meet anyone . (5 . 3_ M_39_single) . The number In the brackets at the end of the quotes marks the respondent’s number (according to Table 1 ) and the stage of the interview (after the dash), further is information about gender (F/M), age of the respondent and family status. Linguistic errors in the quotes reflect the spoken language of the respondents.

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https://doi.org/10.1371/journal.pone.0258133.t001

Changes over time . Over the course of the 6 months of the study, an evolution in the attitudes to the restriction of face-to-face contact could be seen: from full acceptance, to later questioning its rationale. Initially (March and April), almost all the respondents understood the reasons for the isolation and were compliant. At the beginning, people were afraid of the unknown COVID-19. They were concerned that the tragic situation from Italy, which was intensively covered in the media, could repeat itself in Poland (stage 1–2 of the study). However, with time, the isolation started to bother them more and more, and they started to look for solutions to bypass the isolation guidelines (stage 3–4), both real (simply meeting each other) and mental (treating isolation only as a guideline and not as an order, perceiving the family as being less threatening than acquaintances or strangers in a store). The turning point was the long May weekend that, due to two public holidays (1 st and 3 rd May), has for many years been used as an opportunity to go away with family or friends. Many people broke their voluntary isolation during that time encouraged by information about the coming loosening of restrictions.

During the summer (stage 5 of the survey), practically no one was fully compliant with the isolation recommendations anymore. At that time, a growing familiarity could be observed with COVID-19 and an increasing tendency to talk about it as “one of many diseases”, and to convince oneself that one is not at risk and that COVID-19 is no more threatening than other viruses. Only a small group of people consciously failed to comply with the restrictions of contact with others from the very beginning of the pandemic. This behavior was mostly observed among people who were generally less anxious and less afraid of COVID-19.

I’ve had enough. I’ve had it with sitting at home. Okay, there’s some kind of virus, it’s as though it’s out there somewhere; it’s like I know 2 people who were infected but they’re still alive, nothing bad has happened to anyone. It’s just a tiny portion of people who are dying. And is it really such a tragedy that we have to be locked up at home? Surely there’s an alternative agenda there? (17.4_F_35_Adult and child)

Ways of dealing . In the initial phase, when almost everyone accepted this restriction and submitted to it, the use of communication platforms for social meetings increased (see Ways of dealing with challenges in Table 1 ) . Meetings on communication platforms were seen as an equivalent of the previous face-to-face contact and were often even accompanied by eating or drinking alcohol together. However, over time (at around stage 4–5 of the study) people began to feel that such contact was an insufficient substitute for face-to-face meetings and interest in online meetings began to wane. During this time, however, an interesting phenomenon could be seen, namely, that for many people the family was seen as a safer environment than friends, and definitely safer than strangers. The belief was that family members would be honest about being sick, while strangers not necessarily, and—on an unconscious level—the feeling was that the “family is safe”, and the “family can’t hurt them”.

When it became clear that online communication is an insufficient substitute for face-to-face contacts, people started to meet up in real life. However, a change in many behaviors associated with meeting people is clearly visible, e.g.: refraining from shaking hands, refraining from cheek kissing to greet one another, and keeping a distance during a conversation.

I can’t really say that I could ‘feel’ Good Friday or Holy Saturday. On Sunday, we had breakfast together with my husband’s family and his sister. We were in three different places but we connected over Skype. Later, at noon, we had some coffee with my parents, also over Skype. It’s obvious though that this doesn’t replace face-to-face contact but it’s always some form of conversation. (9.3_F_25_Couple, no children)

Challenge 2 –restrictions on movement and travel . In contrast to the restrictions on contact with other people, the restrictions on movement and the closing of borders were perceived more negatively and posed bigger challenges for some people (especially those who used to do a lot of travelling). In this case, it was less clear why these regulations were introduced (especially travel restrictions within the country). Moreover, travel restrictions, particularly in the case of international travels, were associated with a limitation of civil liberties. The limitation (or complete ban) on travelling abroad in the Polish situation evoked additional connotations with the communist times, that is, with the fact that there was no freedom of movement for Polish citizens (associations with totalitarianism and dictatorship). Interestingly, the lack of acceptance of this restriction was also manifested by people who did not travel much. Thus, it was not just a question of restricting travelling abroad but more of restricting the potential opportunity (“even if I’m not planning on going anywhere, I know I still can”).

Limitations on travelling around the country were particularly negatively felt by families with children, where parents believe that regular exercise and outings are necessary for the proper development of their children. For parents, it was problematic to accept the prohibition of leaving the house and going to the playground (which remained closed until mid-May). Being outdoors was perceived as important for maintaining immunity (exercise as part of a healthy lifestyle), therefore, people could not understand the reason underlying this restriction and, as a consequence, often did not accept it.

I was really bothered by the very awareness that I can’t just jump in my car or get on a plane whenever I want and go wherever I want. It’s not something that I have to do on a daily basis but freedom of movement and travelling are very important for me. (14.2_M_55_Two adults and children)

Changes over time . The travel and movement limitations, although objectively less severe for most people, aroused much greater anger than the restrictions on social contact. This was probably due to a greater sense of misunderstanding as to why these rules were being introduced in the first place. Moreover, they were often communicated inconsistently and chaotically (e.g., a ban on entering forests was introduced while, at the same time, shopping malls remained open and masses were allowed to attend church services). This anger grew over time—from interview to interview, the respondents’ irritation and lack of acceptance of this was evident (culminating in the 3 rd -4 th stage of the study). The limitation of mobility was also often associated with negative consequences for both health and the economy. Many people are convinced that being in the open air (especially accompanied by physical activity) strengthens immunity, therefore, limiting such activity may have negative health consequences. Some respondents pointed out that restricting travelling, the use of hotels and restaurants, especially during the holiday season, will have serious consequences for the existence of the tourism industry.

I can’t say I completely agree with these limitations because it’s treating everything selectively. It’s like the shopping mall is closed, I can’t buy any shoes but I can go to a home improvement store and buy some wallpaper for myself. So I don’t see the difference between encountering people in a home improvement store and a shopping mall. (18.2_F_48_Two adults and children)

Ways of dealing . Since the restriction of movement and travel was more often associated with pleasure-related behaviors than with activities necessary for living, the compensations for these restrictions were usually also from the area of hedonistic behaviors. In the statements of our respondents, terms such as “indulging” or “rewarding oneself” appeared, and behaviors such as throwing small parties at home, buying better alcohol, sweets, and new clothes were observed. There were also increased shopping behaviors related to hobbies (sometimes hobbies that could not be pursued at the given time)–a kind of “post-pandemic” shopping spree (e.g., a new bike or new skis).

Again, the reaction to this restriction also depended on the level of fear of the COVID-19 disease. People who were more afraid of being infected accepted these restrictions more easily as it gave them the feeling that they were doing something constructive to protect themselves from the infection. Conversely, people with less fears and concerns were more likely to rebel and break these bans and guidelines.

Another way of dealing with this challenge was making plans for interesting travel destinations for the post-pandemic period. This was especially salient in respondents with an active lifestyle in the past and especially visible during the 5 th stage of the study.

Today was the first day when I went to the store (due to being in quarantine after returning from abroad). I spent loads of money but I normally would have never spent so much on myself. I bought sweets and confectionery for Easter time, some Easter chocolates, too. I thought I’d do some more baking so I also bought some ingredients to do this. (1.2_ F_25_single)

Challenge 3 –necessary change in active lifestyle . Many of the limitations related to COVID-19 were a challenge for people with an active lifestyle who would regularly go to the cinema, theater, and gym, use restaurants, and do a lot of travelling. For those people, the time of the COVID constraints has brought about huge changes in their lifestyle. Most of their activities were drastically restricted overnight and they suddenly became domesticated by force, especially when it was additionally accompanied by a transition to remote work.

Compulsory spending time at home also had serious consequences for people with school-aged children who had to confront themselves with the distance learning situation of their children. The second challenge for families with children was also finding (or helping find) activities for their children to do in their free time without leaving the house.

I would love to go to a restaurant somewhere. We order food from the restaurant at least once a week, but I’d love to go to the restaurant. Spending time there is a different way of functioning. It is enjoyable and that is what I miss. I would also go to the cinema, to the theater. (13.3_M_46_Two adults and child.)

Changes over time . The nuisance of restrictions connected to an active lifestyle depended on the level of restrictions in place at a given time and the extent to which a given activity could be replaced by an alternative. Moreover, the response to these restrictions depended more on the individual differences in lifestyle rather than on the stage of the interview (except for the very beginning, when the changes in lifestyle and everyday activities were very sudden).

I miss that these restaurants are not open . And it’s not even that I would like to eat something specific . It is in all of this that I miss such freedom the most . It bothers me that I have no freedom . And I am able to get used to it , I can cook at home , I can order from home . But I just wish I had a choice . (2 . 6_F_27_single ).

Ways of dealing . In the initial phase of the pandemic (March-April—stage 1–3 of the study), when most people were afraid of the coronavirus, the acceptance of the restrictions was high. At the same time, efforts were made to find activities that could replace existing ones. Going to the gym was replaced by online exercise, and going to the cinema or theater by intensive use of streaming platforms. In the subsequent stages of the study, however, the respondents’ fatigue with these “substitutes” was noticeable. It was then that more irritation and greater non-acceptance of certain restrictions began to appear. On the other hand, the changes or restrictions introduced during the later stages of the pandemic were less sudden than the initial ones, so they were often easier to get used to.

I bought a small bike and even before that we ordered some resistance bands to work out at home, which replace certain gym equipment and devices. […] I’m considering learning a language. From the other online things, my girlfriend is having yoga classes, for instance. (7.2_M_28_Couple, no children)

Challenge 4 –boredom , monotony . As has already been shown, for many people, the beginning of the pandemic was a huge change in lifestyle, an absence of activities, and a resulting slowdown. It was sometimes associated with a feeling of weariness, monotony, and even of boredom, especially for people who worked remotely, whose days began to be similar to each other and whose working time merged with free time, weekdays with the weekends, and free time could not be filled with previous activities.

In some way, boredom. I can’t concentrate on what I’m reading. I’m trying to motivate myself to do such things as learning a language because I have so much time on my hands, or to do exercises. I don’t have this balance that I’m actually doing something for myself, like reading, working out, but also that I’m meeting up with friends. This balance has gone, so I’ve started to get bored with many things. Yesterday I felt that I was bored and something should start happening. (…) After some time, this lack of events and meetings leads to such immense boredom. (1.5_F_25_single)

Changes over time . The feeling of monotony and boredom was especially visible in stage 1 and 2 of the study when the lockdown was most restrictive and people were knocked out of their daily routines. As the pandemic continued, boredom was often replaced by irritation in some, and by stagnation in others (visible in stages 3 and 4 of the study) while, at the same time, enthusiasm for taking up new activities was waning. As most people were realizing that the pandemic was not going to end any time soon, a gradual adaptation to the new lifestyle (slower and less active) and the special pandemic demands (especially seen in stage 5 and 6 of the study) could be observed.

But I see that people around me , in fact , both family and friends , are slowly beginning to prepare themselves for more frequent stays at home . So actually more remote work , maybe everything will not be closed and we will not be locked in four walls , but this tendency towards isolation or self-isolation , such a deliberate one , appears . I guess we are used to the fact that it has to be this way . (15 . 6_M_43_Two adults and child) .

Ways of dealing . The answer to the monotony of everyday life and to finding different ways of separating work from free time was to stick to certain rituals, such as “getting dressed for work”, even when work was only by a computer at home or, if possible, setting a fixed meal time when the whole family would gather together. For some, the time of the beginning of the pandemic was treated as an extra vacation. This was especially true of people who could not carry out their work during the time of the most severe restrictions (e.g., hairdressers and doctors). For them, provided that they believed that everything would return to normal and that they would soon go back to work, a “vacation mode” was activated wherein they would sleep longer, watch a lot of movies, read books, and generally do pleasant things for which they previously had no time and which they could now enjoy without feeling guilty. Another way of dealing with the monotony and transition to a slower lifestyle was taking up various activities for which there was no time before, such as baking bread at home and cooking fancy dishes.

I generally do have a set schedule. I begin work at eight. Well, and what’s changed is that I can get up last minute, switch the computer on and be practically making my breakfast and coffee during this time. I do some work and then print out some materials for my younger daughter. You know, I have work till four, I keep on going up to the computer and checking my emails. (19.1_F_39_Two adults and children)

Challenge 5 –uncertainty about the future . Despite the difficulties arising from the circumstances and limitations described above, it seems that psychologically, the greatest challenge during a pandemic is the uncertainty of what will happen next. There was a lot of contradictory information in the media that caused a sense of confusion and heightened the feeling of anxiety.

I’m less bothered about the changes that were put in place and more about this concern about what will happen in the future. Right now, it’s like there’s these mood swings. […] Based on what’s going on, this will somehow affect every one of us. And that’s what I’m afraid of. The fact that someone will not survive and I have no way of knowing who this could be—whether it will be me or anyone else, or my dad, if somehow the coronavirus will sneak its way into our home. I simply don’t know. I’m simply afraid of this. (10.1_F_55_Couple, no children)

Changes over time . In the first phase of the pandemic (interviews 1–3), most people felt a strong sense of not being in control of the situation and of their own lives. Not only did the consequences of the pandemic include a change in lifestyle but also, very often, the suspension of plans altogether. In addition, many people felt a strong fear of the future, about what would happen, and even a sense of threat to their own or their loved ones’ lives. Gradually (interview 4), alongside anxiety, anger began to emerge about not knowing what would happen next. At the beginning of the summer (stage 5 of the study), most people had a hope of the pandemic soon ending. It was a period of easing restrictions and of opening up the economy. Life was starting to look more and more like it did before the pandemic, fleetingly giving an illusion that the end of the pandemic was “in sight” and the vision of a return to normal life. Unfortunately, autumn showed that more waves of the pandemic were approaching. In the interviews of the 6 th stage of the study, we could see more and more confusion and uncertainty, a loss of hope, and often a manifestation of disagreement with the restrictions that were introduced.

This is making me sad and angry. More angry, in fact. […] I don’t know what I should do. Up until now, there was nothing like this. Up until now, I was pretty certain of what I was doing in all the decisions I was making. (14.4_M_55_Two adults and children)

Ways of dealing . People reacted differently to the described feeling of insecurity. In order to reduce the emerging fears, some people searched (sometimes even compulsively) for any information that could help them “take control” of the situation. These people searched various sources, for example, information on the number of infected persons and the number of deaths. This knowledge gave them the illusion of control and helped them to somewhat reduce the anxiety evoked by the pandemic. The behavior of this group was often accompanied by very strict adherence to all guidelines and restrictions (e.g., frequent hand sanitization, wearing a face mask, and avoiding contact with others). This behavior increased the sense of control over the situation in these people.

A completely opposite strategy to reducing the feeling of uncertainty which we also observed in some respondents was cutting off information in the media about the scale of the disease and the resulting restrictions. These people, unable to keep up with the changing information and often inconsistent messages, in order to maintain cognitive coherence tried to cut off the media as much as possible, assuming that even if something really significant had happened, they would still find out.

I want to keep up to date with the current affairs. Even if it is an hour a day. How is the pandemic situation developing—is it increasing or decreasing. There’s a bit of propaganda there because I know that when they’re saying that they have the situation under control, they can’t control it anyway. Anyhow, it still has a somewhat calming effect that it’s dying down over here and that things aren’t that bad. And, apart from this, I listen to the news concerning restrictions, what we can and can’t do. (3.1_F_54_single)

Discussion and conclusions

The results of our study showed that the five greatest challenges resulting from the COVID-19 pandemic are: limitations of direct contact with people, restrictions on movement and travel, change in active lifestyle, boredom and monotony, and finally uncertainty about the future. As we can see the spectrum of problems resulting from the pandemic is very wide and some of them have an impact on everyday functioning and lifestyle, some other influence psychological functioning and well-being. Moreover, different people deal with these problems differently and different changes in everyday life are challenging for them. The first challenge of the pandemic COVID-19 problem is the consequence of the limitation of direct contact with others. This regulation has very strong psychological consequences in the sense of loneliness and lack of closeness. Initially, people tried to deal with this limitation through the use of internet communicators. It turned out, however, that this form of contact for the majority of people was definitely insufficient and feelings of deprivation quickly increased. As much data from psychological literature shows, contact with others can have great psychological healing properties [e.g., 29 ]. The need for closeness is a natural need in times of crisis and catastrophes [ 30 ]. Unfortunately, during the COVID-19 pandemic, the ability to meet this need was severely limited by regulations. This led to many people having serious problems with maintaining a good psychological condition.

Another troubling limitation found in our study were the restrictions on movement and travel, and the associated restrictions of most activities, which caused a huge change in lifestyle for many people. As shown in previous studies, travel and diverse leisure activities are important predictors of greater well-being [ 36 ]. Moreover, COVID-19 pandemic movement restrictions may be perceived by some people as a threat to human rights [ 37 ], which can contribute to people’s reluctance to accept lockdown rules.

The problem with accepting these restrictions was also related to the lack of understanding of the reasons behind them. Just as the limitation in contact with other people seemed understandable, the limitations related to physical activity and mobility were less so. Because of these limitations many people lost a sense of understanding of the rules and restrictions being imposed. Inconsistent communication in the media—called by some researchers the ‘infodemic’ [ 18 ], as well as discordant recommendations in different countries, causing an increasing sense of confusion in people.

Another huge challenge posed by the current pandemic is the feeling of uncertainty about the future. This feeling is caused by constant changes in the rules concerning daily functioning during the pandemic and what is prohibited and what is allowed. People lose their sense of being in control of the situation. From the psychological point of view, a long-lasting experience of lack of control can cause so-called learned helplessness, a permanent feeling of having no influence over the situation and no possibility of changing it [ 38 ], which can even result in depression and lower mental and physical wellbeing [ 39 ]. Control over live and the feeling that people have an influence on what happens in their lives is one of the basic rules of crisis situation resilience [ 30 ]. Unfortunately, also in this area, people have huge deficits caused by the pandemic. The obtained results are coherent with previous studies regarding the strategies harnessed to cope with the pandemic [e.g., 5 , 10 , 28 , 33 ]. For example, some studies showed that seeking social support is one of the most common strategies used to deal with the coronavirus pandemic [ 33 , 40 ]. Other ways to deal with this situation include distraction, active coping, and a positive appraisal of the situation [ 41 ]. Furthermore, research has shown that simple coping behaviors such as a healthy diet, not reading too much COVID-19 news, following a daily routine, and spending time outdoors may be protective factors against anxiety and depressive symptoms in times of the coronavirus pandemic [ 41 ].

This study showed that the acceptance of various limitations, and especially the feeling of discomfort associated with them, depended on the person’s earlier lifestyle. The more active and socializing a person was, the more restrictions were burdensome for him/her. The second factor, more of a psychological nature, was the fear of developing COVID-19. In this case, people who were more afraid of getting sick were more likely to submit to the imposed restrictions that, paradoxically, did not reduce their anxiety, and sometimes even heightened it.

Limitations of the study.

While the study shows interesting results, it also has some limitations. The purpose of the study was primarily to capture the first response to problems resulting from a pandemic, and as such its design is not ideal. First, the study participants are not diverse as much as would be desirable. They are mostly college-educated and relatively well off, which may influence how they perceive the pandemic situation. Furthermore, the recruitment was done by searching among the further acquaintances of the people involved in the study, so there is a risk that all the people interviewed come from a similar background. It would be necessary to conduct a study that also describes the reaction of people who are already in a more difficult life situation before the pandemic starts.

Moreover, it would also be worthwhile to pay attention to the interviewers themselves. All of the moderators were female, and although gender effects on the quality of the interviews and differences between the establishment of relationships between women and men were not observed during the debriefing process, the topic of gender effects on the results of qualitative research is frequently addressed in the literature [ 42 , 43 ]. Although the researchers approached the process with reflexivity and self-criticism at all stages, it would have seemed important to involve male moderators in the study to capture any differences in relationship dynamics.

Practical implications.

The study presented has many practical implications. Decision-makers in the state can analyze the COVID-19 pandemic crisis in a way that avoids a critical situation involving other infectious diseases in the future. The results of our study showing the most disruptive effects of the pandemic on people can serve as a basis for developing strategies to deal with the effects of the crisis so that it does not translate into a deterioration of the public’s mental health in the future.

The results of our study can also provide guidance on how to communicate information about restrictions in the future so that they are accepted and respected (for example by giving rational explanations of the reasons for introducing particular restrictions). In addition, the results of our study can also be a source of guidance on how to deal with the limitations that may arise in a recurrent COVID-19 pandemic, as well as other emergencies that could come.

The analysis of the results showed that the COVID-19 pandemic, and especially the lockdown periods, are a particular challenge for many people due to reduced social contact. On the other hand, it is social contacts that are at the same time a way of a smoother transition of crises. This knowledge should prompt decision-makers to devise ways to ensure pandemic safety without drastically limiting social contacts and to create solutions that give people a sense of control (instead of depriving it of). Providing such solutions can reduce the psychological problems associated with a pandemic and help people to cope better with it.

Conclusions

As more and more is said about the fact that the COVID-19 pandemic may not end soon and that we are likely to face more waves of this disease and related lockdowns, it is very important to understand how the different restrictions are perceived, what difficulties they cause and what are the biggest challenges resulting from them. For example, an important element of accepting the restrictions is understanding their sources, i.e., what they result from, what they are supposed to prevent, and what consequences they have for the fight against the pandemic. Moreover, we observed that the more incomprehensible the order was, the more it provoked to break it. This means that not only medical treatment is extremely important in an effective fight against a pandemic, but also appropriate communication.

The results of our study showed also that certain restrictions cause emotional deficits (e.g., loneliness, loss of sense of control) and, consequently, may cause serious problems with psychological functioning. From this perspective, it seems extremely important to understand which restrictions are causing emotional problems and how they can be dealt with in order to reduce the psychological discomfort associated with them.

Supporting information

S1 table. a full description of the changes occurring in poland at the time of the study..

https://doi.org/10.1371/journal.pone.0258133.s001

S2 Table. Characteristics of study participants.

https://doi.org/10.1371/journal.pone.0258133.s002

S1 Dataset. Transcriptions from the interviews.

https://doi.org/10.1371/journal.pone.0258133.s003

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Conclusion: What Did We Learn from the COVID-19 Pandemic?

• First Online: 24 March 2023

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The COVID-19 pandemic transformed the world, and in one word, created a new one. No sphere of human life remained untouched by what has been described as the worst human disaster of the last century. Although the world is preparing for a new post-pandemic normal, it will take years for human beings to truly appreciate the grave consequences of a catastrophic nightmare. Despite its unforgettable and irrecoverable damages, the pandemic offered a much-needed house-shaking in many aspects of our individual and social life. One of the areas worse affected at the beginning but which is hoped to gain in the long-run was the education sector. This chapter delineates what lessons the pandemic had to offer in second language teacher education and professional development. It also considers the same from the perspectives of the contributors to this volume, one of the first devoted to language teacher education issues during the pandemic.

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Sadeghi, K., Thomas, M. (2023). Conclusion: What Did We Learn from the COVID-19 Pandemic?. In: Sadeghi, K., Thomas, M. (eds) Second Language Teacher Professional Development. Digital Education and Learning. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-031-12070-1_15

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• v.12(5); 2020 May

COVID-19 Pandemic: Knowledge and Perceptions of the Public and Healthcare Professionals

Priyanka a parikh.

1 Department of Pediatrics, Pramukhswami Medical College, Karamsad, IND

Binoy V Shah

Ajay g phatak.

2 Central Research Services, Bhaikaka University, Karamsad, IND

Amruta C Vadnerkar

3 Department of Public Health, Child Health Foundation, Gandhidham, IND

Shraddha Uttekar

4 Department of Public Health, International Pediatric Association, Gandhidham, IND

Naveen Thacker

5 Department of Pediatrics, Deep Children Hospital, Gandhidham, IND

Somashekhar M Nimbalkar

Background and objective

The recent pandemic due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a major concern for the people and governments across the world due to its impact on individuals as well as on public health. The infectiousness and the quick spread across the world make it an important event in everyone’s life, often evoking fear. Our study aims at assessing the overall knowledge and perceptions, and identifying the trusted sources of information for both the general public and healthcare personnel.

Materials and methods

This is a questionnaire-based survey taken by a total of 1,246 respondents, out of which 744 belonged to the healthcare personnel and 502 were laypersons/general public. There were two different questionnaires for both groups. The questions were framed using information from the World Health Organization (WHO), UpToDate, Indian Council of Medical Research (ICMR), Center for Disease Control (CDC), National Institute of Health (NIH), and New England Journal of Medicine (NEJM) website resources. The questions assessed awareness, attitude, and possible practices towards ensuring safety for themselves as well as breaking the chain of transmission. A convenient sampling method was used for data collection. Descriptive statistics [mean(SD), frequency(%)] were used to portray the characteristics of the participants as well as their awareness, sources of information, attitudes, and practices related to SARS-CoV-2.

The majority (94.3%) of the respondents were Indians. About 80% of the healthcare professionals and 82% of the general public were worried about being infected. Various websites such as ICMR, WHO, CDC, etc., were a major source of information for the healthcare professional while the general public relied on television. Almost 98% of healthcare professionals and 97% of the general public, respectively, identified ‘Difficulty in breathing” as the main symptom. More than 90% of the respondents in both groups knew and practiced different precautionary measures. A minority of the respondents (28.9% of healthcare professionals and 26.5% of the general public) knew that there was no known cure yet. Almost all respondents from both the groups agreed on seeking medical help if breathing difficulty is involved and self-quarantine if required.

Most healthcare professionals and the general public that we surveyed were well informed about SARS-CoV-2 and have been taking adequate measures in preventing the spread of the same. There is a high trust of the public in the government. There are common trusted sources of information and these need to be optimally utilized to spread accurate information.

Introduction

In December 2019, the 2019 novel coronavirus disease (COVID-19) caused by novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in China, followed by a rapid spread all over the world. On March 11, 2020, the World Health Organization (WHO) raised its pandemic alert. As of April 11, 2020, COVID-19 had caused over 95,269 deaths in 189 countries and overseas territories or communities [ 1 ].

In a connected world, fake news and rumor-mongering are common due to a surge in the use of the internet and social media. A confused comprehension in an emerging communicable disease of which even the experts have inadequate knowledge can lead to fear and chaos, even excessive panic, which has the probability to aggravate the disease epidemic [ 2 ]. During the SARS epidemic from 2002 to 2004, there were misconceptions and hence excessive panic in the general public concerning SARS. This led them to be resistant to comply with suggested preventive measures such as avoiding public transportation, going to a hospital when sick, etc. This contributed to the rapid spread of SARS and resulted in a more serious epidemic situation [ 3 ]. A similar experience occurred during the Ebola outbreak in 2009 in Africa. These experiences underscore the vital role of engaging with the general public and healthcare professionals and the importance of monitoring their perception of disease epidemic control, which may affect the compliance of community to the precautionary strategies. Understanding related factors affecting and influencing people to undertake precautionary behavior may also help decision-makers take appropriate measures to promote individual or community health. Hence, it is crucial to understand people’s risk perception and identify their trusted sources of information to effectively communicate and frame key messages in response to the emerging disease [ 4 ].

Since it is the novel coronavirus, its epidemiological features are not well known and new studies and publications will take anywhere from a month to a year making it important to know and understand the level of knowledge and preparedness of the healthcare personnel in terms of the managing the virus affected patients. Today healthcare professionals managing COVID-19 across the world are in an unprecedented situation, having to make tough decisions and working under extreme pressures. Decisions include equitable distribution of scant resources among the needy patients, balancing their own physical and mental healthcare needs along with those of the patients, aligning their desire and duty to patients with those to family and friends, and providing care for all unwell patients with constrained or inadequate resources. This may cause some to experience moral distress or mental health problems [ 5 ].

Effective communication is a priority in WHO’s COVID-19 roadmap; accurate and salient messages will enhance trust and enable the public to make informed choices based on recommendations [ 6 ].

As the outbreak intensified, social media has taken on new and increased importance with the large-scale implementation of social distancing, quarantine measures, and lockdown of complete cities. Social media platforms have become a way to enable homebound people to survive isolation and seek help, co-ordinate donations, entertain, and socialize with each other.

Social media platforms arguably support the conditions necessary for attitude change by exposing individuals to correct, accurate, health-promoting messages from healthcare professionals

In order to investigate community responses to SARS-CoV-2, we conducted this online survey among the general public and healthcare professionals to identify awareness of SARS-CoV-2 (perceived burden and risk), trusted sources of information, awareness of preventative measures and support for governmental policies and trust in authority to handle SARS-CoV-2 outbreak and put forward policy recommendations in case of similar future conditions.

We performed a cross-sectional survey of a convenient sample of respondents. The ethical approval for the study was taken from the Institutional Ethics Committee - 2, HM Patel Centre for Medical Care and Education, Karamsad via letter IEC/ HMPCMCE/ 2019 / Ex. 07/ dated March 23, 2020. All participants were above 18 years of age conveniently selected from the public at large by reaching out to the general public and healthcare professionals by the authors. The participants were largely from India. The consent of the participants was taken at the beginning of the survey. Two different self-administered questionnaires were used. The one for non-medical personnel (general public) is shown in Table ​ Table1, 1 , while the one for medical and paramedical personnel is shown in Table ​ Table2 2 .

WHO, World Health Organization

The questions were framed using information from the WHO, UpToDate, Indian Council of Medical Research (ICMR), Center for Disease Control (CDC), National Institute of Health (NIH), and New England Journal of Medicine (NEJM) website resources as updated till March 19, 2020. They were validated consensually by experts from the Department of Pediatrics, Pulmonary Medicine, Public Health, and General Internal Medicine. The COVID-19 questions for healthcare professionals, i.e., medical and paramedical personnel were applicable to consultants, residents, interns, medical students, physiotherapists, physiotherapy students, nurses, nursing students, dentists, etc. The questionnaire was administered in English with the help of Google forms, which is a cloud-based data management tool used for designing and developing web-based questionnaires and available free. A link to the online surveys was sent out to them via e-mails and different social media platforms, namely WhatsApp, Facebook, LinkedIn, and Instagram messages, hence without any geographical barrier. The data collection was started on the March 23, 2020 and was continued up till March 27, 2020 midnight. The dates are important as on 22 March there was a self-imposed Janata Curfew in response to Prime Minister of India’s call while from the midnight of March 24, 2020, there was a nationwide lockdown across India. The data was automatically collected in the form of a google sheet and the collected data was being exported automatically to google sheets (similar to Microsoft Excel).

Descriptive statistics [mean (SD), frequency (%)] were used to portray the characteristics of the participants as well as their awareness, sources of information, attitudes, and practices related to SARS-CoV-2. Due to large sample sizes in the healthcare professional group as well as the general public group, exploratory visual comparisons were presented without typical statistical tests of significance.

A total of 744 health and allied professionals and 502 persons from people at large consented and completed the survey. A majority (94.3%) of the participants were Indian residents with insignificant responses from outside India. It is presumed that the majority of the respondents are of Indian residents but the possibility of a handful of them being non-Indians cannot be ruled out because we did not collect demographic data. A comparison of awareness about SARS-CoV-2 between the general public and healthcare professionals is shown in Table ​ Table3 3 .

The gender distribution was equal in the healthcare professionals group, whereas it was more male-dominated in the general public group (49.7% vs 56.4% males). The respondents were younger in the healthcare professionals group as compared to the general public group [mean (SD) age: 29.55 (12.53) vs 32.16 (13.32) years].

The majority of the participants from the healthcare professionals group [594 (80%)] and the general public group [410 (82%)] were worried about getting SARS-CoV-2 infection. Those who were not worried expressed justified reasons (mainly precautions) for their attitude. Online resources, television, peer group discussions, and scientific literature constituted the main sources of information in the healthcare professionals group, whereas television, social networking sites, and newspapers/magazines constituted the main sources of information in the general population group. Participants in both groups reported WHO and official Indian Government websites (ICMR, Ministry of Health and Family Welfare (MOHFW)) as the most trusted online resources.

Most of the healthcare professionals reported that they had accessed videos by WHO/other sources [514 (69%)], read scientific articles [407 (54.7%)], and attended online lectures [242 (32.5%)] related to SARS-CoV-2.

Most healthcare professionals [727(98%)] as well as the general public [486(97%)] identified “difficulty in breathing” as the main symptom of SARS-CoV-2 infection along with cough and fever. Respondents from both the groups were aware of precautionary measures such as hand washing/sanitizer, wearing masks, social distancing, covering mouth while sneezing, and self-quarantine. Majority of the participants (62.7% in the general public and 71.8% in healthcare professionals) were aware of the infection period and the asymptomatic period (91% in the general public and 94.3% in healthcare professionals), but there appeared to be some confusion regarding curative treatment and vaccine availability in both the groups. Most participants rightly endorsed medical masks for healthcare workers, symptomatic patients, and persons who are coughing/sneezing. However, an appreciable proportion of healthcare professionals [303(40.7%)], as well as respondents from the general public [253(50.4%)], wrongly endorsed medical masks for healthy persons to protect themselves. 

Most healthcare professionals [648(87.1%)] expressed their trust in the ICMR task force on SARS-CoV-2. Similar feelings were echoed by the general public [426(85%)] in trusting the current government. 

Half of the general public respondents showed eagerness for the SARS-CoV-2 test without difficulty in breathing. A similar trend was observed among health professionals. Almost all respondents from the general public (98%) and the healthcare professionals (100%) endorsed seeking medical help if the breathing difficulty was involved.

Slightly more healthcare professionals reported regular influenza vaccination as compared to the general public [175(23.5%) vs 76(15.1%)]. Almost all the respondents agreed for self-isolation if needed. The majority of the respondents reported that they were washing the hands more frequently and knew the correct way of handwashing.

We present here a study of the awareness of SARS-CoV-2 among healthcare professionals and the general public with a comparison of many features among them. It is heartening to note that the knowledge with respect to SARS-CoV-2 is relatively high among the respondents.

There are, however, various limitations of the study and these are inherent due to the circumstances in which this survey was done. The study was begun on March 23, 2020, one day after Janata Curfew in India as requested by the Prime Minister and one day before the lockdown on March 24, 2020 [ 7 ]. The survey was filled during the days of the lockdown when the respondents had a lot of time on their hands and were probably active on social media as well as watching the television news. Hence, it is quite relevant that many individuals have their information from these two sources, making it important to ensure that accurate information through verified channels and healthcare professionals are presented and broadcasted to the people. This also points towards the importance of the right people being active on social media so that they can communicate the scientifically validated information to the masses.

The curfew and the lockdown ensured that the seriousness of the disease was impressed upon by the highest offices in the country, which is reflected in people taking good precautionary measures to protect themselves from the disease as well as break the chain of transmission. The cases in India have hence not risen to a very high number as rapidly as expected/projected, which also probably indicates that the message was well conveyed and well perceived. As this is a survey that was filled remotely, we need to be cautious in drawing strong conclusions.

Another limitation of the study is that the questionnaire was in the form of google forms and the language of conduct was English. This implies that the people who did not have access to the internet and were not literate were unable to be a part of this survey. But as the source of information for all the general public remains similar (television is ubiquitous in India), we can infer that they would have a similar response. We base this inference as the main sources of information of the public at large were newspapers, television, and WhatsApp despite having access to websites and other online sources. In villages, often the literate readout regional newspapers and news received on mobiles to the rest of the family/friends to ensure dissemination of information.

It is now known that the basic reproductive number (R0) of coronavirus is more in healthcare professionals as compared to the lay public and hence the relative indifference or "no worries" approach of healthcare professionals towards getting infected by SARS-CoV-2 is a concern. In the scenario where adequate personal protective equipment (PPE) may not be available to the healthcare facilities in India due to increased global demand, it is important that healthcare workers know their risk for being infected. In a recent study in Mumbai, 79% of the healthcare professionals were aware of the various PPE required with only 54.5% of them being aware of isolation procedures needed for SARS-CoV-2 infected patients [ 8 ]. The numbers for paramedical staff were also lower. India imports raw materials for PPE production from China and South Korea. Due to the shortage of materials and low rate of supply, the availability has taken a massive hit resulting in an acute shortage in the market. It is highly likely that many healthcare professionals will not use appropriate PPE, will get infected, and further spread infections to patients [ 9 - 11 ]. The Bhilwara cohort in Rajasthan is an example of how a healthcare professional needs to protect against infection since he/she is likely to transmit it to others [ 12 ]. Another example in Mumbai is Saifee hospital, which was shut down due to an infected healthcare professional who continued to work and passed on the infection to many during the asymptomatic phase. The SARS-CoV-2 disease presents a unique organism that can be spread for at least five days before developing symptoms and up to 37 days after presentation [ 13 , 14 ]. Given its high infectivity, it is a recipe for disaster if healthcare personnel gets it. We have not collected demographic information from the participants and hence it is possible that many of them work in situations where they may not anticipate getting infected. The previous few months have shown how surgeons, orthopedicians, dentists, etc., who typically do not deal with infectious diseases are getting infected by coronavirus [ 15 , 16 ]. In this scenario, it is worrying that only 80% of healthcare professionals were worried while the public was slightly more worried (82%).

The difference in the source of information for healthcare professionals and the general public is stark when we compare information garnered through social media. Social media at 78.3% is the second-highest source for the general public, while the healthcare professionals give it a measly 1%. Since social media is prone to fake news, it is heartening that healthcare professionals are not learning from it. However, the reliance of the general public on social media indicates that healthcare professionals, professional organizations, and government officers need to invest a significant proportion of their time and resources to be active on social media to disseminate correct news. The shots heard round the world rapid-response network is an example that needs to be followed [ 17 ]. In another example, we have Dr. Roberto Burioni who has successfully given accurate data on social media. If more healthcare professionals were to enrich social media, it would be a useful platform for the public [ 18 , 19 ]. While many government officials are active on Twitter in India, the platform that is commonly used in India is WhatsApp, Telegram, Instagram, and TikTok and these are dynamic and keep changing. WhatsApp in the middle of this pandemic reduced the forwarding to just one person for a message that had been forwarded five times from the previous number of forwarding to five people (which was unlimited initially) [ 20 ]. It indicates the importance of this platform across the world for the spreading of messages. The healthcare professionals rated scientific journals at just about 40.9%. It may be due to the low availability of high-quality evidence or poor access that many healthcare professionals in India have to scientific journals, which are mostly published out of developed countries [ 21 ]. In a pandemic situation, this disparity in access can be catastrophic and hence most journals have provided open access to all coronavirus-related publications. Healthcare professionals accessed websites such as WHO, Medscape, MOHFW, CDC, Worldometers, covid19.com , ICMR, UpToDate, and PubMed, for reliable information, which is an indicator of their faith in health organizations across the world. Interestingly though at a low 29.3%, much of the general public accessed similar websites such as WHO, MOHFW, CDC, and ICMR. At the time that the survey was administered, online webinars via zoom or other applications were just beginning in India to educate clinicians searching for answers. This is not reflected in our current study due to many of the responses being filled before the same or the respondents not being part of these audiences. The study authors have attended many of these meetings conducted by the Indian Academy of Pediatrics, etc., and this information is made available via email or WhatsApp messages. In a changing world, both healthcare professionals and the general public need to have reliable and accurate sources of information.

The severity of illness was well identified by all who were surveyed as being difficulty in breathing. Another heartening aspect was that precautionary measures were well known to both the groups of participants with appropriate hand washing techniques, avoidance of public gatherings, and covering of the mouth while coughing and sneezing as the top three precautionary measures. During the first week of March in India, all the telephone and cellular caller tunes were changed to advisories of how to prevent coronavirus disease and when to seek medical help, which included the above messages apart from appeals on television, etc [ 22 ].

There was less knowledge related to treatment and vaccine among both healthcare professionals and the general public, which was a disappointing finding for healthcare professionals as they were expected to be aware of this. The same could be said of the knowledge of the infectivity period and duration of being asymptomatic after infection. There was a good knowledge of the usage of masks among the general public and healthcare professionals except for the usage of medical masks for healthy people to protect themselves. The ICMR and other bodies have issued guidelines on the usage of masks and this seems to have been disseminated widely [ 23 ]. There was also a low insistence on the need for testing those without respiratory difficulty. In a scenario where testing resources are limited, this is an appropriate response but since it is possible to have the infection without respiratory difficulty, especially early on, this disinterest in getting tested, especially in healthcare personnel is worrisome when there is enough evidence of spread from asymptomatic and mildly symptomatic persons. It is also likely that this response may be due to the fact during the time that this questionnaire was administered, the total cases rose from 400+ to about 800+ and the testing strategy of ICMR was limited to those with contact or travel to SARS-CoV-2-affected areas [ 24 ].

Since writing this manuscript, except for a single source event of a religious gathering in Delhi, which caused the doubling of cases to increase from about seven days to 4.1 days, it is reasonable to conclude that adequate knowledge exists among the general public. We can only hope that this would be enough to ensure that lockdown to reduce transmission and flatten the curve will be successful [ 25 - 28 ].

Conclusions

The COVID-19 pandemic has affected the world in various ways. The deficiency of information, the need for accurate information, and the rapidity of its dissemination are important, as this pandemic requires the cooperation of entire populations. The rapid survey that we conducted had a good response and we show that healthcare professionals and the general public were quite well informed about the coronavirus. They are aware of the measures needed to be taken to reduce the spread of the disease. The knowledge present allows the authors to speculate that the lockdown in India would be effective. The public receives a large amount of information from social media such as WhatsApp and the medical fraternity and government need to develop strategies to ensure that accurate information needs to spread in these fora. The public awareness is quite high and it is important that the knowledge of communication channels be known and be kept at the topmost priority throughout the pandemic.

Acknowledgments

We are thankful to Dr. Mili Shah for language check of our manuscript.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained by all participants in this study. INSTITUTIONAL ETHICS COMMITTEE ‐ 2 H M PATEL CENTRE FOR MEDICAL CARE AND EDUCATION, KARAMSAD [ECR/1123/Inst/GJ/2018] issued approval IEC/ HMPCMCE/ 2019 / Ex. 07/. The following is part of the text of the approval letter indicating approval for the study. "Your research proposal ‘Response of the public and health care providers to a pandemic of a new virus’ was submitted for review and approval by committee members under Exempt Review. As it involves collection of data using anonymous online questionnaire with maintenance of privacy and confidentiality, it qualified for an Exempt from Full Committee Review. The matter was reviewed by Committee Members and decided to review it under ‘Exempt from full committee’ review. After review and subsequent clarification by you, the project is approved by IEC in its present form. As the online form has information and consent section, which needs to be read and accepted by the respondents before answering the study questions, committee waivers the need for any other consent for data collection."

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

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The impact of an enhanced health surveillance system for COVID-19 management in Serrana, Brazil

Affiliations.

• 1 Serrana State Hospital, SP, Brazil.
• 2 Health Department, Serrana, SP, Brazil.
• 3 Ribeirão Preto Medical School, University of São Paulo, São Paulo, SP, Brazil.
• 4 Instituto Butantan, São Paulo, SP, Brazil.
• PMID: 35946045
• PMCID: PMC9354446
• DOI: 10.1016/j.puhip.2022.100301

Objective: To describe the successful implementation of an enhanced public health surveillance system based on early detection, tracing contacts, and patient follow-up and support.

Study design: A prospective observational cohort study conducted in Serrana, São Paulo State, Brazil.

Methods: The implementation was based on four axes: increasing the access to SARS-CoV-2 testing; correct swab collection; testing patients with mild symptoms; and patient follow-up. Positivity rate, patient demographic and clinical characteristics, dynamics of disease severity, SARS-CoV-2 genome evolution, and the impact on COVID-19 research were assessed from August 23, 2020 to February 6, 2021 (between epidemiological week 35/2020 and 5/2021, a total of 24 weeks).

Results: The number of sites collecting rt-PCR for SARS-CoV-2 was increased from one to seven points and staff was trained in the correct use of personal protective equipment and in the swab collection technique. During the study period, 6728 samples were collected from 6155 participants vs. 2770 collections in a similar period before. SARS-CoV-2 RNA was detected in 1758 (26.1%) swabs vs. 1117 (36.7%) before the implementation of the surveillance system ( p < 0.001 ). Positivity rates varied widely between epidemiological weeks 35/2020 and 5/2021 (IQR, 12.8%-31.3%). Out of COVID-19 patients, 91.1% were adults at a median age of 35 years (IQR, 25-50 years), 42.6% were men and 57.4% were women, with a SARS-CoV-2 positivity rate of 28.6% and 24.4% ( p < 0.001 ), respectively. The most common symptoms were headache (72.6%), myalgia (65.0%), and cough (61.7%). Comorbidities were found in 20.8% of patients, the most common being hypertension and diabetes. According to the World Health Organization clinical progression scale, 93.5% of patients had mild disease, 1.6% were hospitalized with moderate disease, 3.2% were hospitalized with severe disease, and 1.4% died. The enhanced surveillance system led to the development of COVID-19 related research.

Conclusions: The enhanced surveillance system in Serrana improved COVID-19 understanding and management. By integrating community and academic institutions, it was possible to monitor SARS-CoV-2 positive cases and variants, follow the epidemic trend, guide patients, and develop relevant research projects.

Keywords: COVID-19; Public health; Public health surveillance; SARS-CoV-2.

© 2022 The Authors.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

SARS-CoV-2 positivity rate per epidemiological…

SARS-CoV-2 positivity rate per epidemiological week in Serrana, Brazil, from epidemiological week 35,…

SARS-CoV-2 positivity rate per health…

SARS-CoV-2 positivity rate per health unit in Serrana, Brazil, from epidemiological week 35,…

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Long-Term Health Effects of COVID-19: Disability and Function Following SARS-CoV-2 Infection (2024)

Chapter: 6 overall conclusions.

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6 Overall Conclusions This chapter presents nine conclusions derived by the committee from evidence presented throughout the report. This chapter does not include ref- erences. Citations to support the text and conclusions herein are provided in previous chapters of the report. DIAGNOSIS OF LONG COVID Long COVID is associated with a wide range of new or worsening health conditions and encompasses more than 200 symptoms involving nearly every organ system. There currently are no consensus-based diagnos- tic criteria for the condition; criteria for diagnosis are evolving as experi- ence and research findings develop. Diagnosis of Long COVID is generally based on a known or presumed history of acute SARS-CoV-2 infection (as indicated by a positive viral test or patient self-report; as of this writing, no diagnostic test for Long COVID is available), the presence of Long COVID health effects and symptoms, and consideration of other conditions and etiologies that could be causing the symptoms. Testing to diagnose acute SARS-CoV-2 infection, as well as testing capacity and behaviors, has changed dramatically over the course of the COVD-19 pandemic. Testing was constrained during the early phase of the pandemic, although it subsequently became increasingly available, and the introduction of at-home testing meant that many people may not have reported their positive results to health care systems. As a result of these two drivers, many individuals infected with SARS-CoV-2 never received formal 215 PREPUBLICATION COPY—Uncorrected Proofs A02506-Long-Term_Health_Effects_of_COVID-19_Ch06.indd 215 5/21/24 11:25 AM 

216 LONG-TERM HEALTH EFFECTS OF COVID-19 documentation of their diagnosis. Sole reliance on a documented history of SARS-CoV-2 infection when diagnosing Long COVID will miss these indi- viduals. Therefore, the presence of signs and symptoms and self-reported prior infection are generally considered sufficient to establish a diagnosis of SARS-CoV-2 infection. Continued research on and discussion of Long COVID will help inform a case definition and standardized diagnosis. Based on its review of the literature, the committee reached the follow- ing conclusion: 1. Long COVID is a complex chronic condition caused by SARS-CoV-2 infection that affects multiple body systems. Because of wide variability in testing practices over the course of the pandemic, many people expe- riencing Long COVID have not received a formal diagnosis of prior SARS-CoV-2 infection. A positive test for SARS-CoV-2 is not necessary to consider a diagnosis of Long COVID. EPIDEMIOLOGY Long COVID can impact people across the lifespan, from children to older adults, as well as across sex, gender, racial, ethnic, and other demo- graphic groups. Women are twice as likely as men to experience Long COVID. Population surveys suggest that, as noted above, in 2022, the over- all prevalence of Long COVID was around 3.4 percent in U.S. adults and 0.5 percent in children. Estimates of the prevalence of specific long-term health effects of SARS-CoV-2 vary in the literature. This variation reflects the dynamic nature of the pandemic itself, as the virus has evolved and spawned many variants and subvariants (likely with different propensities to cause Long COVID), as well as the introduction of vaccines and treatments for acute infection (e.g., antivirals, steroids), both of which have been shown to reduce the risk of long-term health effects. Variation in incidence and preva- lence estimates also stem from the heterogeneity of study designs, including choice of control groups, methods used to account for the effect of baseline health, specification of outcomes, and other methodological differences. In addition, the broad multisystem nature of Long COVID and the fact that the associated health effects are expressed differently by age group and sex and by baseline health compound the challenge of identifying and quan- tifying affected populations. Symptoms of SARS-CoV-2 infection range in severity from mild to severe, and the literature suggests that the severity of acute SARS-CoV-2 infection is a risk factor for Long COVID. For example, a large Scottish population-based study found that 5 percent of those with mild infection had not recovered at least 6 months following infection, compared with 16 percent of those who required hospitalization—a ratio of approximately 1:3. PREPUBLICATION COPY—Uncorrected Proofs A02506-Long-Term_Health_Effects_of_COVID-19_Ch06.indd 216 5/21/24 11:25 AM 

OVERALL CONCLUSIONS 217 Based on its review of the literature, the committee reached the follow- ing conclusion: 2. The risk of Long COVID increases with the severity of acute infec- tion. By the committee’s best estimate, people whose infection was suf- ficiently severe to necessitate hospitalization are 2–3 times more likely to experience Long COVID than are those who were not hospitalized, and among those who were hospitalized, individuals requiring life support in the intensive care unit may be twice as likely to experience Long COVID. However, people with mild disease can also develop Long COVID, and given the much higher number of people with mild versus severe disease, they make up the great majority of people with Long COVID. HEALTH EFFECTS Long COVID is associated with hundreds of symptoms and new or worsening health effects that manifest in many different body systems. In keeping with the three domains of functioning in the International Clas- sification of Functioning, Disability and Health model of disability, health effects experienced in Long COVID may manifest as impairments in body structures and physical and psychological functions, with resulting activity limitations and restrictions on participation. Evidence on clustering of the post-acute and long-term health effects of SARS-CoV-2 infection remains inconsistent across studies. Consensus is needed on terms, definitions, and methodological approaches for generating better-quality and more consis- tent evidence. Based on its review of the literature, the committee reached the follow- ing conclusion: 3. Long COVID is associated with a wide range of new or worsening health conditions impacting multiple organ systems. Long COVID can cause more than 200 symptoms and affects each person differently. Attempts to cluster symptoms have yielded heterogeneous results. FUNCTIONAL IMPACT AND RISK FACTORS Some of the symptoms and health effects associated with Long COVID can be severe enough to interfere with an individual’s day-to-day functioning, including participation in work and school activities. Functional disability associated with Long COVID has been characterized as the inability to return to work, poor quality of life, diminished ability to perform activities of daily living, decreased physical and cognitive function, and overall disability. PREPUBLICATION COPY—Uncorrected Proofs A02506-Long-Term_Health_Effects_of_COVID-19_Ch06.indd 217 5/21/24 11:25 AM 

218 LONG-TERM HEALTH EFFECTS OF COVID-19 The severity of acute COVID-19 is a major risk factor for poor functional outcomes, but even people with mild initial illness can experience long-term functional impairments. Increased number and severity of long-term symp- toms correlate with decreased quality of life, physical functioning, and ability to work or perform in school. Other risk factors for poor functional out- comes include female sex, lack of vaccination against SARS-CoV-2, baseline disability or comorbidities, and smoking. There is some overlap between SSA’s current Listing of Impairments (Listings) and health effects associated with Long COVID, such as impaired lung and heart function. However, it is likely that most individuals with Long COVID applying for Social Security disability benefits will do so based on health effects not covered in the Listings. Three frequently reported health effects that can significantly interfere with the ability to perform work or school activities and may not be captured in the SSA Listings are chronic fatigue and post-exertional malaise, post-COVID-19 cognitive impairment, and autonomic dysfunction, all of which can be difficult to assess clinically in terms of their severity and effects on a person’s functioning. Based on its review of the literature, the committee reached the follow- ing conclusion: 4. Long COVID can result in the inability to return to work (or school for children and adolescents), poor quality of life, diminished ability to perform activities of daily living, and decreased physical and cognitive function for 6 months to 2 years or longer after the resolution of acute infection with SARS-CoV-2. Increased number and severity of long- term health effects correlates with decreased quality of life, physical and mental functioning, and ability to participate in work and school. Health effects that may not be captured in SSA’s Listing of Impairments yet may significantly affect an individual’s ability to participate in work or school include, but are not limited to, post-exertional malaise and chronic fatigue, post-COVID-19 cognitive impairment, and autonomic dysfunction. LONG COVID IN CHILDREN AND ADOLESCENTS While there are various definitions of children, adolescents, and young people, for the purposes of this report, “children” or “pediatrics” refers to the entire pediatric age range and “adolescents” to children at the older end of the spectrum (i.e., ages ~11 to 18 years). Even though most children experience mild acute COVID-19 illness, they can experience Long COVID regardless of the severity of their acute infection. As with adults, they may experience health effects across many body systems. Commonly reported symptoms include fatigue, weakness, headache, sleep disturbance, muscle PREPUBLICATION COPY—Uncorrected Proofs A02506-Long-Term_Health_Effects_of_COVID-19_Ch06.indd 218 5/21/24 11:25 AM 

OVERALL CONCLUSIONS 219 and joint pain, respiratory problems, palpitations, altered sense of smell or taste, dizziness, and dysautonomia. Although pediatric presentations and intervention options may overlap with those in adults—particularly among adolescents, who may be more likely than children to mimic the adult presentation and trajectory—pediatric management of Long COVID entails specific considerations related to developmental age and/or dis- abilities and history gathering. In general, children have fewer preexisting chronic health conditions compared with adults; thus, long COVID may represent a substantial change from their baseline, particularly for those that were previously healthy. Limited data are available on long-term outcomes in children. Some youth with persistent symptoms experience difficulties that affect their quality of life and result in increased school absences, as well as decreased participation and performance in school, sports, and other activities. Risk factors for the development of Long COVID include acute-phase hospi- talization, preexisting comorbidity, and infection with pre-Omicron vari- ants. Most children with Long COVID recover slowly over time, but not all. In one prospective cohort study of 1,243 children (ages 4-10) with Long COVID, for example, 48 percent remained symptomatic at 6 months, 13 percent at 12 months, and 5 percent at 18 months after infection. Impor- tantly, severity of symptoms and functional impairment from Long COVID symptoms were not correlated with traditional clinical testing (e.g., lung ultrasound, standard systolic and diastolic function on echocardiogram). It is important to note that in pediatrics, because of typical develop- ment, the baseline for performance of skills is constantly changing, espe- cially among young children. This can make deviations in their performance during Long COVID challenging to assess, and there may be a delay in recognition of any deviations (e.g., lack of developing a skill at the appro- priate age). Additionally, the duration of symptoms (e.g., 1 or 3 months) can feel very different to and have a greater impact on children compared with adults. Currently, there is a dearth of prospective and cross-sectional studies on the prevalence, risk factors, and time course and pattern of Long COVID in children. More research is needed to identify the long-term functional implications of Long COVID in children, because information from adult studies may not be directly applicable to the pediatric population. Based on its review of the literature, the committee reached the follow- ing conclusion: 5. Although the large majority of children recover fully from SARS-CoV-2 infection, some develop Long COVID and experience persistent or intermittent symptoms that can reduce their quality of life and result in increased school absences as well as decreased participation and per- formance in school, sports, and other activities. Overall, the trajectory PREPUBLICATION COPY—Uncorrected Proofs A02506-Long-Term_Health_Effects_of_COVID-19_Ch06.indd 219 5/21/24 11:25 AM 

220 LONG-TERM HEALTH EFFECTS OF COVID-19 for recovery is better among children compared with adults. More research is needed to understand the long-term functional implications of Long COVID in children, as information from adult studies may not be directly applicable. DISEASE MANAGEMENT Currently there are no Food and Drug Administration (FDA)–approved drugs or disease-modifying treatments for Long COVID. As with other complex multisystem conditions, management of Long COVID relies on techniques for controlling symptoms and improving functional ability, such as pacing (i.e., balancing periods of activity and rest in daily life), mobility support, social support, diet modulation, pharmacological treatment of secondary health effects, cognitive-behavioral therapy, and rehabilitation. Management often requires a multidisciplinary team. Because of the mul- tisystem nature of the condition, different approaches may be needed to address the variety of clinical presentations and environmental factors (e.g., living situation, work requirements, family support) among individuals. Numerous randomized controlled trials are currently being undertaken to determine the efficacy of a number of identified pharmacological agents; however, limited data have been published, and trials are yet to be finalized. Based on its review of the literature, the committee reached the follow- ing conclusion: 6. There currently is no curative treatment for Long COVID itself. Man- agement of the condition is based on current knowledge about treating the associated health effects and other sequelae. As with other complex multisystem chronic conditions, treatment focuses on symptom man- agement and optimization of function and quality of life. DISEASE COURSE AND PROGNOSIS Recovery from Long COVID varies among individuals, and data on recovery trajectories are rapidly evolving. Initial data suggest that peo- ple with persistent Long COVID symptoms generally improve over time, although preliminary studies suggest that recovery can plateau 6–12 months after acute infection. Studies have shown that only 18–22 percent of those who have persistent symptoms at 5–6 months following infection have fully recovered by 1 year. Among those who do not improve, most remain stable, but some worsen. More information on recovery trajectories at 1 year or longer may become available in the next few years. Rehabilitation and symptom management, including pacing, may improve function in some people with Long COVID, regardless of the severity of disease or duration PREPUBLICATION COPY—Uncorrected Proofs A02506-Long-Term_Health_Effects_of_COVID-19_Ch06.indd 220 5/21/24 11:25 AM 

OVERALL CONCLUSIONS 221 of symptoms, although the benefits are greater for those who are younger and who have had Long COVID for a shorter period of time. Based on its review of the literature, the committee reached the follow- ing conclusion: 7. Recovery from Long COVID varies among individuals, and data on recovery trajectories are rapidly evolving. There is some evidence that many people with persistent Long COVID symptoms at 3 months following acute infection, including children and adolescents, have improved by 12 months. Data for durations longer than 12 months are limited, but preliminary data suggest that recovery may plateau or progress at a slower rate after 12 months. HEALTH EQUITY The burden of seeking care and finding adequate services for Long COVID is challenging and can impact the potential for recovery. Patients with Long COVID may encounter skepticism about their symptoms when they present in medical settings, which discourages care seeking. This is particularly true for individuals disadvantaged by their social or economic status, geographic location, or environment, and can result in preventable disparities in the burden of disease and opportunities to achieve optimal health. Disadvantaged groups include members of some racial and ethnic minorities, people with disabilities, women, LGBTQI1 (lesbian, gay, bisex- ual, transgender, queer, intersex, or other) individuals, people with limited English proficiency, and others. Individuals with Long COVID have increased health care utilization and financial burden, which may be exacerbated if they are unable to work to gain income and or receive health insurance coverage. Members of dis- advantaged groups, especially early in the pandemic, were more likely to contract SARS-CoV-2, more likely to be hospitalized with acute COVID-19, more likely to have adverse clinical outcomes, and less likely to be vac- cinated, potentially increasing their risk of developing Long COVID. In addition, these groups are more likely to be uninsured or underinsured. Even for those with insurance coverage, some of the services that have been shown to improve function may not be covered by their benefits. Moreover, the availability of specialized Long COVID services is limited, and capacity does not match the demand for rehabilitation specialists. Limited transpor- tation, distance from clinics, and the inability to take time away from work or school are known barriers to care. The availability issue is particularly problematic for individuals living in medically underserved areas. Information about COVID is rapidly evolving, and this dynamic nature of the science may contribute to some patient hesitancy regarding PREPUBLICATION COPY—Uncorrected Proofs A02506-Long-Term_Health_Effects_of_COVID-19_Ch06.indd 221 5/21/24 11:25 AM 

222 LONG-TERM HEALTH EFFECTS OF COVID-19 prophylactic and therapeutic management for acute infection or Long COVID. Low levels of health literacy may also place some individuals at increased risk for misinformation, which may prevent them from fully tak- ing advantage of health care resources to protect and improve their health. Low health literacy may also impact individual self-management of the symptoms and conditions associated with Long COVID. Based on its review of the literature, the committee reached the follow- ing conclusion: 8. Social determinants of health, such as socioeconomic status, geographic location, health literacy, and race and ethnicity, affect access to health care. With respect to acute SARS-CoV-2 infection and Long COVID, adverse social determinants of health have contributed to disparities in access to SARS-CoV-2 testing; vaccination; and therapeutics, includ- ing treatments for acute infection and specialized rehabilitation clinics for Long COVID. In addition, the demand for specialty care exceeds capacity, resulting in waitlists for the receipt of services. SIMILAR CHRONIC CONDITIONS Long COVID shares many features with other complex multisystem conditions, including myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), fibromyalgia, and postural orthostatic tachycardia syndrome (POTS). The mechanism of action for infection-associated chronic illnesses remains unclear, and further investigation is needed. Current theories regarding potential mechanisms of action include viral persistence, immune dysregulation (including cytokine dysregulation or mast cell activation), neurological disturbances (e.g., neuroinflammation), cardiovascular damage (e.g., endothelial dysfunction, coagulation issues, orthostatic intolerance), gastrointestinal dysfunction (e.g., secondary to gut microbiome dysbiosis), metabolic issues (energy insufficiency, reactive oxygen species production, mitochrondrial dysfunction), and genetic variations. Currently, there are no specific laboratory-based diagnostic tests for Long COVID or ME/CFS, and diagnosis involves consideration of other potential causes of the symptoms. In general, Long COVID (especially that which does not meet criteria for ME/CFS) has a better prognosis than ME/ CFS. Some manifestations of Long COVID are similar to those of ME/CFS, and like ME/CFS, Long COVID appears to be a chronic illness, with few patients achieving full remission. Studies comparing Long COVID and ME/ CFS have several limitations, however. Because Long COVID is a new dis- ease, study participants are usually newly diagnosed, while ME/CFS study participants often have had the condition for longer and so are less likely to improve. Moreover, the definition of ME/CFS requires that symptoms PREPUBLICATION COPY—Uncorrected Proofs A02506-Long-Term_Health_Effects_of_COVID-19_Ch06.indd 222 5/21/24 11:25 AM 

OVERALL CONCLUSIONS 223 be ongoing for 6 months or more, whereas the duration criteria for Long COVID vary in the literature from 2 to 6 months, making the two condi- tions difficult to compare. Based on its review of the literature, the committee reached the follow- ing conclusion: 9. Complex, infection-associated chronic conditions affecting multiple body systems are not new, and Long COVID shares many features with such conditions as myalgic encephalomyelitis/chronic fatigue syn- drome, fibromyalgia, and postural orthostatic tachycardia syndrome. Current theories about the pathophysiology of these conditions include immune dysregulation, neurological disturbances, cardiovascular dam- age, gastrointestinal dysfunction, metabolic issues, and mitochondrial dysfunction. More research is needed to understand the natural history and management of complex multisystem chronic conditions, including Long COVID. PREPUBLICATION COPY—Uncorrected Proofs A02506-Long-Term_Health_Effects_of_COVID-19_Ch06.indd 223 5/21/24 11:25 AM 

PREPUBLICATION COPY—Uncorrected Proofs A02506-Long-Term_Health_Effects_of_COVID-19_Ch06.indd 224 5/21/24 11:25 AM 

Since the onset of the coronavirus disease 2019 (COVID-19) pandemic in early 2020, many individuals infected with the virus that causes COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have continued to experience lingering symptoms for months or even years following infection. Some symptoms can affect a person's ability to work or attend school for an extended period of time. Consequently, in 2022, the Social Security Administration requested that the National Academies convene a committee of relevant experts to investigate and provide an overview of the current status of diagnosis, treatment, and prognosis of long-term health effects related to Long COVID. This report presents the committee conclusions.

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ORIGINAL RESEARCH article

Phd-supervisors experiences during and after the covid-19 pandemic: a case study.

• 1 Department of Education, University of Bergen, Bergen, Norway
• 2 Department of Educational Studies in Teacher Education, Faculty of Education, Inland Norway University of Applied Sciences, Hamar, Norway
• 3 Department of Psychosocial Science, University of Bergen, Bergen, Norway
• 4 Faculty of Arts and Physical Education, Volda University College, Volda, Norway

Introduction: The COVID-19 pandemic has significantly impacted the education sector, and this case study examined nearly three hundred PhD supervisors in Norway. The study was driven by the urgent need to better understand the professional, social, and existential conditions faced by doctoral supervisors during extended societal shutdowns. This explorative case study builds on a former study among PhD candidates and investigates the experiences of doctoral supervisors when remote work, digital teaching, and digital supervision suddenly replaced physical presence in the workplace, largely between March 12, 2020, and autumn 2022, due to the COVID-19 pandemic.

Methods: A mixed-methods research approach, incorporating formative dialog research and case study design, was employed to bridge the conceptual and contextual understanding of this phenomenon. The primary data sources were a survey ( N = 298, 53.7% women, 46.3% men, response rate 80.54%) and semi-structured interviews (with nine PhD supervisors). Supplementary data collection was based on formative dialog research. It included field dialog (four PhD supervision seminars), open survey responses ( n = 1,438), one focus group ( n = 5), an additional survey ( n = 85), and document analysis of PhD policy documents and doctoral supervision seminar evaluations ( n = 7). The survey data, interview data, focus group data, and supplementary data focus also retrospectively on the first year of the pandemic and were collected from August 2022 until October 2023.

Results: The findings from the explorative case study revealed that the PhD supervisors faced numerous challenges during the pandemic, both professionally and personally. For PhD supervisors who extensively worked from home over a long period, the situation created new conditions that affected their job performance. These altered conditions hindered their research capacity, their ability to follow up with their PhD candidates, and their capacity to fulfill other job responsibilities. Although the PhD supervisors received some support during the pandemic, it seems that the incremental measures provided were insufficient.

Discussion: The case study results indicate that it is more important than ever to understand the gap between the formulation, transformation, and realization arenas when distinguishing between incremental, semi-structural changes and fundamental changes in PhD regulations and guidelines brought on by societal crises. This highlights the need for better crisis preparedness at the doctoral level in the years to come.

1 Introduction

Effective doctoral supervision is crucial for guiding PhD candidates through the complexities of their research, ensuring academic rigor and the successful completion of their dissertations ( Bastalich, 2017 ; Wichmann-Hansen, 2021 ; Kálmán et al., 2022 ). The role of PhD supervisors during the pandemic and their impact on educational quality at various levels has been an under-researched area both nationally and internationally ( Börgeson et al., 2021 ; Krumsvik et al., 2022 ). Supervisors who have varying experiences and work under diverse conditions are key players in the transformation arena where central policies are applied at the institutional level. Their interaction with PhD-candidates, whether in-person or remotely, shapes partly the quality of PhD-programs and candidates’ learning experiences. The COVID-19 pandemic has influenced the education sector in numerous ways, and this case study examined nearly three hundred PhD-supervisors in Norway with a Mixed Method Research design and different methods and data. The impetus for the study was the urgent need for a better knowledge base to understand the professional, social, and existential conditions for doctoral supervisors when society is shut down for an extended period. This explorative case study builds on our former study among PhD-candidates ( Krumsvik et al., 2022 ) and investigates the experiences of doctoral supervisors when remote work, digital teaching, and digital supervision suddenly replaced physical presence in the workplace (to varying extents).

First, the introduction contextualizes the study; second, the methodology is described; third, the main part presents the results from the survey part of the study; fourth, the data from the interviews and Supplementary data are presented; fifth, the discussion and conclusion are presented.

International policy documents underline the importance of PhD-supervision [ European University Association (EUA), 2010 , 2015 ] and, in Norway, it is crucial to view PhD supervision considering the specific frame factors for the PhD’s and some general trends of changed frame factors in doctoral education over the last 10 years ( Krumsvik, 2016a , 2017 ). It is therefore important to examine such frame factors in light of PhD-supervisors’ experiences during the pandemic, but the current state of knowledge is still limited around this topic. However, “The United Kingdom Research Supervision Survey Report 2021″ found that among the 3,500 PhD supervisors in the United Kingdom, 65% felt that supervisory responsibilities have increased during the pandemic, 32% agreed that “concerns over supervision have kept me awake at night over the last 12 months” and 31% agreed that “supervising doctoral candidates makes me feel anxious over the last 12 months” ( UK Council for Graduate Education, 2021 ). With these abovementioned issues in mind, this doctoral supervision study builds on our previous research on doctoral-level education ( Krumsvik and Jones, 2016 ; Krumsvik and Røkenes, 2016 ; Krumsvik et al., 2016a , b , 2019 , 2021 ; Krumsvik et al., 2022 ) and aims to examine the experiences of PhD supervisors in Norway during the pandemic to answer the research questions below:

1. To what extent has the COVID-19 pandemic impeded the PhD supervisors’ frame factors on the micro-level, and how do they perceive this situation?

2. To what extent has the COVID-19 pandemic influenced PhD supervisors’ frame factors on the meso-level, and how do they perceive this situation?

3. How do the PhD-supervisors experience the more general aspects of their supervision role during and after the pandemic?

1.1 The Norwegian context

To contextualize the research questions to the Norwegian context, one must remember that doctoral candidates in Norway are not students per se but are employees (on a 3–4 years contract) and more regarded as colleagues than students, and in this sense, the roles are more equal than in traditional supervisory relationships at a lower level (supervisor-student). Both by having PhD fellows being considered highly competent adult employees with state employment contracts, where they receive regular salaries, and have regular offices, they are initially part of the work community found within academia with its routines, duties, and rights. Another contextual aspect is that Norwegian PhD-candidates defend their theses relatively late in their careers. The average age for a candidate’s defense is between 37 and 38 years and higher for many candidates within the humanities and social sciences. In comparison, the median age across OECD countries is 29 ( Sarrico, 2022 , p. 1304). Table 1 provides a generalized comparison of doctoral education across Nordic countries, the UK, and the US ( Andres et al., 2015 ; Burner et al., 2020 ). While such broad overviews might exaggerate differences, they provide a framework for understanding doctoral education on a spectrum. This spectrum ranges from countries with significant government influence, where PhD candidates are employed (e.g., Nordic countries), to countries with moderate government influence, where PhD candidates are not employed (e.g., the UK), and finally to countries with minimal government influence, where PhD candidates are also not employed (e.g., the US). Despite these variations, the global trend indicates that doctoral education is becoming increasingly dependent on external funding ( Bengtsen, 2023 , p. 45).

Table 1 . Overview of the Nordic PhD model in comparison to UK and US models.

In addition, women defend their theses on average 2 years later than men. Taking into account that the average age for first-time mothers in Norway is now 30.1 years, there is a lot that needs to happen within a few years, and this may sometimes affect the feasibility of their PhD-projects. This can, e.g., be related to the gender differences in Norway about parental leave days during the pandemic which is much higher for women than for men at the universities ( Krumsvik et al., 2022 ) 1 . Another contextual factor that distinguishes doctoral supervision from other supervision (at lower levels) is that over 90% of the doctoral theses in Norway are article-based theses ( Krumsvik, 2016b ; Mason and Merga, 2018 ; Solli and Nygaard, 2022 ), which implies 3–4 published articles and an extended summary or synopsis (a “kappe” in Norwegian, ranging between 50 and 90 pages). This means that the PhD-candidates receive “supervision” and feedback from approximately 8–10 referees in scientific journals on their articles, in addition to feedback from their PhD supervisors. Because of this, many PhD-supervisors are co-authoring their doctoral candidates’ publications. A final contextual aspect is the recent studies indicating a decrease in doctoral disputations nationwide in Norway over the past two years ( Steine and Sarpebakken, 2023 ) – probably as a consequence of the pandemic. In a survey, Ramberg and Wendt (2023 , p. 22) found that about 60 percent of PhD candidates and 50 percent of postdoctoral candidates ( N = 300) were delayed during the autumn of 2022. The study showed that illness or leave, often due to caregiving responsibilities during the pandemic, was the most common reason for delays among PhD candidates and postdoctoral candidates, particularly impacting women more than men. Following illness, reduced access to supervisors, empirical data, research facilities, and external partners were significant factors contributing to delays in their research activities. Nearly a third of delayed candidates reported reduced access to supervisors, and about a fifth faced issues with external partner access, highlighting the critical role of these resources in completing research projects. When it comes to the PhD-supervisors, more specifically, the supervision differs from other types of supervision in that a formal PhD agreement is signed with a binding supervisor contract that lasts for 3–4 years (the PhD period) and is signed by both the supervisor and the candidate. The supervisor also has an overarching responsibility to avoid delays and ensure that the PhD program can be completed within the standard time frame. Supervisors are primarily responsible for guiding doctoral candidates on the specific, content-related aspects of their projects. This includes helping candidates identify the knowledge frontier in their field, position their study within the research field, develop clear and consistent research questions, choose appropriate scientific and methodological approaches, and provide expert guidance in discussing results and addressing ethical issues related to the thesis. This obviously places relatively high competence requirements on the supervisors, both in terms of their academic and research skills, and in relation to the doctoral supervision itself, as poor or inadequate supervision at this level can expose the candidate to a certain “drop-out risk” in the project.

Maintaining education quality during the COVID-19 pandemic has been challenging due to the widespread shift to digital teaching, supervision, and remote work. Many university teachers were unaccustomed to the online, digital learning environment, working with PhD candidates remotely for extended periods. Some taught in hybrid settings, with some PhD candidates quarantined at home while others attended in-person classes. Additionally, others navigated ordinary learning contexts with COVID-19 precautions like masks and social distancing. This situation altered frame factors, adding complexity to the discussion of education quality.

Considering this, the case study seeks to understand if, and potentially how, external factors in pedagogical contexts over which institutions, academics, and teachers have no direct control play out. Lindensjö and Lundgren (2014) find that such external factors might have a significant impact on the outcomes of educational training, teaching, and supervision. Therefore, it is crucial to contextualize the pandemic experiences among PhD supervisors with respect to these factors, as they imply national and institutional frames for their PhD supervision. Though there exist several quantitative, survey-based studies on the impact of COVID-19 on PhD supervision (e.g., Pyhältö et al., 2023 ; Löfström et al., 2024 ), there is still a lack of in-depth qualitative understanding of the impact of COVID-19 on the supervisory relationship. The studies of Löfström et al. (2024) and Pyhältö et al. (2023) indicated that supervisors faced significant challenges in identifying when PhD candidates needed assistance and providing adequate support for their well-being during the shift to remote supervision. Supporting the progress and wellbeing of full-time candidates, who were more adversely affected by the pandemic than their part-time peers, became increasingly difficult. The increase in email communications could overwhelm supervisors, exceeding manageable levels and complicating their ability to offer timely and effective feedback. The lack of spontaneous, informal conversation, previously facilitated by in-person meetings, further hindered their ability to monitor and support the candidates effectively. These challenges were particularly pronounced for supervisors in scientific fields requiring lab work and practical training, which were severely disrupted by the pandemic, and supporting the progress and wellbeing of full-time candidates, who were more adversely affected by the pandemic than their part-time peers, became increasingly difficult. Furthermore, supervisors reported that their PhD candidates’ lack of a scholarly community and inadequate supervision were significant challenges. This reflects the supervisors’ view that the availability of a supportive research environment and adequate supervision are critical for candidates’ success ( Pyhältö et al., 2023 ). The study by Pyhältö et al. (2023) also found that supervisors generally estimated the impact on candidates’ progress and well-being to be more negative than the candidates themselves did, which may imply that supervisors have a broader perspective on the long-term consequences of disruptions like the COVID-19 pandemic. Research prior to the pandemic ( Pyhältö et al., 2012 ) has shown that apart from the importance of having clear and long-term financing, proper research facilities, and sufficient time to pursue a PhD, supervisors also stress the significance of PhD candidates’ motivation, self-regulation, efficacy, and engagement as essential personal regulators for success in the PhD process.

1.2 Theoretical framework

This case study is exploratory and intrinsic ( Stake, 1995 , 2006 ), utilizing an abductive approach to theory with frame factor theory as our theoretical framework ( Lundgren, 1999 ; Lindensjö and Lundgren, 2014 ). Frame factor theory suggests that society’s influence on education manifests through a target system, an administrative system, and a legal system. This theory, used in educational sciences and pedagogy, acts as a lens for planning and analysis, positing that external factors, beyond the control of institutions and educators, significantly affect educational outcomes. We will further explain the contextual application of frame factor theory in this case study below.

Previous research highlights a gap in (doctoral) education between the formalization and realization arenas in frame factor theory ( Lindensjö and Lundgren, 2014 ; Krumsvik et al., 2019 ). Linde (2012) introduces a transformation arena between these two, explaining the difficulty of implementing measures in complex organizations like universities. There is rarely a straightforward relationship between central decisions (formulation arena or macro-level) and their implementation (realization arena or micro-level). Policy documents require interpretation and application by faculty leaders, PhD program leaders, supervisors, and PhD candidates (transformation arena or meso-level) ( Linde, 2012 ).

Given this context, a main focus of this case study was to evaluate how Norwegian PhD supervisors managed changed frame factors and education quality during the pandemic. The Norwegian Agency for Quality Assurance in Education (NOKUT) defines education quality as “the quality of teaching classes, other learning facilities, and students’ learning outcomes in terms of knowledge, skills, and general competence” ( Skodvin, 2013 , p. 2). It is important to differentiate between educational quality, study quality, and teaching quality.

Education quality is a broad concept encompassing everything from the subject/study program level to the government’s education policy. In contrast, study quality is narrower, referring specifically to the educational institution ( Skodvin, 2013 , p. 3). Teaching quality goes further to the micro-level, focusing on course quality, teacher effectiveness, and PhD supervision. This study examined how PhD supervisors experienced COVID-19 restrictions at the micro- and meso-levels, considering two of the three levels. Figure 1 illustrates the analytical lenses in this mixed methods research (MMR) and formative dialog research case study:

Figure 1 . The analytical focus in the case study ( Krumsvik et al., 2019 ) is based on the frame factor theory ( Linde, 2012 ; Lindensjö and Lundgren, 2014 ).

2 Methodology

To understand and corroborate conditions faced by doctoral supervisors related to COVID-19 extended societal shutdowns, both in breadth and in depth, we employed a mixed-methods research design, combining quantitative data to show the strength of associations and qualitative data to explore their nature ( Johnson et al., 2007 ; Creswell and Plano Clark, 2017 ). We utilized a three-stage design, QUAL-QUANT-QUAL (qualitative-driven sequential design, Schoonenboom and Johnson, 2017 ), making it a qualitative-dominant mixed-methods study ( Johnson et al., 2007 , p. 124). Using mixed methods research allowed us to explore the complex research problem more comprehensively compared to using either quantitative or qualitative data alone. Though the approach is less common in case studies ( Tight, 2016 , p. 380), the mixed methods are increasingly used (e.g., Ertesvåg et al., 2021 ; Hall and Mansfield, 2023 ; Peters and Fàbregues, 2023 ). Advocates of such approaches consider mixed methods to “complement and extend one another and thus lead to better descriptions, clearer explanations and an enhanced understanding of phenomena, research aims and questions” ( Ertesvåg et al., 2021 , p. 655).

Specifically, an exploratory, sequential mixed-methods design was used to address the research questions ( Fetters et al., 2013 ; Creswell and Plano Clark, 2017 ). This design involves collecting and analyzing qualitative data first (QUAL), using those findings to guide the quantitative data collection and analysis in the second phase (QUANT), and then using the quantitative results to inform further qualitative data collection and analysis in the third phase (QUAL). This method integrates through building, where results from one phase inform the next.

We conducted a cumulative data collection and analysis process ( Creswell and Guetterman, 2021 ), basing survey questions on previously collected data from field dialogues, online observations, seminar evaluations, and document analysis. The questionnaire consisted of a general demographic questions (e.g., gender, educational background and what field(s) the supervisor supervised in), in addition to a range of multiple response items addressing four key themes: (1) important factors to complete a PhD, (2) supervisor challenges, (3) working from home experiences, and (4) perceived need for future competences as supervisors. Finally the questionnaire contained a range of statements measured on a Likert-scale from 1 to 5 where 3 was neutral (e.g., to what extent do you feel that your PhD-candidate(s) are on track with their doctoral project?). The qualitative interview guide ( Kvale and Brinkmann, 2015 ) was developed from the prior quantitative data (survey), and the focus group guide was based on earlier survey and qualitative interview data (see Figure 2 below). We integrated research questions, methods, interpretation, and reporting at various points, using narratives where qualitative and quantitative results are presented in different sections of the same article through the contiguous approach ( Fetters et al., 2013 ). This article primarily examines the coherence between qualitative and quantitative findings based on confirmation , expansion , or discordance ( Fetters et al., 2013 ). The approach used in the study is similar to Hall and Mansfield (2023) and the coherence is derived from joint displays using visual means.

Figure 2 . The research process. The yellow arrows show the main data sources, and the blue arrows show the Supplementary data in this article. In addition, we have conducted focus group interviews and an extra survey, which will be published in another article (since they mainly focus on academic writing with the large language models).

As a consequence of the mixed-methods design, this study combines two approaches in case study research. The first, proposed by Stake (1995 , 2006) and Merriam (2009) and Merriam and Tisdell (2016) , is situated in a social constructivist paradigm, and is attached to the qualitative part (connected to the second part of each research question). The second, based on Eisenhardt (1989) , Flyvbjerg (2011) , and Yin (2012) , approaches the case study from a post-positivist perspective ( Hyett et al., 2014 , p. 1) (connected to the first part of each research question). This intrinsic case study ( Stake, 1995 ) aims to focus on ecological validity:

“Ecological validity is the degree of correspondence between the research conditions and the phenomenon being studied as it occurs naturally or outside of the research setting” ( Gehrke, 2018 , p. 563). Informant selection was based on a purposeful method ( Maxwell, 2013 ), in which we recruited PhD supervisors from Norway.

Next, all interviews were analyzed using reflexive thematic analysis ( Braun and Clarke 2019 , 2021 ) where themes were constructed and presented in this paper (see section 4). In addition, we also conducted a sentiment analysis ( Dake and Gyimah, 2023 ) of the nine interviews (see Supplementary file ).

To answer the research question, we combined formative dialog research ( Baklien, 2004 ) and case study research ( Stake, 2006 ). Data collection consisted of fieldwork (see Supplementary file ), a survey N = 298, 53.7% women, 46.3% men, response rate 80.54%, nine semi-structured interviews (with PhD supervisors), and one focus group ( N = 5). Supplementary data consisted of an additional survey ( N = 85), PhD-policy document analysis ( N = 6), field dialogues (4 PhD supervision seminars), open survey data (1,438 responses), seminar observations ( N = 4), and reviews of relevant documents such as evaluations of doctoral supervisor seminars. We also used policy documents and regulations concerning PhD education in Norway as supplementary sources.

We focused on how PhD supervisors experienced changing frame factors, such as university lockdowns, remote work, digital teaching, digital supervision, doctoral progression, and others, with an emphasis on illuminating the micro-level (course and teaching level) from the PhD supervisors’ perspective. This focus is twofold: the program’s structure and quality directly affected the PhD- supervisors during the pandemic. The second is simply that they conducted several evaluations about matters related to the structure and quality compared with the others. However, PhD- candidates’ opinions are also important, and their views are also interwoven because some of them have been present during field dialogs and participated in the PhD-supervision seminars.

When focusing on how PhD-supervisors experience their supervision, PhD’s research progression, psychosocial aspects, their nearest superior, and the main focus are on illuminating the meso-level (institutional and program level).

2.1 Cumulative research process

In our case study, we brought the experiences and our study among PhD’s ( Krumsvik et al., 2022 ) from the period March 12, 2020, to November 30, 2021, into our design of this study. We executed an excessive cumulative data collection process (including a part during the pandemic) and analysis, especially from August 2022 – October 2023. The relatively long time period allowed the researchers to test their interpretations along the way and detect contrary evidence, e.g., reach saturation during the coding and analysis of the qualitative data ( Creswell and Guetterman, 2021 ).

3.1 Quantitative part (survey)

Above and below are the results of the quantitative part of the study, based on the survey data. This analysis is tentative and covers only the survey results. The interview data and Supplementary data will be presented later in the paper. Two hundred and forty respondents completed the survey ( N = 298, 80.54% response rate). The academic backgrounds of the supervisors were diverse, with the three largest groups coming from natural sciences, humanities, education and teacher training. The largest group of supervisors (41.75%) supervised PhD candidates in education and teacher training (see Table 2 ).

Table 2 . Distribution of supervisors by academic background and PhD supervision in various fields.

A narrow majority (58.08%) of the supervisors had submitted an article-based dissertation (see more in attachment 5 in the Supplementary file ), in the Supplementary file meaning that approximately four out of ten supervisors have not “hands on” experience with article-based thesis as their thesis in their own doctoral degree. A large majority (81.67%) had supervised PhD candidates before and after the pandemic, while 11.67% had only supervised during and after. 41.27% of the supervisors stated that the coronavirus pandemic (from March 12, 2020 - January 2022) had impeded their candidate(s) progress in their doctoral project. 21.12% agreed (to a large or very large extent) that the PhDs’ publication process of articles to scientific journals has been delayed because of the journal’s peer review process during the pandemic (i.e., journal processing times seemed to increase due to several factors including a lack of available peer reviewers because of heavy workloads, health issues, more teaching, etc.).

3.1.1 Challenges in supervision

Results in Table 3 indicate that the most commonly reported challenges faced by supervisors during the pandemic were balancing work and family life and working from home, each affecting more than a third of the supervisors. Psycho-social aspects, such as loneliness, also emerged as a notable challenge. The cancelation of conference participation and stays abroad were significant issues, reflecting the broader impact on professional development opportunities. Concerns about supervision quality were also prominent. Some supervisors reported no challenges, highlighting a degree of variability in experiences. Other challenges included delays in the peer review process for journals, difficulties with publishing, and issues related to research ethics, though these were less commonly reported.

Table 3 . Challenges faced by supervisors during the pandemic in terms of supervision.

3.1.2 Challenges in working from home

Results in Table 4 indicated that supervisors faced multiple challenges while working from home during the pandemic. The most common issue was having little contact with colleagues, which affected more than six in ten supervisors. Supervisors also frequently reported having little contact with their PhD candidates. Distractions from others at home were another prevalent challenge. Many supervisors experienced an increased workload due to digital teaching from home, and lacking office equipment, such as desks and office chairs, was also commonly reported. Psycho-social aspects, such as loneliness, were significant issues as well. The lack of space and increased home responsibilities, such as childcare, were notable challenges. A smaller number of supervisors reported having no challenges at all. Other less commonly reported issues included limited access to library services and poor internet access.

Table 4 . Challenges faced by supervisors during the pandemic working from home.

3.1.3 Factors PhD candidates need to complete their doctorate

We find that there is a high degree of consistency between what supervisors ( Table 5 ) and PhD candidates ( Table 6 ) consider to be the most important factors for completing the doctorate. In particular, it is persistence, resilience, and the ability to work independently are the most important factors, in addition to supervision and co-writing with supervisors.

Table 5 . Most important factors in completing a PhD as reported by PhD supervisors.

Table 6 . Most important factors in completing a PhD as reported by PhD Candidates.

Thus, there is considerable agreement between what the supervisors and the PhD candidates report, which may indicate that within the academic tradition, the doctoral journey is primarily seen as an individual endeavor (feat of strength) where the supervisor is the closest supporter.

3.1.4 Appreciation of supervision

The supervisors mostly agreed that both they and the PhD candidates value supervision. 89.91% responded they agree or strongly agree to this question for themselves, and 92.47% responded they agree or strongly agree on behalf of the PhD candidates. In comparison, 61.25% responded similarly to whether the department values supervision, while 24.17% were neutral, and 14.59% responded they disagree or strongly disagree. This may suggest that the supervisory relationship is primarily between the PhD candidate and the supervisor, with less firm ties to the institution.

When it comes to what extent the supervisors think that their institution has been accommodating regarding compensating the loss of progress due to the coronavirus pandemic for their own PhDs, 27.2% stated that this had been done to a small extent or very small extent and 29.39% stated that this had been done to a large extent or very large extent. 30.1% agreed (large extent and very large extent) that supervisory responsibilities have increased during the pandemic. 13.3% expressed (to a large or very large extent) that supervising doctoral candidates makes them feel anxious’ over the last 24 months” (pandemic), but the majority (64.3%) experienced this to a small and very small extent. 9.3% expressed (to a large and a very large extent) that concerns over doctoral supervision have kept them awake at night over the last 24 months (pandemic), but the majority (69.3%) experienced this to a small and very small extent. 56.1% of the supervisors have not discussed any challenges with the progress of their doctoral candidate(s) project due to the coronavirus pandemic with the department’s human resources manager/head.

When asked how many hours they have enshrined in their working plan per semester as the main supervisor per PhD candidate, supervisors state this varies from zero to above 80 h, but for the majority, it is between 20 and 40 h per semester (40.46%). 23.1% state they do not think that their PhD-candidate(s) are on track with their doctoral project, while 50.2% state that their PhD-candidate(s) are on track with their doctoral project. Some PhDs publish their articles in their thesis based on pre-collected data (e.g., as a part of bigger projects), while others publish their articles in their thesis based on data collections done by themselves. 58.77% of the supervisors think this affects the completion time for the last group of PhDs (large and very large extent). 53.4% of the supervisors have been co-authoring their doctoral candidates’ publications.

3.1.5 What competencies supervisors need

As seen from Table 7 , nearly half of the supervisors believed they needed more pedagogical and methodological competence related to supervision. Additionally, about one-third felt they lacked knowledge about formal aspects, such as guidelines, related to the PhD program. The supervisors reported that the guidelines for the doctoral program were somewhat clear, particularly those for article-based dissertations. This perceived clarity was positively correlated ( r = 0.23, p = 0.002) with the extent to which the institution offered “continuing professional development” (CPD), and 39.88% of the supervisors stated that their institution did not provide supervisors with CPD. Thus, while many supervisors recognized the need for enhanced pedagogical and methodological skills, as well as a better understanding of formal guidelines, the availability of CPD programs was associated with clearer doctoral program guidelines. This suggests that increasing access to professional development opportunities could improve supervisors’ competence and clarity regarding program requirements, ultimately benefiting the supervision process.

Table 7 . Competencies PhD supervisors believe they need to increase.

3.1.6 Female academics with children

About four out of ten supervisors (41.07%) agreed (to a large or very large extent) that female PhDs with children seem to have more home responsibilities than men (e.g., for childcare, household, homeschooling, own children in quarantines, etc.) during the pandemic. About three out of ten (27.77%) agreed (to a large or very large extent) that female PhDs’ (with own children) submission rates to scientific journals have been delayed as a consequence of COVID-19, considering that women seem to have more home responsibilities (e.g., for childcare, household, homeschooling, own children in quarantine, etc.) during the pandemic. About two out of ten (23.64%) agreed (to a large or very large extent) that female supervisors’ (with their own children) submission rates to scientific journals have been delayed as a consequence of COVID-19, considering that women seem to have more home responsibilities (e.g., for childcare, household, homeschooling, own children in quarantine, etc.) during the pandemic.

Cronbach’s alpha ( α = 0.87) indicated a high level of consistency among three statements concerning the increased home responsibilities faced by female researchers with children compared to their male counterparts during the pandemic. These statements highlighted that female researchers with children appeared to bear more responsibilities at home, such as childcare, household tasks, and homeschooling, and as a result, their submission rates to scientific journals had been adversely affected by COVID-19. The average response (mea n = 3.18, standard deviatio n = 0.88) indicated that the supervisors were generally neutral toward these statements. However, closer inspection revealed that female supervisors (mea n = 3.29, standard deviatio n = 0.92) agreed with these statements more than male supervisors (mea n = 3.03, standard deviatio n = 0.79), a difference that was statistically significant ( p = 0.017) but with a small effect size (Cohen’s d = 0.30). There was a positive correlation ( r = 0.23, p = 0.002) between whether the PhD candidate had considered quitting the PhD program and the three statements, which suggests that supervisors who reported that PhD candidates had considered quitting also agreed more with the statements. Conversely, a negative correlation ( r = −0.21, p = 0.002) was found between considering quitting the PhD program and the belief that the institution made sufficient efforts to compensate for the lack of progress during the pandemic, indicating that better institutional support might have reduced the likelihood of candidates considering quitting.

3.2 Qualitative part (interview data and other types of qualitative data)

We conducted a cumulative data collection process where the qualitative interview guide questions were built upon previously collected quantitative data (survey). Based on a snowballing sample ( Patton, 2015 ), we recruited nine doctoral supervisors from the humanities, social-, and educational sciences with diverse experience and approaches to supervising PhD candidates during the pandemic. Using semi-structured interviews ( Brinkmann, 2022 ), each supervisor was interviewed online using Zoom with interviews lasting from 30 to 60 min. All interviews were conducted in Norwegian and later transcribed verbatim. We followed Braun and Clarke’s, (2019 , 2021) approach to reflexive thematic analysis to analyse the interview data. The themes constructed from the analysis of the interview data focus issues, such as “The Impact of the Pandemic on Supervision,” “Home Office Experience,” Workload and Employer Support,” “PhD Candidate Preparation for Article-Based Theses,” “Competence in Supervising Article-Based Theses,” and “Guidelines and Structuring the PhD Process.”

3.2.1 Analyzing the interview with Kyle

Introduction: Kyle, aged 47, specializes in professional ethics. He completed his doctoral degree through a monographic thesis and is relatively new to supervising PhD candidates, currently guiding three, two of whom he is the main supervisor.

Impact of the Pandemic : Kyle wore two hats during the pandemic: as a PhD supervisor and as a leader of a doctoral program. He noted that the pandemic did not significantly impact his supervisees due to well-planned data collection that adapted to digital formats when necessary. His role as the program leader gave him broader insights into how other candidates fared, with some experiencing difficulties in recruiting interviewees and needing to adjust their research plans accordingly.

PhD Supervision During the Pandemic : Kyle’s supervision was largely unaffected by the pandemic as most of it was conducted digitally, catering to students located in different parts of the country. He emphasized the importance of maintaining frequent contact, especially when usual social and professional gatherings were suspended. The pivot to online platforms like Zoom and increased digital communication tools helped maintain the continuity and quality of supervision.

Home Office Experience : Working from home was generally positive for Kyle, who appreciated the reduced distractions and the ability to maintain productivity with a well-equipped home office. However, he missed informal interactions with colleagues, which were hard to replicate through digital means.

Workload and Employer Support : Kyle experienced a slight increase in workload as more effort was required to monitor and support students remotely. His interactions with his Head of Department/direct manager were supportive, helping him navigate the challenges of remote supervision.

PhD Candidate Preparation for Article-Based Theses : Kyle observed that many PhD candidates were unprepared for the intricacies of article writing, including the lengthy processes of submission and peer review. He attributed this to their educational background, which primarily focused on monographic work at the bachelor’s and master’s levels.

Competence in Supervising Article-Based Theses : Although Kyle has not written a synopsis (‘kappe’, i.e., a synthesis chapter for article-based theses) himself, he feels prepared due to his involvement in supervisor training programs that include synopsis writing. He believes in collaborative supervision where co-supervisors with more experience in specific areas can complement his guidance.

Guidelines and Structuring the PhD Process : Kyle praised the clarity of guidelines regarding the synopsis writing at his program, highlighting proactive efforts to discuss and understand these guidelines among candidates and supervisors. He supports the idea of starting the synopsis early in the PhD journey, allowing candidates to develop a clear perspective on how their articles will integrate into their larger thesis narrative.

Summary: Kyle’s approach to PhD supervision during the pandemic was proactive and adapted to the challenges of remote interactions. He emphasizes the importance of clear guidelines, structured support from the academic program, and the benefits of collaborative supervision. His perspective offers valuable insights into managing PhD supervision under crisis conditions and highlights areas for potential improvement in preparing candidates for the demands of article-based theses.

3.2.2 Analyzing the interview with Sally

Introduction: Sally, aged 46, is experienced in the field of educational sciences and professional research, having supervised 15 PhD candidates to completion. She conducted her doctoral research through an article-based thesis.

Impact of the Pandemic on PhD Candidates : Sally observed that the pandemic had a limited impact on most of her PhD candidates, except for 2–3 individuals who experienced delays, partially due to the pandemic. Disputations were delayed for some candidates who preferred physical attendance, affecting their completion timeline.

Adaptations in Supervision Methods: The pandemic made Sally diversify her supervision methods, including more frequent digital meetings with Zoom or Teams and asynchronous communications like email. She shifted from paper-based to digital comments on drafts, which enhanced the efficiency and immediacy of feedback. This change is something she intends to continue using beyond the pandemic.

Home Office Experience: Sally found working from home manageable and returned to the office as soon as feasible, particularly because she needed to balance work with family responsibilities. The transition to the home office did not significantly disrupt her supervision activities, though it introduced minor challenges like occasional distractions from family.

Increased Workload During the Pandemic: Sally reported a slight increase in her workload during the pandemic due to a need for more frequent communication to ensure the continuity and quality of supervision. This was compounded by the timing of her candidates being in critical phases of their thesis work.

Support from Employer: She felt that the focus of her institution’s support during the pandemic was more on ensuring that PhD candidates were well-supported rather than directly supporting the supervisors themselves.

Preparedness of PhD Candidates: Sally noted that while the PhD candidates were generally well-prepared academically, they often lacked specific training in writing article-based theses, a significant adjustment from writing monographic theses typical at the bachelor’s and master’s levels.

Competence in Supervising Article-Based Theses: Sally felt confident in her ability to supervise article-based theses despite recognizing the ongoing need to adapt and learn, particularly in managing the synthesis chapter or “kappen.”

Clarity of Guidelines for the Synopsis: She found the guidelines for writing the synopsis at her institution clear and involved in educational efforts to help candidates understand these guidelines better. However, she questioned whether standardization would improve understanding or unnecessarily restrict academic freedom.

Timing for Writing the Synopsis: Reflecting on her experience and current practices, Sally advocated for thinking about the synopsis early in the doctoral process but cautioned against producing extensive texts prematurely. She emphasized the importance of adapting the scope of the synopsis as the research evolves.

Use of Doctoral Committees’ Guidelines: Sally observed that adherence to guidelines varies depending on whether committee members are national or international, with international members often impressed by the candidate’s ability to publish in high-ranking journals.

Overall, Sally’s experiences and insights provide a nuanced view of PhD supervision during the pandemic, highlighting flexibility, adaptation, and the importance of maintaining high standards of communication and support. Her approach demonstrates a balance between structured guidance and allowing academic independence, aiming to foster resilience and adaptability among her PhD candidates.

3.2.3 Analyzing the interview with Gabbie

Introduction: Gabbie, aged 54, specializes in school and teacher education. She has supervised two PhD candidates to completion and is currently guiding four others. Her doctoral thesis was article-based.

Impact of the Pandemic on PhD Candidates : Gabbie observed varied impacts of the pandemic on her PhD candidates. While two of her students were minimally affected, one faced significant challenges in data collection due to difficulties in recruiting informants. This disparity seems to have been influenced by the candidates’ approaches or perhaps their personal rapport with potential informants.

Changes in Supervision Practices: The pandemic shifted Gabbie’s supervision to entirely online formats using Zoom, Teams, or phone apps. While she was accustomed to digital interaction, the lack of informal, face-to-face interactions led to a more formal and structured supervision style. The spontaneous “corridor conversations” that often enhance relational aspects of supervision were missing, which she felt detracted from the personal connection in the supervisor-supervisee relationship.

Home Office Experience: Gabbie had a positive experience working from home, finding it efficient and beneficial due to eliminating commute times and the conducive environment at home for focused work. Her family setup supported this arrangement well, allowing her to balance work and home life effectively during the pandemic.

Workload Changes During the Pandemic: Her workload in terms of PhD supervision remained roughly the same, though the nature of interactions changed. Instead of impromptu office drop-ins, there were more scheduled meetings, primarily online via Zoom or Teams, which required a different kind of preparation and possibly led to more structured discussions.

Support from Employer: Gabbie noted a lack of specific support for supervisors from her employer during the pandemic; the focus was more on ensuring that she, like other staff, was generally coping with the pandemic’s challenges. There was an emphasis on looking out for the PhD candidates’ well-being, translating into a directive for supervisors to maintain close contact and support.

Preparedness of PhD Candidates for Article-Based Theses: Similar to Kyle and Sally, Gabbie agreed with the survey findings that many candidates are not well-prepared for writing article-based theses. She attributes this to their academic background, which primarily focuses on monograph writing. She advocates for collaborative writing for the first article to help familiarize candidates with the process of scholarly writing and peer review.

Evaluation of Own Competence in Supervising Article-Based Theses: She feels confident in her supervisory skills but acknowledges that continuous learning and discussion with peers are essential for handling complex or unfamiliar issues that arise during supervision. Gabbie appreciates the collaborative nature of the supervisory teams at her institution, which helps in managing any gaps in her experience or knowledge.

Clarity of Guidelines for the Synopsis: Gabbie finds the guidelines for writing the synopsis to be somewhat unclear and open to interpretation, suggesting that more explicit guidelines could help, especially for those new to supervising or external committee members who evaluate the theses.

When to Start Writing the Synopsis : She recommends that PhD candidates consider the synopsis throughout their doctoral journey but compile it towards the end. Gabbie advises keeping a file of potential content for the synopsis from the start of the doctoral process, which can include discarded sections from articles or ideas that do not fit into the articles but are valuable for the overarching thesis narrative.

Overall, Gabbie’s experience reflects a pragmatic and flexible approach to PhD supervision. She adapts to the demands of the pandemic while trying to maintain the quality of academic mentorship. Her strategies for managing remote supervision and her positive attitude toward the enforced changes highlight a successful adaptation to the challenges posed by the pandemic.

3.2.4 Analyzing the interview with Henrik

Introduction: Henrik, aged 46, specializes in school and educational research. He has successfully guided three PhD candidates as a primary supervisor and is supervising four more. His doctoral thesis was a monograph.

Impact of the Pandemic on PhD Candidates: Henrik noted that the pandemic affected his PhD candidates differently based on the nature of their research. Those engaged in classroom interventions faced significant challenges due to pandemic-related restrictions, particularly in accessing schools and conducting fieldwork. Conversely, candidates focused on desk-based research, such as literature reviews, experienced fewer disruptions. One of his candidates, involved in empirical research, had to receive an eight-month extension due to difficulties in data collection, exacerbated by strikes in the secondary education sector.

Changes in Supervision Practices: The transition to online supervision did not significantly affect Henrik, as he was already accustomed to conducting supervision via video conferencing tools like Teams and Zoom. However, he missed the informal, face-to-face interactions that often enrich the supervisory relationship. He noted that the absence of casual corridor conversations led to a more formal and structured online interaction.

Home Office Experience: Henrik found the exclusive home office setup challenging and detrimental to his well-being. He prefers a balance between working at the office and from home. The lack of physical interaction with colleagues and the continuous remote work environment negatively impacted his mental health, requiring him to seek professional health support.

Workload Changes During the Pandemic: Henrik reported that his workload related to PhD supervision did not increase significantly during the pandemic. However, other responsibilities became more demanding, and the overall context of working from home without the usual workplace interactions made certain tasks more difficult.

Support from Employer: There was no specific support provided by his employer concerning his role as a PhD supervisor during the pandemic. Support efforts were more generalized and not tailored to the unique challenges faced by supervisors.

Concerns for PhD Candidates: Henrik was particularly concerned about the mental health of his candidates, noting that the isolation and disruption caused by the pandemic were significant stressors. He proactively discussed these issues with his candidates, acknowledging the challenges faced by those with families and those who were isolated without a support network.

Personal Health Concerns: The pandemic had a substantial impact on Henrik’s mental health, highlighting the importance of considering the well-being of supervisors along with their candidates during such crises.

Effect on Completion Times: Henrik observed that the pandemic inevitably led to delays in the completion times of his PhD candidates, with some requiring extensions. He noted a disparity in how extensions were granted, suggesting a need for more consistent criteria.

Preparation for Article-Based Theses: Henrik believes that most PhD candidates are not well-prepared to write article-based theses, as their previous academic training typically does not include writing journal articles. He spends significant time discussing the publication process with his candidates to demystify it and help them understand the expectations of journal editors and peer reviewers.

Overall Reflection: Henrik’s experience reflects the diverse impacts of the pandemic on different types of research activities and highlights the importance of flexibility and support in PhD supervision. His proactive approach to discussing mental health and the structural changes in supervision practices illustrate adaptive strategies that can be beneficial in navigating future disruptions in academic settings.

3.2.5 Analyzing the interview with Luna

Introduction: Luna, aged 55, specializes in English as an Additional Language didactics. She completed her doctoral degree with an article-based thesis and has supervised a total of 11 PhD candidates, two of whom have completed their dissertations under her primary supervision.

Impact of the Pandemic on PhD Candidates : Luna discussed the varying impacts of the pandemic on her supervisees. One candidate, who was already far along in her research when the pandemic hit, was less affected in terms of supervision but faced uncertainty and stress related to her digital dissertation defense using Zoom. For two new candidates who started during the pandemic, the experience was particularly challenging. They struggled with integrating into the academic community and adapting to remote work, significantly affecting their progress and emotional well-being.

Changes in Supervision Practices : The pandemic required Luna to adapt her supervision methods, emphasizing digital communication tools and frequent check-ins via Teams, Zoom, or phone apps. She noted that these changes allowed for maintaining close communication but shifted many supervision interactions to support coping with the emotional and logistical challenges posed by the pandemic.

Home Office Experience: Luna had a positive experience working from home, which was facilitated by having enough space and a family structure that supported a conducive work environment. She did not face significant challenges balancing work and family life, which helped maintain her productivity and well-being.

Workload Changes During the Pandemic: While her direct supervision workload remained stable, Luna’s role as a researcher education coordinator significantly increased her overall responsibilities. She was deeply involved in supporting a broader range of PhD candidates beyond her direct supervisees, which included mediating between candidates and their supervisors and helping navigate the challenges posed by the pandemic.

Support from Employer: Luna felt well-supported by her employer, particularly in terms of responsiveness to her needs and concerns as she navigated her roles during the pandemic. This support was crucial in managing the increased demands on her time and ensuring the well-being of the candidates for whom she was responsible.

Concerns for PhD Candidates: Luna expressed significant concern for the mental well-being of her candidates, noting that the pandemic exacerbated feelings of isolation and stress. She was particularly worried about those who could not integrate into the academic community or faced severe disruptions in their personal lives.

Personal Health Concerns: Despite managing her workload and maintaining her health, Luna acknowledged the intense pressures of her role during the pandemic, which were compounded by the high demands of her coordinator position.

Effect on Completion Times: Luna observed that the pandemic delayed completion times for many PhD candidates, with extensions being necessary but variably granted. She emphasized the importance of transparent and equitable handling of extension requests to ensure fairness.

Preparation for Article-Based Theses: Luna believes that PhD candidates are generally underprepared for writing article-based theses, attributing this to the educational focus on monographic rather than article-based work before the PhD level. She highlighted the importance of guidance in academic writing and understanding publication processes as essential components of PhD education.

Overall Reflection: Luna’s experience during the pandemic underscores the critical role of adaptability in supervision, the importance of mental health support for PhD candidates, and the need for clear communication and guidelines in managing extended impacts on doctoral education. Her proactive approach to addressing these challenges reflects a comprehensive and empathetic supervision style aimed at supporting candidates through unprecedented times.

3.2.6 Analyzing the interview with Lydia

Introduction: Lydia, aged 52, specializes in educational research, focusing on professional development, assessment, and teacher education. She completed her doctoral degree through a monographic thesis and has supervised three PhD candidates to completion, with six currently under her guidance.

Impact of the Pandemic on PhD Candidates: Lydia noted that the pandemic affected the progress of her PhD candidates, especially those with young children or those who started their projects around the onset of the pandemic. The challenges of remote work and caring for family members led to minor delays in their research timelines.

Changes in Supervision Practices: For candidates who had already started their projects, Lydia managed to continue effective supervision by meeting them on campus when possible. However, starting a supervisory relationship entirely online via Zoom or Teams with new candidates presented difficulties, particularly in building rapport and trust.

Home Office Experience: Lydia found working from home to be somewhat liberating and enjoyed the quiet environment, which contrasted with the often-hectic campus life. Her home setup, which included adult family members who managed their responsibilities independently, provided a conducive environment for work without significant distractions.

Workload Changes During the Pandemic: While the actual supervision tasks did not significantly increase in time, Lydia spent more effort on providing emotional support to her candidates. Discussions often veered from academic topics to personal well-being, reflecting the heightened anxieties and social isolation experienced by the candidates.

Support from Employer : Lydia expressed disappointment with her institution’s lack of direct support during the pandemic. The focus remained on expecting faculty to adapt and manage without specific interventions aimed at easing the transition to remote supervision or addressing the unique challenges posed by the pandemic.

Concerns for PhD Candidates: She was particularly concerned about the psychological well-being of her candidates, as many were navigating difficult life stages compounded by the pandemic. Lydia felt a strong responsibility to reassure them and help them maintain confidence in their ability to progress in their research.

Personal Health Concerns: Lydia did not report significant concerns about her own health, feeling relatively privileged and well-adapted to the circumstances. She maintained a positive outlook, supported by stable family dynamics and the ability to engage in outdoor activities, which helped preserve her mental well-being.

Effect on Completion Times: Acknowledging the inevitable delays caused by the pandemic, Lydia noted that extensions were likely necessary for most PhD candidates during this period. She appreciated that post-pandemic policies allowed for extensions to address disruptions, especially those related to family responsibilities.

Preparation for Article-Based Theses: Despite not having written a synopsis herself, Lydia observed that candidates often lack preparedness for writing article-based theses, a gap she attributes to the traditional focus on monographic work at earlier academic stages. She advocates for enhanced training and support for candidates transitioning to this format.

Overall Reflection: Lydia’s reflections reveal a nuanced understanding of the challenges faced by PhD candidates and supervisors during the pandemic. Her approach highlights the importance of flexibility, emotional support, and the need for institutions to provide clearer guidelines and more robust support systems to adapt to such unprecedented circumstances effectively. Her experience underscores the critical role of empathy and adaptability in academic leadership during crises.

3.2.7 Analyzing the interview with Michelle

Introduction: Michelle, 41, specializes in educational science, teacher education, and language didactics. She has previously supervised five PhD students to completion and is currently the main and co-supervisor for ten PhD candidates.

Impact of the Pandemic on PhD Candidates: Michelle reported varied impacts of the pandemic on her PhD candidates. Those who were in the final stages of their research before the pandemic began experienced minimal disruptions, benefiting from the shift to remote work which allowed them more focused time for writing. However, candidates in earlier stages of their projects or those with young children faced significant challenges due to reduced childcare hours and the need to juggle multiple responsibilities.

Changes in Supervision Practices: The pandemic greatly affected Michelle’s ability to provide regular supervision. With the demands of her own childcare responsibilities and the limitations of remote work, the frequency and quality of her interactions with her PhD candidates suffered. Supervision sessions were delayed, and Michelle had to adjust her practices, often conducting meetings via phone, online with Zoom or Teams, or in socially distanced outdoor settings.

Home Office Experience: Michelle found working from home to be extremely challenging, particularly due to the presence of young children and the constant interruptions that blurred the lines between work and home life. She experienced a persistent sense of being unable to adequately meet all her responsibilities as a supervisor and a parent.

Workload Changes During the Pandemic : Her workload related to PhD supervision became more demanding due to the difficulties in maintaining regular and effective communication. Michelle had to find creative ways to support her students, which often meant extended work hours and adapting to less conventional interaction methods.

Support from Employer: Michelle expressed significant disappointment with the lack of support from her employer during the pandemic. She felt that the institutions did not provide clear guidelines or additional support for managing the unique challenges brought on by the pandemic, leaving supervisors to manage as best they could under difficult circumstances.

Concerns for PhD Candidates: Michelle was particularly concerned about the psychological well-being of her candidates, noting that the isolation and disruptions affected different groups in varied ways. She observed that while parents were stressed and overextended, single young men often felt isolated and unproductive, which sometimes led to detrimental lifestyle changes.

Personal Health Concerns: Michelle mentioned that, like many in academia, she was accustomed to working excessively and did not have time to focus on her own health due to the demands of the pandemic situation.

Effect on Completion Times: Michelle anticipated that the pandemic would likely extend the completion times for many PhD candidates due to delays in data collection and the general disruption of academic schedules. She noted that while some extensions were granted, many were not, which added to the stress and uncertainty for the candidates.

Preparation for Article-Based Theses: Michelle believes that PhD candidates are generally not well-prepared to write article-based theses, which is often not addressed until during the PhD program itself. She emphasized the importance of structuring doctoral education to prepare better candidates for the realities of academic publishing and the peer review process.

Overall Reflection: Michelle’s experience during the pandemic highlights the complex challenges faced by PhD supervisors. Her insights underscore the need for better institutional support and clearer guidelines to navigate such unprecedented situations. Her commitment to adapting her supervisory practices despite personal and professional challenges demonstrates her dedication to her role and the success of her students.

3.2.8 Analyzing the interview with Ollie

Introduction: Ollie, aged 55, specializes in educational science and has completed his doctoral degree with a monograph. He has guided one PhD candidate to completion and is currently supervising three, with one about to defend their thesis.

Impact of the Pandemic on PhD Candidates: Ollie noted significant disruptions for his PhD candidates due to the pandemic. One candidate was fortunate to have completed major data collection just before lockdowns, which somewhat insulated their progress. However, others struggled as their research depended heavily on data collection in schools, which became nearly impossible due to access restrictions and subsequent strikes affecting the school system.

Changes in Supervision Practices: While the physical data collection was hindered, Ollie found digital supervision effective, especially for discussing and editing texts. He appreciated the direct focus on the text that digital platforms such as Teams or Zoom facilitated, contrasting with the sometimes-awkward setups of physical meetings. Nonetheless, the lack of access to schools for his candidates meant there was less content to supervise, which altered the dynamics of his guidance.

Home Office Experience: Ollie had a relatively positive experience working from home, appreciating the convenience and reduced commute time. He noted that being at home allowed for a more relaxed dress code and flexible work hours, although he acknowledged a potential for decreased social interaction and the blurring of work-life boundaries.

Workload Changes During the Pandemic: Ollie’s workload in terms of PhD supervision remained largely the same, but the nature of the supervision changed. He spent more time helping candidates pivot their projects to adapt to the new realities, which included more discussions and finding alternative approaches to research obstacles.

Support from Employer: Ollie felt that there was a lack of specific support for PhD supervisors from his employer during the pandemic. The focus seemed to be more on undergraduate and master’s students, with little attention paid to the challenges faced by PhD candidates and their supervisors.

Concerns for PhD Candidates: He was concerned about the delays and the psychological impact on his students, noting the challenges of maintaining motivation and morale under such uncertain and stressful conditions.

Personal Health Concerns: Ollie was proactive about maintaining his physical health during the pandemic, investing in ergonomic furniture to ensure comfort while working from home. He did not express concerns about his psychological health, suggesting a pragmatic approach to dealing with the pandemic’s challenges.

Effect on Completion Times: He anticipated that the pandemic would significantly delay his PhD candidates’ completion times, mainly due to disrupted data collection processes. Ollie stressed the importance of data quality and how difficulties in data collection could impact the overall quality of doctoral research and subsequent publication opportunities.

Overall Reflection: Ollie’s insights reflect a nuanced understanding of the diverse challenges posed by the pandemic to doctoral education. His adaptation to online supervision using videoconferencing platforms such as Zoom or Teams highlights the potential benefits of digital platforms for focused academic work, even as he recognizes the significant disruptions to traditional research pathways. His experience underscores the need for institutions to provide more robust support systems for doctoral candidates and supervisors, ensuring that doctoral training quality and integrity are maintained even in adverse circumstances.

3.2.9 Analyzing the interview with Tyler

Introduction: Tyler, aged 60, specializes in the philosophy of science, organization, and educational leadership. He completed his doctorate with a monograph and has guided two PhD candidates to completion, with four currently under his supervision.

Impact of the Pandemic on PhD Candidates: The pandemic significantly disrupted the plans of Tyler’s PhD candidates, particularly affecting those involved in international collaborations and empirical research. One candidate missed a crucial research stay in Italy, impacting their opportunity to engage with an international academic community. Another had to revise their empirical approach due to restricted access to schools, which was a common issue during the pandemic.

Changes in Supervision Practices: Tyler’s supervision was heavily affected by the pandemic, with all interactions moving to digital platforms, including Teams and Zoom. This shift resulted in less frequent and less personal guidance, which he felt was less effective than the planned intensive seminars abroad. Like Ollie, however, Tyler noted some benefits to digital supervision using videoconferencing platforms, such as the ability to engage with text during sessions directly.

Home Office Experience: Initially, Tyler took on additional teaching responsibilities to compensate for colleagues struggling with digital formats, which increased his workload. Over time, he found a rhythm of working from home and even appreciated the focused time that allowed him to complete a book. He alternated working from home and the office, leveraging the strengths of both environments to maintain productivity.

Workload Changes During the Pandemic: Tyler’s workload in terms of PhD supervision did not increase significantly. Digital Teams or Zoom meetings tended to be shorter and more focused, which somewhat compensated for the increased preparatory work required for effective digital instruction.

Support from Employer: Tyler expressed frustration with his institution’s management during the pandemic, particularly concerning doctoral courses and the increased bureaucratic oversight that he felt stifled academic freedom. He noted a lack of focus on the needs of PhD supervisors and candidates compared to other groups within the university.

Concerns for PhD Candidates: While not overly concerned about the mental and physical health of his candidates, Tyler was worried about the practical aspects of their research, especially those needing to conduct fieldwork, which was severely impacted by the pandemic restrictions.

Personal Health Concerns: Tyler did not express particular concerns about his health; however, he took proactive measures to ensure a comfortable working environment by investing in ergonomic office equipment.

Effect on Completion Times: Tyler anticipated that the pandemic would extend the completion times for his PhD candidates, especially due to disruptions in data collection and the broader impact on academic research activities.

Overall Reflection: Tyler’s experiences reflect the complex challenges faced by academic supervisors during the pandemic, balancing the shift to digital platforms with maintaining academic rigor and support for their candidates. His story highlights the need for institutions to provide better support and flexibility for supervisors and PhD candidates during crises, ensuring that academic standards and well-being are maintained. Tyler’s ability to adapt and find personal benefits during the pandemic, such as completing a book, also underscores the potential for finding opportunities in the face of challenges.

3.2.10 Comprehensive analysis of the Main findings across nine interviews of doctoral supervisors in Norway

3.2.10.1 overview.

This analysis integrates the findings from interviews with nine doctoral supervisors in Norway, structured by the interview guide (based on the main findings from the survey) and analyzed using Braun and Clarke’s (2021) approach to reflexive thematic analysis. The analysis focuses on how the COVID-19 pandemic affected the progression of PhD candidates and the corresponding changes in supervision practices.

Main Themes Identified:

1. Impact of the Pandemic on PhD Progression:

• Disruptions in Data Collection : Most supervisors reported significant disruptions in their candidates’ ability to collect data, especially those requiring access to external facilities like schools or international institutions. This was primarily due to lockdowns and restrictions imposed to curb the spread of the virus. As one supervisor noted: “One of my candidates had to delay their project significantly due to the inability to collect data as schools were not accessible.” (Ollie)

• Adaptations in Research Plans : Many candidates had to alter their research methodologies or adjust their empirical scopes to suit the new constraints, highlighting the flexibility required under crisis conditions. However, one of the supervisors mentioned that: “It affected them very differently. I had three candidates before the pandemic, and two of them were barely affected. However, the third struggled significantly with data collection due to difficulties in recruiting informants.” (Gabbie)

2. Changes in Supervision Practices:

• Shift to Digital Supervision : All supervisors transitioned to online platforms for conducting supervision, such as Zoom, Teams, or phone apps (e.g., Facebook Messenger, WhatsApp). While some found digital tools effective for sharing and reviewing written work, others felt the lack of physical presence reduced the quality of interaction and guidance they could provide. As one supervisor noted: “Digital supervision worked very well because it allowed sharing and discussing texts more effectively than in-person meetings. This actually enhanced the focus on the text during sessions” (Ollie).

• Increased Need for Emotional Support : Supervisors noted an increased need to support the psychological well-being of their candidates, as many struggled with isolation and stress due to the pandemic. As one supervisor noted: “I was particularly attentive to the mental health of my candidates, especially those without local family support. Regular check-ins were crucial during this period” (Gabbie).

3. Work Environment and Work-Life Balance:

• Home Office Challenges : Responses about working from home were mixed; some supervisors appreciated the flexibility and reduced commute times, while others struggled with distractions and the blending of personal and professional spaces. As one supervisor mentioned: “I actually enjoyed working from home as it provided a peaceful environment, but I missed the informal interactions with colleagues.” (Lydia)

• Institutional Support : There was a notable lack of targeted support for supervisors from their institutions. This often left supervisors and their candidates feeling overlooked in broader university responses to the pandemic. As one supervisor noted: “There was no specific support for me as a PhD supervisor during the pandemic. The general support was the same as for all staff members” (Lydia).

4. Professional Development and Academic Output:

• Delays in Academic Milestones : The pandemic delayed key academic milestones, including thesis submissions and defenses, primarily due to halted data collection and extended research timelines.

• Publication Challenges : The disruption also impacted candidates’ abilities to publish their research, a crucial component of their academic careers, due to delays and changes in their research projects.

Integration of Findings with Saldaña’s Coding Framework and Interview Guide:

• Using Saldaña’s coding method allowed for identifying recurring challenges and adaptations among the supervisors’ experiences. The thematic analysis revealed a consistent need for increased flexibility in research planning and supervision methods.

• The interview guide helped maintain a focus on how the pandemic specifically impacted various aspects of PhD supervision and candidate progression. It ensured that all relevant areas, such as changes in work routines, supervision adjustments, and overall impacts on PhD timelines, were systematically explored.

Comprehensive Assessment : The interviews collectively underscore the resilience and adaptability required by PhD candidates and their supervisors during the pandemic. They highlight several areas for improvement:

• Enhanced Institutional Support : Institutions clearly need to provide more structured support tailored to the needs of PhD candidates and supervisors during crises.

• Flexibility in Research and Supervision Plans : Adapting research plans and supervision methods to accommodate unexpected disruptions is crucial for maintaining the integrity and continuity of PhD education.

• Focus on Mental Health : The increased emotional and psychological support needed by candidates suggests that institutions should integrate mental health resources more fully into their doctoral training programs.

• Preparedness and Training : The experience has shown the importance of preparing PhD candidates for unexpected changes in their research environment, including training in digital tools and remote research methodologies.

In conclusion, the pandemic has not only disrupted traditional PhD education paths but also provided insights into how flexibility, digital preparedness, and institutional support can be enhanced to better prepare for future crises. These insights are vital for shaping resilient and adaptive academic environments that can withstand global challenges while supporting doctoral candidates’ academic and personal well-being.

From the analysis of the nine interviews, a few aspects stood out as particularly notable, offering deeper insights (expansion) into the unique challenges and responses within the context of PhD supervision during the pandemic:

1. Resilience and Innovation in Supervision:

• Some supervisors noted that despite the significant challenges, the shift to digital platforms allowed them to explore new forms of engagement with texts and supervision methods. For example, one supervisor highlighted the effectiveness of digital tools for collaborative work on documents, suggesting that these might even surpass traditional face-to-face interactions in certain aspects. This adaptation was a positive takeaway that some found surprising and worth integrating into their post-pandemic practices.

2. Diverse Impacts on Different Research Types:

• The differential impact of the pandemic on empirical versus theoretical research was striking. Supervisors of candidates who needed to conduct fieldwork, especially in schools or abroad, faced severe disruptions. As one supervisor noted: “We had to adjust research plans significantly, shifting to alternative data sources and methods where possible.” (Kyle). In contrast, those whose work was more theoretical or could be conducted remotely experienced fewer setbacks. This variance highlighted certain types of research vulnerability to external disruptions, which was a notable point of concern.

3. Underestimation of Emotional Challenges:

• Another well known, but still important aspect was the depth of emotional and psychological impacts on PhD candidates as noted by their supervisors. The extent to which these challenges affected the candidates’ productivity and well-being was significant and perhaps underappreciated by the institutions themselves. This underscores a critical area for future academic support systems to address more robustly.

4. Lack of Institutional Support:

• The widespread sentiment of insufficient institutional support was particularly striking. Several supervisors felt that there was a lack of targeted strategies to support PhD supervision during the pandemic. This lack of support was not just in terms of transitioning to online modes but also in addressing the specific needs of PhD candidates and their projects during such a disruptive period.

5. The Positive Impact of Forced Adaptation:

• Interestingly, some supervisors pointed out that the forced adaptation to new circumstances led to unexpected benefits, such as enhanced focus and productivity in certain cases, and even opportunities for personal and professional growth, such as writing a book or developing new teaching methods. These outcomes, while not universal, were surprising positives that emerged from a generally challenging time.

The sentiment analysis of the 9 interviews (see attachment 4 in the Supplementary file ) showed some individual variations, but that resilience and adaptability among doctoral supervisors during the pandemic were quite common. Supervisors recognized the challenges but overall maintained a positive and proactive stance, focusing on solutions and effective management of their supervisory roles. The objective nature of their responses indicates a practical approach to dealing with the pandemic’s impact, emphasizing the importance of communication, adaptation to remote supervision, and institutional support.

These insights not only highlight the varied experiences of PhD supervisors during the pandemic but also suggest areas for improvement in how institutions support doctoral education in times of crisis. The resilience and innovative approaches developed during this period could inform future policies and practices to better support PhD candidates and supervisors alike.

3.2.11 Integrated analysis: the main findings from the interviews and the open survey responses

To integrate and analyze the findings from the interviews (see attachment 1) and the 1,483 open survey responses (see attachment 2) from the survey among 293 doctoral supervisors, we can draw on several key themes and concerns that emerge consistently across these data sources. This approach will help us understand the broader implications of the insights gathered from different perspectives within the same study.

1. Adaptation to Digital Tools and Platforms:

• Interviews : The interviews highlighted how supervisors adapted to using digital tools for communication and supervision. This was generally seen as effective but lacking in certain qualitative aspects, particularly in building deeper relationships and managing more nuanced discussions.

• Open Survey Responses : The survey also reflected a reliance on digital tools, with many supervisors recognizing their utility in maintaining continuity. However, there was also an acknowledgment of the challenges in fully replicating face-to-face interactions.

2. Ethical and Practical Concerns with Digital Supervision:

• Interviews : Concerns were raised about the relational and ethical implications of the lack of physical presence and interaction, and the extensive use of digital tools in academic settings during the pandemic.

• Open Survey Responses : Similar concerns were noted, with supervisors emphasizing the importance of ensuring academic integrity and the genuine intellectual development of PhD candidates.

3. Impact of the Pandemic on Supervisory Practices:

• Interviews : The pandemic’s impact was a significant theme, affecting the logistical aspects of supervision and the mental well-being of both supervisors and their candidates.

• Open Survey Responses : Responses indicated varied impacts of the pandemic, with some supervisors noting increased stress and difficulty in maintaining research productivity and supervisory quality.

4. Institutional Support and Professional Development:

• Interviews : There was a noted lack of sufficient institutional support for adapting to new modes of supervision and research during the pandemic.

• Open Survey Responses : This theme was echoed in the survey responses, with mixed reports about the availability and effectiveness of continuing professional development (CPD) related to research supervision. Some respondents felt unsupported, particularly in navigating the challenges posed by remote supervision and digital tools.

5. Preparedness of PhD Candidates:

• Interviews : Discussions highlighted concerns about the varying levels of preparedness among PhD candidates, especially in writing the synopsis and adapting to new research methodologies that include digital tools and remote data collection.

• Open Survey Responses : Supervisors expressed a range of experiences regarding candidate preparedness. While some noted their candidates were well-equipped, others pointed out significant gaps, especially in writing the synopsis and article-based theses and handling the referee process, the timeline and complex research independently.

6. Valuation of Supervision:

• Interviews : Supervisors discussed feeling that their efforts were not adequately valued by institutions, with a need for greater recognition and support for their roles.

• Open Survey Responses : This sentiment was reinforced by survey data, where some supervisors felt that their contributions to doctoral training were undervalued by their institutions, particularly when compared to other academic duties.

7. Suggestions for Institutional Changes:

• Interviews : There were calls for institutions to adapt more proactively to the changing landscape of doctoral education, including better training for using digital tools and more robust support systems for both supervisors and candidates.

• Open Survey Responses : Supervisors suggested various improvements, such as more structured professional development opportunities, better guidelines for remote supervision, and enhanced support for mental health and well-being.

3.2.12 Summary

The integrated analysis across interviews and open survey responses suggests a complex landscape of doctoral supervision during and potentially beyond the pandemic era. Key themes highlight both challenges and potential areas for policy and practice enhancements:

• Digital Adaptation and Ethical Concerns : While digital tools have provided necessary solutions for continuity in supervision, they bring up ethical concerns that institutions need to address more thoroughly, particularly concerning academic integrity and the quality of student learning.

• Support and Development Needs : There is a clear need for institutions to offer more targeted support and development opportunities for supervisors, addressing both the technical aspects of digital supervision and the broader pedagogical skills required in a changing academic environment.

• Recognition and Valuation of Supervision : Supervisors feel that their work is not sufficiently valued, suggesting that institutions should reevaluate how they recognize and support supervisory roles within the academic career framework.

• Candidate Preparedness : There is variability in how prepared PhD candidates are for the demands of modern doctoral research, indicating the need for more robust preparatory programs and entry assessments.

• These insights call for a strategic reassessment of doctoral training programs, supervisory support mechanisms, and institutional policies to better align with the evolving needs of both supervisors and their candidates.

4 Limitations and future research

The present study provides in-depths insights into PhD supervision during the pandemic; however, the study also has several limitations apart from inherited limitations of self-reports and interview data. Firstly, the findings might be context-specific to the educational setting in Norway. The unique characteristics of the Norwegian educational system, cultural aspects, and institutional structures may not be entirely generalizable to other countries. However, the globalization of doctoral education, with increasing international collaborations, international publishing, and standardization of academic practices, might mitigate this issue to some extent, making the findings relevant beyond the Norwegian context. Secondly, the study lacks data on PhD supervisors’ experiences prior to the pandemic. This absence of baseline data means we cannot directly compare the pre-pandemic and pandemic periods. Nonetheless, the experiences reported in this study correspond well with prior research on academic supervision ( Pyhältö et al., 2012 , 2023 ; Löfström et al., 2024 ), indicating that the challenges and adaptations observed are not entirely unprecedented, even if intensified by the pandemic context.

Future research should aim to explore the long-lasting impacts of COVID-19 on doctoral education. It is necessary to investigate whether the changes observed in supervisory practices during the pandemic are fleeting or have led to a permanent shift in how supervision is approached. Specifically, studies should examine if new models of remote supervision, increased flexibility, and the use of digital tools will continue to be integrated into doctoral education post-pandemic, or if traditional methods will resume dominance. This is of special interest in cases where PhD supervisors and PhD candidates are located at different institutions. By addressing these questions, future research can contribute to a deeper understanding of the pandemic’s legacy on doctoral education.

5 Conclusion

In this article we examined the experiences of PhD supervisors in Norway during the pandemic to answer the research questions:

1. To what extent has the COVID-19 pandemic impeded the PhD supervisors’ frame factors on the micro- level, and how do they perceive this situation?

2. To what extent has the COVID-19 pandemic influenced PhD supervisors’ frame factors on the meso- level, and how do they perceive this situation?

We conducted a cumulative data collection process and analysis, where survey questions were based on previously collected field dialog data, online observation data, seminar evaluation data, and document analysis data. The qualitative interview guide questions were built upon previously collected quantitative data (survey), and the Supplementary data was based on previously collected quantitative data (survey) and qualitative interview data.

The coherence between qualitative and quantitative findings is mainly examined based on confirmation , expansion , or discordance in this article ( Fetters et al., 2013 ).

The findings from the explorative case study revealed that the PhD supervisors faced numerous challenges during the pandemic, both professionally and personally. They found digital supervision with their PhD fellows via platforms like Teams and Zoom to be convenient and efficient but occasionally lacking in quality. They also encountered difficulties in addressing the psychosocial aspects of their PhD candidates’ experiences and faced various research-related challenges with their PhD-candidates during the pandemic. For PhD supervisors who extensively worked from home over a long period, the situation created new conditions that affected their job performance. These altered conditions hindered their research capacity, their ability to follow up with their PhD candidates and their capacity to fulfill other job responsibilities. Although the PhD supervisors received support during the pandemic, it seems that the incremental measures provided were insufficient. The PhD regulations were established before the pandemic under normal conditions and for normal circumstances. However, it appears that no significant adjustments have been made to accommodate the extraordinary pandemic conditions, which have altered some aspects of their professional roles as academics and PhD supervisors. This was particularly critical for PhD supervisors with young children, especially female supervisors, who had to deal with lockdowns, social distancing, remote work, homeschooling, quarantine for themselves and their children, and COVID-19 illness, since the data showed that they seemed to have more home responsibilities than men during the pandemic. We also found that some supervisors thought that female PhDs’ (with own children) submission rates to scientific journals have been delayed as a consequence of COVID-19, considering that women seem to have more home responsibilities. In addition, the supervisors thought that female supervisors (with own children) submission rates to scientific journals have been delayed as a consequence of COVID-19, considering that female supervisors seem also to have more home responsibilities (e.g., for childcare, household etc.).

This slow-motion disaster lasted up to 20 months and can be perceived as an “external intervention” or a naturalistic experiment which was impossible to predict for universities and society. The case study results indicate that it is more important than ever to plan for the unforeseen in order to be better prepared for the next societal crisis. Therefore, it is important to be vigilant and understand the gap between the formulation, transformation, and realization arenas when it comes to the distinction between incremental, semi-structural changes and fundamental changes in PhD regulations and guidelines brought on by societal crises. Although some support from employers has been offered, the overall PhD guidelines, regulations, and supervision norms remained unchanged in the transformation arena (meso- level) during the pandemic. On a general level, this highlights the need for better crisis preparedness at the doctoral level in the years to come.

A common finding related to RQ1 and RQ2 and across the different data sources was that the COVID-19 pandemic has significantly impacted some of the PhD supervisors in different ways on both micro- and meso-levels, and some of them perceive this long-lasting pandemic challenging and difficult, while others have experienced this to a lesser degree. This reveals a confirmation across the quantitative and qualitative data in the study. Also, these findings mostly confirmed and expanded on the understanding of the impact of the pandemic on PhD candidates ( Krumsvik et al., 2022 ), with some minor discordance.

More specifically, the PhD supervisors in the study were somewhat satisfied with the educational quality regarding digital teaching but experienced various supervision, research-related and psycho-social challenges. Although some of the supervisors received support during the pandemic, it seems like the majority did not receive sufficient support and their workload increased significantly during the pandemic. This is due to the high complexity of frame factors that have changed the underlying premises for doctoral education during the pandemic, affecting both the PhD- supervision and the PhD candidates’ feasibility on several levels. The regulations for PhD scholarships and PhD regulations, implemented before the pandemic in 2018, were designed under normal educational and social conditions and may not fully address the challenges faced during the pandemic. Therefore, this study shows that to reduce this gap and strengthen the feasibility of the PhDs and the frame factors for PhD-supervision, the institutions must significantly enhance their preparedness to effectively manage demanding situations at both micro- and meso-levels, ensuring they are fully equipped to address future societal crises of a similar nature.

When it comes to RQ3 we find both confirmation, expansion, and discordance across the quantitative and qualitative data. We find confirmation across the quantitative and qualitative data when it comes to the variability in preparedness of PhD candidates for writing the article-based thesis. Article-based theses present unique challenges compared to traditional monograph-based dissertations, particularly in terms of integration and the breadth of skills required. One of the primary challenges with article-based theses is integrating articles that may cover slightly different aspects of a research topic into a coherent overall thesis. This integration is critical, it requires a high level of academic writing skills and ability to secure the coherence of the synopsis. Candidates often come into PhD programs with varying levels of experience in academic writing and publication. The survey and interviews, as well as Supplementary data , indicate that many candidates are not well-prepared for writing article-based theses, highlighting a need for more targeted training in academic writing and publishing early in the doctoral process. The need for robust supervisory support is acutely felt in guiding article-based theses, where candidates must navigate the complexities of publishing in peer-reviewed journals alongside synthesizing their research in the synopsis. This implies that PhD-candidates both are taking a doctoral degree in the Norwegian context and at the same time are publishing articles for the international research context, which can be challenging.

We find expansion when it comes to the need to have guidelines for the synopsis. Supervisors reported significant variation in the guidelines for the synopsis across institutions, both in the qualitative and quantitative part, which can lead to confusion and inconsistency in expectations for candidates and supervisors. Some respondents found these guidelines sufficient, while others find them unclear or obscure, complicating their task of effectively guiding PhD candidates. Clear, comprehensible guidelines are essential for ensuring that the synopsis effectively synthesizes the research in a manner that meets academic standards ( Wollenschläger et al., 2016 ).

And we find some discordance regarding variability in candidate preparedness where both strands of the data indicated a significant variability in how prepared PhD candidates are when they enroll in doctoral programs. Candidates’ preparedness often depends on their previous educational experiences, which can vary widely regarding exposure to research methods, academic writing, and critical thinking skills. The variability in preparedness suggests a need for more robust preparatory programs to equip all incoming doctoral candidates with the necessary skills and knowledge to succeed in their research endeavors. Implementing comprehensive entry assessments could help identify specific areas where candidates might need additional support, allowing programs to tailor preparatory courses or early doctoral training to address these gaps.

These findings collectively point to a need for doctoral programs to clarify guidelines, particularly for the synopsis in article-based theses, to enhance support for supervisory roles, and to develop preparatory programs that address the broad variability in candidate preparedness. This is also based on research on the need for rubrics ( Wollenschläger et al., 2016 ), which shows that transparency around requirements and guidelines is important for students learning. By tackling these issues, institutions can better prepare PhD candidates for the demands of modern doctoral research, ultimately leading to more consistent and successful outcomes in doctoral education. And despite that only 20 (8.3%) of the supervisors agreed or strongly agreed that they were supervising a PhD candidate who had considered quitting the PhD program during the pandemic, it is important to be vigilant around the (complex) reasons that causes this, since this is in many ways a drastic decision, first of all for the candidate themselves, but also for the supervisors, as well as for the society in general who has invested almost 5 million Norwegian kroner in each PhD-scholarship. Dropping out can partly be related to the observed findings that many PhD candidates were unprepared for the intricacies of article writing, including the lengthy processes of submission and peer review, attached to their educational background, which primarily focused on monographic work at the bachelor’s and master’s levels. This also implies that while PhD’s are perceived, assessed and evaluated as student/candidates when they are completing assignments in a doctoral program, there might be a quite new situation for them when they submit their articles to scientific journals with blind review, where they are evaluated as other researchers (and not only as students/candidates). Such findings (and similar findings) seem to go “under the radar” in doctoral programs in Norway and by taking into account such “tacit knowledge” we might be better prepared to bridge the formulation arena and realization arena within doctoral education in the years to come. This development also demands a vigilance within doctoral education of the importance of theory development within doctoral education since international research shows that doctoral supervision is under-theorized and lacks a solid knowledge base ( Halse and Malfroy, 2010 ; Halse, 2011 ) where also eclectic use of theories ( Dalland et al., 2023 ) can improve this area.

Author note

GPT-4o ( OpenAI, 2024 ) was employed in this article to translate interview findings to English after a general thematic analysis conducted in Norwegian and as one of several validity communities for the open survey responses. The GPT-4’s output was manually examined, edited, and reviewed by the authors. The sentiment analysis of the 9 interviews was done by the first author and by using the GPT-4o. Then it was carried out a validation of this sentiment analysis by SurveyMonkey ( SurveyMonkey, 2024 ), Claude ( Anthropic, 2024 ) and Gemini Advanced ( Google, 2024 ).

Data availability statement

The original contributions presented in the study are included in the article/ Supplementary material , further inquiries can be directed to the corresponding author.

Author contributions

RK: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing. FR: Conceptualization, Data curation, Formal analysis, Methodology, Validation, Writing – review & editing, Writing – original draft. ØSk: Conceptualization, Data curation, Investigation, Methodology, Writing – original draft, Writing – review & editing. LJ: Conceptualization, Data curation, Methodology, Validation, Writing – original draft, Writing – review & editing. SS: Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. ØSa: Data curation, Validation, Writing – original draft, Writing – review & editing. KH: Methodology, Validation, Writing – original draft, Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Acknowledgments

We would like to thank all doctoral supervisors for their responses to the surveys and for participating in interviews and focus groups on this study.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/feduc.2024.1436521/full#supplementary-material

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Keywords: PhD-supervisors, experiences, COVID-19, supervision, PhD-fellows, frame factors

Citation: Krumsvik RJ, Røkenes FM, Skaar &O, Jones L, Solstad SH, Salhus & and Høydal KL (2024) PhD-supervisors experiences during and after the COVID-19 pandemic: a case study. Front. Educ . 9:1436521. doi: 10.3389/feduc.2024.1436521

Received: 22 May 2024; Accepted: 15 July 2024; Published: 09 August 2024.

Reviewed by:

Copyright © 2024 Krumsvik, Røkenes, Skaar, Jones, Solstad, Salhus and Høydal. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Rune J. Krumsvik, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Long COVID science, research and policy

• Ziyad Al-Aly   ORCID: orcid.org/0000-0002-2600-0434 1 , 2 ,
• Hannah Davis   ORCID: orcid.org/0000-0002-1245-2034 3 ,
• Lisa McCorkell   ORCID: orcid.org/0000-0002-3261-6737 3 ,
• Letícia Soares 3 ,
• Sarah Wulf-Hanson 4 ,
• Akiko Iwasaki   ORCID: orcid.org/0000-0002-7824-9856 5 , 6 &
• Eric J. Topol   ORCID: orcid.org/0000-0002-1478-4729 7  

Nature Medicine ( 2024 ) Cite this article

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Long COVID represents the constellation of post-acute and long-term health effects caused by SARS-CoV-2 infection; it is a complex, multisystem disorder that can affect nearly every organ system and can be severely disabling. The cumulative global incidence of long COVID is around 400 million individuals, which is estimated to have an annual economic impact of approximately $1 trillion—equivalent to about 1% of the global economy. Several mechanistic pathways are implicated in long COVID, including viral persistence, immune dysregulation, mitochondrial dysfunction, complement dysregulation, endothelial inflammation and microbiome dysbiosis. Long COVID can have devastating impacts on individual lives and, due to its complexity and prevalence, it also has major ramifications for health systems and economies, even threatening progress toward achieving the Sustainable Development Goals. Addressing the challenge of long COVID requires an ambitious and coordinated—but so far absent—global research and policy response strategy. In this interdisciplinary review, we provide a synthesis of the state of scientific evidence on long COVID, assess the impacts of long COVID on human health, health systems, the economy and global health metrics, and provide a forward-looking research and policy roadmap.

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Long COVID is best defined as the constellation of post-acute and long-term health effects caused by SARS-CoV-2 infection 1 , 2 , 3 . Long COVID was initially reported by patients who coined the term and, through research and advocacy, drove much of the progress in understanding this condition over the past several years (Fig. 1 ).

The history of long COVID has been defined largely by the patients themselves. In March 2020, as the COVID-19 pandemic began to unfold across the globe, patients with infection-associated chronic conditions presciently warned of the potential emergence of long-term illness after SARS-CoV-2 infection 293 .The first mainstream written personal account of non-recovery from acute COVID-19 was an op-ed by the American journalist Fiona Lowenstein in the New York Times in April 2020 (ref. 294 ). Around the same time, patients began self-organizing, coined the term long COVID 295 and conducted the first known survey—which was subsequently formally published—documenting the breadth of symptomatology experienced by people with long COVID 42 . Considerable activity then ensued, including mainstream media coverage (first by Ed Yong in The Atlantic ) 296 , recognition by national governments (of the United States 281 , Canada 297 , United Kingdom 298 , European Union 299 , Australia 300 and others) and the WHO. Patients continue to lead the way in advocacy and research, which led the US Senate to hold its first-ever hearing on long COVID 275 , 301 . This timeline was curated to provide a brief overview of the history of long COVID, with a focus on the role played by patients and advocates, and does not comprehensively include all events and milestones. ICD, International Classification of Diseases.

Long COVID is a complex, multisystem disorder that affects nearly every organ system, including the cardiovascular system 4 , the nervous system 5 , 6 , 7 , 8 , the endocrine system 9 , 10 , 11 , the immune system 12 , 13 , the reproductive system 14 and the gastrointestinal system 15 . It affects people across the age spectrum (from children 16 , 17 , 18 to older adults 19 , 20 ), people of different race and ethnicities, sex and gender, and baseline health status 21 . Cardinal manifestations include brain fog (or cognitive dysfunction) 7 , fatigue, dysautonomia (which commonly manifests as postural orthostatic tachycardia syndrome (POTS)) 22 and post-exertional malaise 23 . Many of the health effects seen in long COVID are shared across several infection-associated chronic conditions, also called post-acute infection syndromes 23 , 24 , 25 , 26 .

The epidemiology of long COVID is influenced by various factors. The Omicron variant of SARS-CoV-2 is associated with less risk of long COVID than the Delta and pre-Delta variants 27 . Vaccines (before infection) and antivirals (during the acute phase of infection) may reduce the risk of long COVID. Reinfection, on the other hand, is a risk factor for long COVID 28 , 29 ; even if individuals did not experience long COVID after a first SARS-CoV-2 infection, they remain at risk of developing it with subsequent infections 28 , 29 , 30 . Reinfection can trigger de novo long COVID or exacerbate the severity of existing long COVID 28 , 29 . Cumulatively, two infections yield a higher risk of long COVID than one infection and three infections yield a higher risk than two infections 28 , 29 .

A unifying thread of evidence across most studies evaluating the risk of long COVID is the finding that the risk increases as the severity of acute infection increases 3 . People who had severe COVID-19 that necessitated hospitalization exhibit a higher risk of long COVID than those with mild COVID-19. However, because most people around the globe had mild COVID-19, they constitute more than 90% of people with long COVID, despite their lower relative risk compared with that of people with severe COVID-19 (ref. 31 ).

Studies evaluating recovery from long COVID are sparse and inconsistent 32 ; this is largely due to use of various definitions, incomplete accounting for all the manifestations of long COVID and misclassification of remission as ‘recovery’ 33 . However, studies carefully evaluating individual manifestations show that recovery rates are generally low at 1 year 34 , and several studies show only 7–10% fully recovered at 2 years 30 , 33 , 35 , 36 . Furthermore, some manifestations of long COVID, including heart disease, diabetes, myalgic encephalomyelitis and dysautonomia are chronic conditions that last a lifetime 31 , 37 , 38 , 39 . Adding to this are the concerns about the possible emergence of new latent sequelae—that have not yet been characterized—years after the acute infection 37 , 40 , 41 .

The impact of long COVID is not limited to the health and well-being of individual patients and their communities. Owing to its prevalence and the breadth of its clinical manifestations 42 , 43 , 44 , 45 , 46 , it represents a major public health crisis 47 ; it strains health systems and national economies, and threatens progress on global health, including the Sustainable Development Goals (SDGs).

In this interdisciplinary review, we provide a brief synthesis of the current state of scientific evidence on long COVID, including knowns, unknowns and the key controversies. We provide an assessment of the impacts of long COVID on human health, health systems, the economy and global health metrics and, finally, we provide a forward-looking research and policy roadmap that we hope will stimulate global discussion on how to address the challenge of long COVID.

State of the science on long COVID

The global burden.

Estimating the global burden of long COVID presents substantial challenges due to the variability in study designs and populations, follow-up times, choice of control groups (for example, whether studies evaluated people with negative SARS-CoV-2 tests or no known SARS-CoV-2 infection as controls), assessment of baseline health before the infection (to ascertain emergence of a true new health condition) and definitions of what constitutes ‘long COVID' 48 , 49 . Variation in risk estimates also reflects the dynamic nature of the pandemic itself, which gave rise to many variants and subvariants, each yielding potentially different rates of long COVID; the effect of COVID-19 vaccines and use of antivirals in the acute phase, which may reduce the risk of long COVID; and the effect of SARS-CoV-2 reinfections, which contribute additional risk 28 , 29 .

Few countries established surveillance systems to estimate the burden of long COVID at the population level. Data from the US Centers for Disease Control and Prevention (CDC)’s National Health Interview Survey show that in 2022, 6.9% of US adults 50 and 1.3% of children 51 ever had long COVID. Data from the Medical Expenditure Panel Survey—a nationally representative survey of US adults—found that 6.9% of adults had ever had long COVID as of early 2023 (ref. 52 ). Estimates from the CDC’s Household Pulse Survey show that prevalence of current long COVID in US adults was around 6.7% in March 2024 (ref. 53 ). In the United Kingdom, point prevalence estimates from the Office of National Statistics show that 2.9% of the UK population (including children) were experiencing self-reported long COVID in March 2023 (ref. 54 ). Overall, estimates of the burden of long COVID in the general population converge around a point prevalence of 6% to 7% in adults and ~1% in children 50 , 51 , 52 , 53 , 54 .

Also important are estimates of the incidence of long COVID, which can be informed by high-quality meta-analyses of large-scale cohort studies among people infected with SARS-CoV-2. For instance, one analysis pooled results from 54 studies in 22 countries and estimated that approximately 6.2% of symptomatic COVID-19 survivors experience at least one of three common symptom clusters at 3 months after acute infection, across all ages and accounting for different severity levels of the initial infection and pre-COVID health status 31 . This analysis only considers three major symptom clusters in long COVID (fatigue with bodily pain/mood swings, and cognitive and respiratory symptom clusters); however, it sets a conservative benchmark to estimate the global risk of long COVID 31 .

We estimated the global incidence of long COVID on the basis of meta-regression studies that pool together all the available evidence 31 (Fig. 2 ). Incorporating a number of assumptions, including the Institute for Health Metrics and Evaluation’s annual estimates of SARS-CoV-2 infections 31 , 55 , 56 , 57 , 58 , 59 , a proportion symptomatic cases among infections of 65% (ref. 31 ), and a reduction in the risk of long COVID for 2022 and 2023 to account for the putative lower severity of the Omicron variant and the effect of vaccination 60 , we estimated a cumulative global incidence of long COVID by the end of 2023 of approximately 400 million. It is crucial to emphasize that these estimates only represent cases arising from symptomatic infections and are likely to be conservative. The actual incidence of long COVID, including cases from asymptomatic infections 61 or those with a broader range of symptoms, is expected to be higher. Furthermore, the estimates do not account for the added burden of long COVID due to reinfection 29 and the possibility of latent risks (that is, risks that are not yet manifest and may emerge years or decades after infection) 3 , 37 , 41 . The emergence of new variants, changes in public health measures and changes in the effectiveness and uptake of vaccination may also substantially influence these estimates in the future.

We estimated the global incidence of long COVID on the basis of meta-regression estimates that pool together all the available evidence. Considering the Institute for Health Metrics and Evaluation’s annual estimates of SARS-CoV-2 infections 31 , 55 , 56 , 57 , 58 , 59 and assuming the lower risk estimate of 6.2% for long COVID at 3 months after infection 31 , a proportion symptomatic cases among infections of 65% (ref. 31 ), and a reduction in the risk of long COVID for 2022 and 2023 (to account for the combination of the putative lower severity of the Omicron variant and the mildly protective effect of vaccination) 60 , the estimated cumulative global incidence of long COVID was 65 million, 211 million, 337 million and 409 million in 2020, 2021, 2022 and 2023, respectively.

While it is challenging to provide estimates of new cases with high precision, the current evidence makes it compellingly clear that long COVID represents a substantial and ongoing challenge to global health.

Mechanisms of long COVID

The pathophysiological mechanisms of long COVID are still being elucidated 2 , 62 , and it is unlikely that a single mechanism can explain the broad and heterogeneous set of symptoms and diseases spanning various organ systems. Long COVID likely represents a disease with many subtypes; each may have their own risk factors, biological mechanisms and disease trajectory, and may respond differently to treatments 3 . Multiple pathological pathways may be engaged depending on various factors, including prior environmental exposures, genetic makeup, age, sex, prior health, microbiome health, viral characteristics (SARS-CoV-2 variant, viral load), the immune response (which may be influenced by prior infections, vaccines and use of immunosuppressive agents) and medical treatments (antivirals, steroids). All of these drivers likely shape the human host response during the acute phase of SARS-CoV-2 infection and may trigger pathophysiological mechanisms that ultimately produce phenotypes of long COVID.

Several mechanistic pathways have been proposed for long COVID, including viral persistence, immune dysregulation, mitochondrial dysfunction, complement dysregulation, prothrombotic inflammation and microbiome dysbiosis 3 , 7 , 12 , 63 , 64 , 65 , 66 , 67 , 68 , 69 (Fig. 3 ). Viral persistence (either replicating virus or viral RNA or protein fragments)—which may be common 70 —in immune-privileged sites may trigger chronic low-grade inflammation and tissue injury 63 , 71 , 72 , 73 , and may correlate with long COVID symptomatology 72 .

Initial triggers (gray boxes) include viral persistence in tissue reservoirs (or immune-privileged sites) and possible replication of SARS-CoV-2 leading to the generation of viral antigens and RNA, which stimulates adaptive and innate immune cells, respectively. This can lead to immune cell activation, cytokine secretion, T cell exhaustion, antibody secretion against SARS-CoV-2 antigens and complement activation (top yellow box). Innate recognition of viral RNA by myeloid cells can lead to enhanced phagocytosis and cytokine secretion and inflammasome activation (bottom yellow box). These events can trigger autoimmunity (bystander activation or molecular mimicry) and reactivation of dormant herpesviruses (EBV, VZV) and uncoordinated cross-talk between cellular and adaptive immunity. Immune activation can cause downstream pathologies (pink boxes), including mitochondrial dysfunction and impaired energy metabolism; microbiome dysbiosis and translocation and gut nervous system dysregulation; neuronal inflammation, activation of microglia and immune cells with reduced neurogenesis and loss of oligodendrocytes and myelinated axons, possible fusion between neurons and neurons and glial cells and formation of multicellular syncytia, which compromises neuronal activity; dysfunctional hypothalamic–pituitary–adrenal response leading to inappropriately low levels of cortisol; complement activation, endothelial inflammation, platelet activation and red blood cell lysis leading to thromboinflammation and tissue injury. These mechanisms are non-exclusive and may cause inflammation, tissue dysfunction and tissue damage (blue box) leading to clinical manifestations of long COVID.

Studies have demonstrated persistence of the virus in extrapulmonary sites, including the brain and coronary arteries, of individuals with severe COVID-19 (refs. 68 , 74 ). Studies in human and mouse brain organoids showed that SARS-CoV-2 infection induces fusion between neurons and between neurons and glial cells, which may progressively lead to formation of multicellular syncytia compromising neuronal activity 75 . Neuroimaging studies performed in humans 10 months after they ‘recovered’ from mild-to-moderate SARS-CoV-2 infection showed significant alterations (commensurate with 7 ‘years of healthy aging’) of cerebral white matter, including widespread increases of extracellular free water and mean diffusivity (indicative of inflammation) encompassing all brain lobes 76 . Pre- and post-SARS-CoV-2 infection imaging studies showed structural abnormalities and accelerated aging in the brains of people with mild-to-moderate SARS-CoV-2 infection 74 , 77 , 78 . Even in the absence of direct infection in the brain, a transient respiratory infection with SARS-CoV-2 induces prolonged neuroinflammatory responses, activation of microglial cells and impaired neurogenesis 64 , 77 . In addition to neuroinflammation, people with brain fog due to long COVID were shown to have disrupted blood–brain barriers 79 .

Abnormalities in the immune system have been documented in people with long COVID, including increased humoral responses directed against SARS-CoV-2; higher antibody responses against Epstein–Barr virus (EBV) 66 , varicella zoster virus (VZV) 66 and cytomegalovirus 67 (suggesting possible reactivation of herpesviruses 80 ); exhausted T cell responses 12 , 66 ; and uncoordinated cross-talk between the cellular and humoral adaptive immunity 12 , 13 . Autoimmune responses triggered by SARS-CoV-2 infection may underlie long COVID symptoms 81 , 82 . Passive transfer of IgG antibodies from patients with long COVID to healthy mice recapitulated heightened pain sensation and locomotion deficits 82 , 83 .

In the heart, SARS-CoV-2 infects coronary vessels, preferentially targeting coronary artery plaque macrophages and inducing plaque inflammation 68 . Vascular disease in long COVID is likely triggered by complement activation, red blood cell lysis, platelet activation and thromboinflammation—leading to altered coagulation and tissue injury 67 , 84 . Dysfunctional hypothalamic–pituitary–adrenal response with inappropriately low levels of cortisol may mediate some of the symptomatology observed in long COVID (including fatigue, sleep abnormalities and metabolic derangements) 66 , and has been seen in those with persistent respiratory symptoms of long COVID 80 . SARS-CoV-2 infection may lead to reduced intestinal absorption of tryptophan (a serotonin precursor) and subsequently reduced levels of circulating serotonin, which may impair cognition via reduced vagal signaling 85 . SARS-CoV-2 infection may also lead to mitochondrial dysfunction, systemic metabolic abnormalities and abnormal skeletal muscle response to exercise—including exercise-induced myopathy and tissue infiltration of amyloid-containing deposits and leukocytes 65 .

The proposed mechanisms of long COVID share similarities with those of other post-acute infection syndromes, which are beyond the scope of this article and are discussed in detail elsewhere 24 .

Prevention, treatment and care models

Non-pharmaceutical interventions (for example, masking, improved indoor air quality) can reduce the risk of SARS-CoV-2 infection and consequently reduce the risk of long COVID. COVID-19 vaccines may partially reduce the risk of long COVID in adults by 15–70% (mean, ~40%) 86 , 87 , 88 , 89 ; they may also partially reduce the risk of long COVID in children 90 , 91 . In nonhospitalized individuals (mild-to-moderate COVID-19) who have at least one risk factor for the development of severe COVID-19, use of the SARS-CoV-2 antivirals (ritonavir-boosted nirmatrelvir and molnupiravir) in the acute phase may reduce the risk of long COVID 92 , 93 , 94 , 95 , 96 , 97 . However, the effectiveness of these antivirals in reducing risk of long COVID in low-risk groups, including younger individuals with no comorbidities 98 , has not been evaluated. Simnotrelvir—a new SARS-CoV-2 antiviral available in China 99 —resulted in earlier reduction in viral load and faster resolution of acute symptoms (than placebo) 100 , but its effectiveness against long COVID has not yet been evaluated. Exploratory analyses showed that another new SARS-CoV-2 antiviral, ensitrelvir (currently available in Japan), reduced the risk of long COVID when initiated in the acute phase of COVID-19 (refs. 101 , 102 ). Furthermore, metformin (initiated within 7 days of SARS-CoV-2 infection) has been shown to reduce the risk of long COVID in a randomized controlled trial 103 .

Evidence for long COVID treatments is beginning to emerge, but it is still limited. A randomized, double-blind, placebo-controlled trial showed that treatment with a synbiotic preparation (a gut microbiome modulator) alleviated multiple symptoms of long COVID—highlighting the need to further explore microbiome modulators as potential therapeutics in this setting 104 . Another randomized, controlled trial showed that a 15-day course of ritonavir-boosted nirmatrelvir did not reduce the burden of long COVID symptoms in comparison to ritonavir with placebo 105 .

Due to near-total absence of evidence from randomized clinical trials to guide treatment decisions, approaches for the assessment and treatment of respiratory sequelae 106 , cardiovascular complications 107 , fatigue 108 , cognitive symptoms 109 , autonomic dysfunction (including POTS) 110 , 111 , 112 , 113 , 114 and neuropsychiatric impairment 115 , 116 in adults and children 117 are based on evidence of treating similar symptomatology from other conditions—including myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and Gulf War illness 26 , 118 , 119 , 120 .

Care for people with long COVID varies widely across settings and practitioners 118 , 119 , 121 , 122 , 123 . It is often challenged by lack of widespread recognition and understanding of long COVID among medical professionals, constrained resources and competing demands on healthcare systems still recovering from the shock of the pandemic, lack of standardized care pathways, lack of definitive diagnostic and treatment tools, and a general pervasive pandemic fatigue with an urge to ‘move on’ 124 , 125 . Much of the global burden of long COVID remains undiagnosed, particularly in low-resource settings, and in many instances are erroneously attributed to psychosomatic causes 126 .

Overall, care models for long COVID are evolving, with substantial variability across health systems 127 . While there is still no empirical evidence evaluating comparative effectiveness of long COVID care models 121 , optimal models should be context dependent—based on available resources, expertise and the population being served 121 , 128 .

Impacts of long COVID

In addition to its impact on patients’ daily lives and health outcomes, long COVID has a devastating impact on communities and can have wide-reaching ramifications for health systems, national economies and global health metrics.

Impact on individuals and communities

Long COVID drastically affects patients’ well-being and sense of self, as well as their ability to work, socialize, care for others, manage chores and engage in community activities—which also affects patients’ families, caregivers and their communities 129 . Over three quarters of people with long COVID report a moderate or severe impact on general well-being 130 . The high rates of cognitive and physical symptoms also affect individuals’ identity and sense of self. One in four people with long COVID limit activities outside work in order to continue working 131 . Many patients with long COVID experience social exclusion, isolation and stigma, often from medical providers 43 , 132 , 133 , 134 . These challenges are exacerbated by societal barriers to the inclusion of people with disabilities and chronic illnesses.

Impact on health systems

Because of the large burden of long COVID and its multisystemic effects 135 , it has profound impacts on health systems 136 , 137 . Patients with long COVID frequently require ongoing medical care and multiple specialist consultations to manage their complex symptoms. This increased demand exacerbates existing pressures on health systems, leading to longer wait times, potential delays in essential care and increased costs. In the United States, people with long COVID are more likely to report unmet healthcare needs in the past year because of costs and difficulties finding a clinician and getting an appointment when needed 138 . These issues are exacerbated in low- and middle-income countries 126 , 139 . Furthermore, the lack of standardized diagnostic criteria, treatment protocols and models of care for long COVID adds to the complexity and places additional burdens on healthcare providers 137 , 140 , 141 .

Perhaps the most enduring challenge to health systems lies in the rise in the burden of non-communicable diseases (NCDs; for example, cardiovascular disease and diabetes) as a consequence of SARS-CoV-2 infection 4 , 5 , 9 , 10 , 15 , 136 , 142 , 143 , 144 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 . NCDs are chronic conditions that require lifelong care, impact health system utilization (competing for access and quality of care) and raise healthcare costs 137 .

Impact on economies

Long COVID strains individual financial health 153 and has wide and deep ramifications on national economies 154 , 155 , 156 , 157 , 158 , 159 . In addition to the substantial direct healthcare costs 160 , there is also financial strain on support services and disability benefits. In addition, long COVID affects labor participation, employment and productivity of impacted individuals and their caregivers 129 , 156 , 161 , 162 , 163 —resulting in depleted savings, food and housing insecurity 131 , 164 and negative impact on labor supply, thereby fueling labor shortages 156 . Studies indicate a significant percentage of individuals with long COVID experience a reduced ability to work or may be unable to work at all 165 . A report by the US Brookings Institute estimated that between 2 and 4 million US adults were out of work because of long COVID in 2022 (ref. 165 ). A US Federal Reserve Bank report found that people with long COVID had 10% less likelihood of being employed and worked 25% to 50% fewer hours when employed than uninfected individuals 166 . Survey data from the UK’s Trades Union Congress show that 20% of people with long COVID were not working and that an additional 16% were working reduced hours 167 . An analysis by the European Commission suggested that long COVID had a negative impact on the European labor supply of 0.2–0.3% in 2021 and 0.3–0.5% in 2022 (ref. 168 ).

Quantitative estimates of the total economic impact of long COVID remain preliminary. A study in 2022 estimated the economic cost of three key parameters in the United States, including lost quality of life ($2,195 billion), cost of lost earning ($997 billion) and spending on healthcare ($528 billion), for up to a total cost of $3.7 trillion 154 , 155 —this amounts to $11,000 per capita or 17% of the 2019 gross domestic product (GDP). These economic losses are on par with the global 2008 Great Recession. Assumptions included in these estimates are that burden of disability from long COVID is on par with that of ME/CFS and that long COVID lasts on average for 5 years 155 .

Among OECD (Organization for Economic Co-operation and Development) countries, a preliminary conservative estimate suggested that excluding the direct costs of healthcare, long COVID is likely costing OECD countries as much as $864 billion to $1.04 trillion per year due to reductions in quality of life and labor force participation 169 . A recent analysis by the Economist Impact (a think tank of The Economist) suggested that the economic cost of long COVID in 2024 is expected to be around 0.5% to 2.3% of the GDP of several large economies 170 (Table 1 ). On the basis of all the available data, a conservative estimate of the annual global economic toll of long COVID could be around $1 trillion amounting to 1% of the 2024 global GDP 154 , 155 , 169 , 170 .

Impact on the SDGs

The profound immediate health, social and economic shocks triggered by the COVID-19 pandemic have undermined the ability of many countries to achieve the SDGs by 2030 (ref. 171 ). In addition to the immediate effect of the pandemic, its long tail—in the form of long COVID—presents a more profound and enduring challenge to SDGs than the direct initial disruptions 171 .

Long COVID’s multifaceted impact jeopardizes progress across many SDGs, particularly those aimed at promoting health and economic well-being, and reducing inequalities 172 , 173 , 174 , 175 , 176 , 177 , 178 , 179 . Long COVID can limit access to and quality of healthcare 136 , 137 , reduce labor participation, worsen poverty and hinder economic productivity 169 , and exacerbate existing inequalities 180 , 181 , 182 , 183 . Table 2 lists the impacts of long COVID on several of the SDGs and identifies which collaborative, multi-sectoral partnerships and actions are needed to address these impacts.

The full extent to which long COVID will undermine the SDGs is still evolving and is difficult to fully quantify 174 , 175 ; a deeper understanding of the full scope and scale of this impact is needed.

Research and policy roadmaps

Substantial work lies ahead to address the broad and multifaceted challenges posed by long COVID—including preventing further increase in the number of people with long COVID and addressing the care needs of people already impacted 184 . Responding to these challenges will require coordinated, long-term policy response and visionary research strategies, guided by the principles of health equity and patient centeredness 185 , 186 , 187 . We developed the following research and policy roadmaps on the basis of our assessment of the evidence and policy gaps, as well as our own clinical, research and policy experience and in partnership with patients.

Research roadmap

Biological mechanisms.

Leading mechanistic hypotheses (discussed above) should be examined carefully, particularly for their interactions and potential to guide disease management, trials to test existing drugs and the development of new drugs 3 . Continued investigation (via animal models 188 , 189 or other approaches) of neuroinflammation, immune dysregulation, sex differences 190 , tissue damage and susceptibility features, including genomic 191 , epigenomic 192 , 193 , 194 and other '-omics', is warranted. In evaluating the mechanisms of long COVID, detailed assessment of specific manifestations, for example, understanding the pathophysiology of post-exertional malaise, may yield mechanistic insights that guide clinical management 65 , 195 , 196 .

That SARS-CoV-2 leads to long COVID is unlikely to be a unique property; many other viral agents (including influenza, SARS, Middle East respiratory syndrome, EBV, Dengue, Ebola, Polio, Chikungunya, West Nile virus, Ross River virus, Coxsackie B and VZV) and nonviral agents ( Coxiella burnetii , Borrelia , Giardia lamblia ) also lead to post-acute and long-term health effects 24 , 197 . A deeper understanding of the similarities and distinctions in the biological mechanisms of long COVID and other infection-associated chronic conditions is needed 2 , 3 , 24 , 25 , 26 , 198 , 199 , 200 , 201 , 202 , 203 , 204 , 205 , 206 , 207 , 208 , 209 , 210 , 211 , 212 , 213 , 214 .

Diagnostics

A research agenda is needed to foster the development, testing and validation of more advanced imaging, new blood tests, molecular probes, '-omics' and novel approaches to tissue investigation and analyses—toward better diagnosis of long COVID. Traditional imaging techniques may not reveal abnormalities in long COVID that may be evident in more advanced imaging. For example, new imaging technologies, including magnetic resonance imaging (MRI) with xenon-129 ( 129 XE-MRI) 215 for lungs, diffusion MRI to map glial activity 216 , imaging for glymphatic functioning 217 and arterial spin labeling MRI 218 for cerebral blood flow, have identified abnormalities in long COVID where conventional imaging has not. In a preliminary study, imaging flow cytometry was shown to detect fibrin microclots, which may be more abundant in people with long COVID than controls 219 . Whole-body positron emission tomography imaging using a highly selective radiotracer ([ 18 F]F-AraG) that allows anatomical quantification of activated T lymphocytes, showed increased radiotracer uptake indicative of T cell activation in various anatomic sites (for example, spinal cord, lungs) that were associated with long COVID 220 . These imaging modalities—along with other approaches—should be further investigated for their potential to establish diagnosis of long COVID, to guide trial designs, and for targeted disease management.

Biomarkers are helpful, not only as diagnostics, but also to aid in risk stratification (to guide trials and choice of treatment), determine potential subtypes of disease, and assess severity, prognosis and response to treatment. Candidate biomarkers include immune cell phenotypes, cytokines/chemokines, immunoglobulins, complement and coagulation proteins, acute phase proteins, endocrine markers and markers of neurologic or vascular injury 66 , 67 , 73 , 221 , 222 . Integrated '-omics' analyses 223 , 224 , including genomic, epigenomic, transcriptomic 225 , proteomic 226 , 227 , 228 , metabolomic 229 , lipidomic 230 , and microbiome 231 profiling, may help identify fingerprints for various types of long COVID. However, because of the complexity of long COVID and its diverse manifestations, which likely represent distinct mechanistic pathways, a single or even a panel of laboratory tests may not achieve high-enough performance. Sequela-specific approaches for biomarker discovery may also be productive 221 .

In addition to imaging modalities and biomarkers, harnessing health data from wearable biosensors and other sources may also be useful for diagnosis and to identify triggers and track disease activity.

Epidemiology and clinical course

Studies to understand the incidence, prevalence, severity and trajectory of long COVID over time are critical 35 , 36 , 232 , 233 . Comprehensive understanding of risk factors, including social determinants of health, genetic, environmental, dietary, health behavior (for example, smoking) and other risks of long COVID, is also important.

Research to identify the putative subtypes (or clusters of sequelae) of long COVID has yielded variable results thus far 234 , 235 , 236 , 237 ; greater clarity is needed on putative subtypes and how might they differ in terms of epidemiological features (for example, risk factors), clinical course and potential response to treatment.

Real-world evidence using high-quality data and advanced causal inference approaches (for example, target trial emulation) to evaluate effectiveness of therapeutic interventions will complement evidence generated by randomized trials 238 , 239 . This is particularly relevant in the evaluation of the long-term effects of therapeutic interventions and risks of rare adverse events; trials may have a relatively short follow-up, limiting assessment of long-term outcomes. Moreover, trials may not be adequately powered to detect rare adverse events.

Because long COVID is a new entity (it has been in existence for less than 5 years), longitudinal studies to characterize the long-term health trajectories of people with long COVID—up to 10 years, 20 years and 30 years—are needed, to understand rates and predictors of recovery and relapse of the various manifestations. These long-term studies will also help identify any latent consequences of the disease (that is, impacts that have not yet been realized) and secondary consequences (for example, the downstream health effects that emanate from long COVID). For example, understanding whether people with cognitive dysfunction (or brain fog) are at a higher risk of developing neurodegenerative diseases later in life is critical.

Comparative analyses to understand the post-acute and long-term health consequences of SARS-CoV-2 infection (and reinfection) versus other infections (for example, seasonal and pandemic influenza, respiratory syncytial virus infections and others) is important to enhance our understanding of similarities and differences in their epidemiology and clinical course 197 , 240 , 241 , 242 .

Quantifying the burden of NCDs attributable to long COVID would bring greater clarity to the extent to which billions of SARS-CoV-2 infections around the world may have impacted the global epidemiology of NCDs. The effects of long COVID on global health metrics, including SDGs, should also be periodically evaluated.

Trials to test therapeutics for long COVID

When it comes to clinical trials for long COVID therapeutics, innovation, urgency and scale are all needed 243 , 244 . Long COVID is a complex disease with many manifestations that are likely driven by several different biological mechanisms, and may need different therapeutic approaches. Approaches that reimagine trial design to incorporate the complexities of the disorder and meaningfully incorporate patient input—from trial inception to completion—are needed 244 , 245 . This may include large-scale platform trials with adaptive designs that would test a large battery of potential drug candidates to quickly identify treatments for the various forms of long COVID.

There is a large array of existing drugs that could be readily repurposed and clinically evaluated to address existing hypotheses from viral persistence to immune system dysfunction to vascular damage. Some of these drugs include SARS-CoV-2 antivirals, neutralizing monoclonal antibodies against SARS-CoV-2, non-SARS-CoV-2 antivirals (targeting reactivated EBV and VZV), immunomodulators (for example, JAK–STAT inhibitors, checkpoint inhibitors), anticoagulants, histamine 1 and 2 antagonists, metformin, GLP-1 receptor agonists, SGLT2 inhibitors, microbiome modulators, anti-inflammatory agents, and drugs that improve glymphatic functioning 2 , 62 , 246 . Research agendas must also include development of new antivirals and other new targeted drugs to prepare for the possibility that repurposed drugs may not be sufficiently effective 247 , 248 , 249 . Testing and evaluation of combinations of treatments should also be undertaken when evidence suggests complementary or synergistic mechanisms of action.

Innovation in developing and validating entry criteria and clinical endpoints for long COVID trials is also needed, along with cultivating support for these parameters from stakeholders, including regulators such as the US Food and Drug Administration and European Medicines Agency 250 . Endpoints must include newly developed or improved patient-reported outcomes specific to long COVID and should reflect the often cyclical or relapsing–remitting dynamic of many manifestations of long COVID—with particular focus on tracking post-exertional malaise, a pathophysiological state that impacts all collected data.

Care delivery and health systems research

Research—including comparative analyses—to evaluate the cost and effectiveness of various care pathways in improving quality of care and outcomes in people with long COVID is needed 121 , 127 , 251 . Research to identify and address health inequities and barriers to effective care, especially in low- and middle-income countries, in low-resource settings and in underserved communities, is essential 252 .

Economic impacts

The effect of long COVID on human capital 253 , labor participation, productivity losses (workforce absenteeism, presenteeism and disability) and other economic indicators (including job retention, career advancement and income instability) should be thoroughly evaluated. Research should explore potential disparities in the economic impact of long COVID across various demographic groups, including racial and ethnic minorities, urban and rural communities, socioeconomically marginalized populations, and individuals with preexisting health conditions.

In addition, studies are needed to quantify the direct healthcare costs associated with long COVID. The costs of disability and support systems required to address the needs of people with long COVID should be quantified. The strain that these costs pose on payors (insurance providers and governments) should also be evaluated.

Understanding the economic barriers to healthcare access and affordability for people with long COVID is also important. This includes evaluating out-of-pocket expenses, insurance coverage gaps, and disparities in access to care, rehabilitation services and support services.

Societal impacts

Long COVID affects individual lives and impacts societal well-being. Understanding the effects of long COVID on societies is important, along with understanding the social responses, the perceptions and the genesis and propagation of stigma. Improved knowledge of the social consequences of being affected by long COVID—for example, lost friendships, strained marriages and reduced ability to network—along with the interplay between them and health outcomes, will help to inform supportive interventions. It will also be important to evaluate the burden on caregivers, families and social groups.

Research to develop a deeper understanding of the causes and consequences of misinformation, disinformation and anti-science rhetoric (for example, long COVID denialism) and how to effectively combat them is also needed 254 . Identifying ways to improve science communication, scientific literacy and public trust in science and to bridge the science–policy gap would all help to improve public understanding, as well as the scientific and policy responses to long COVID 254 .

Medical anthropology should also contextualize the response of the science and medicine profession to long COVID within the broader history of medicine. This should include comparative analyses to evaluate and juxtapose the response to long COVID against the responses to the aftereffects of the 1889–1892 flu pandemic and the 1918 flu pandemic and other health crises, including the AIDS crisis in the 1980s 198 , 199 , 201 , 255 , 256 , 257 . Careful anthropologic analysis of how the medical profession approached long COVID as a new disease that emerged in the context of the COVID-19 pandemic is important. It will not only provide historic insights and greater context for our collective response, but also offer insights into how we can optimize responsiveness to emergence of new infection-associated diseases in the future.

Policy roadmap

Given the wide-ranging impact of long COVID on society and the inadequate response thus far, priorities for policy changes are vast. Policies are necessarily dependent on context, resources and various other considerations. The recommendations outlined below are general guidelines that may be adapted to fit the needs of various locales.

Prevention of long COVID

The best way to prevent long COVID is, plainly, to prevent SARS-CoV-2 infection or reinfection in the first place. Masking, especially in high-risk places 258 (for example, healthcare settings), is important—along with isolation guidelines and sick leave policies that permit people with infection to recuperate at home, thereby diminishing the probability of transmission and reducing the risk of long COVID 45 .

Although vaccines may reduce the risk of long COVID, vaccine policies in much of the world restrict vaccine availability to high-risk groups. These policies consider risks of death and hospitalization in the acute phase (which are manifest primarily in older adults and those with comorbidities) and ignore the risk of long COVID. Adding to these policy challenges are the low rates of vaccine uptake in 2023–2024 among eligible populations 259 . Vaccine policies must consider the risk of long COVID, as well as the risk of hospitalization and death during the acute phase of SARS-CoV-2 infection; and strategies to improve vaccine uptake (for example, pairing the COVID-19 vaccine with the annual influenza vaccine and other approaches) should be utilized to achieve wider vaccine coverage and greater protection to populations.

Because SARS-CoV-2 is likely to remain for decades to come, it is important to develop long-term, sustainable prevention solutions. Airborne transmission risk assessment tools, such as the one developed by the World Health Organization (WHO), help inform risk reduction strategies 260 . Ventilation and air filtration systems can play a major role in reducing the risk of infection with airborne pathogens 261 . Calls have been made for mandatory improved air quality standards for public spaces and policies that would support design and equipment of homes to meet these standards 261 . Investment in infrastructure supporting improved indoor air quality will help reduce the risk of SARS-CoV-2 transmission and other airborne pathogens and will ensure greater resilience against future threats from airborne pathogens 262 . Amelioration of indoor air quality also has the added benefit of reducing risk of health effects due to indoor air pollutants 263 , 264 , 265 , thereby improving human health, well-being, productivity and learning 261 , 262 , 266 . Investment in vaccine technologies to develop more durable, variant-proof vaccines that are not rendered ineffective by ongoing mutations of the SARS-CoV-2 virus are important. Vaccine technologies that induce strong mucosal immunity to block SARS-CoV-2 infection and transmission are also needed 267 .

Supporting people with long COVID

Because of the considerable impacts of long COVID on people’s ability to work and care for themselves, it is imperative that an adequate response to the long COVID crisis involves ensuring people have the financial, physical and emotional support 132 . Streamlining of disability benefit processes, as well as increased access to home and community-based services and food and cash assistance is critical. Workplace policies that support individuals with long COVID could include flexible working hours, increased breaks to allow for pacing, the option for remote work, and sick leave policies. Funding should be provided to support patient groups and community-based organizations, which can provide and connect people to critical supports and services.

Access, quality and equity of care

Governments must work to build and expand access to long COVID care, in particular for marginalized communities (for example, rural and indigenous communities). Improving access to care may take various forms in different countries, depending on the structure of the healthcare system and the involvement of national and local governments in financially supporting healthcare services. Adequate coverage of long COVID treatments and rehabilitation services by insurance providers is requisite. Development of quality-of-care metrics for long COVID and policies to monitor and incentivize quality of care should be pursued 121 . As diagnostics and treatments are developed, governments must also ensure equitable access. Shining historical examples include the Brazilian National AIDS Program, which was established in 1996 in response to the HIV/AIDS crisis to ensure free and universal provision of antiretroviral drugs 268 , 269 , and the Ryan White HIV/AIDS Program (based in the United States), which provides outpatient HIV care, treatment and support services to those without health insurance and fills gaps in coverage and cost for those with insurance limitations 270 , 271 , 272 .

Professional education and training

Currently, very few medical schools and health professional training programs include in their curricula any meaningful training about identification and clinical management of infection-associated chronic conditions, including long COVID. A survey of physicians in the United States showed that 78% agree that long COVID is a problem but only about one-quarter feel prepared to address it 273 . Training of healthcare professionals to recognize and manage long COVID effectively must be prioritized. This includes embedding up-to-date information on long COVID and infection-associated chronic conditions into training curricula for health professions, as well as providing regular high-quality continuing education to qualified health providers.

Public health communication

Existing public health education on long COVID has been minimal. A survey in the United States showed that one-third of American adults still had not heard of long COVID as of August 2023 (ref. 274 ), and there remains very low awareness of long COVID in low- and middle-income countries. Through public education campaigns, governments must raise awareness about long COVID and the risk of chronic conditions after infection; combat social stigma across adults and children; and use a harm reduction framework to promote awareness of prevention measures (including vaccination, masking and improved indoor air quality) 258 , 260 , 261 .

Supporting coordinated interdisciplinary research

To achieve the research priorities listed above, governments must substantially increase the amount of funding toward research. In the United States, existing calls for the establishment of a center for infection-associated chronic conditions at the US National Institutes of Health—with a funding request of at least $1 billion per year toward long COVID research and with additional substantial funding for other infection-associated chronic conditions—should be vigorously supported 275 . This proposal would create a coordinating entity to lead a long-term, large-scale interdisciplinary research portfolio to address long COVID research priorities. Other governments should also explore similar proposals.

Policies supporting research should explicitly mandate meaningful patient engagement in research from inception to implementation, and should leverage existing expertise (including scientific, clinical and lived experience) in infection-associated chronic conditions. Furthermore, meaningful efforts must be made to expand the pool of researchers working on infection-associated chronic conditions, by encouraging early career scientists and clinician–researchers to focus on these conditions and providing resources to current experts to lead training and research.

Given the complexity of long COVID and its similarities to other infection-associated chronic conditions, a coordinated approach that integrates research, policy and regulatory efforts across these conditions would reduce duplication of efforts and allow a more comprehensive understanding of the common underlying mechanisms, trial designs and potential treatment strategies.

Policies from funders are needed to mandate meaningful data sharing, which will maximize the utility and pooled insights that can be generated from existing health information. Current open data protocols are insufficient, laden with bureaucratic hurdles and do not allow access to primary data, and consequently do not enable meaningful analyses. Funders must establish data banks (a pioneering exemplar of this is the UK Biobank) for the collection, storage, analysis, retrieval and dissemination of data to make long COVID research more accessible in near real time, all while upholding data privacy and data security standards 276 , 277 .

Building consensus on definitions and clinical endpoints for long COVID

Various interim definitions of long COVID exist 39 , 278 , 279 , 280 , 281 , 282 , 283 , but there is not yet a universal consensus on the most optimal definition—which must be sufficiently nuanced to capture the complexity of the condition and its various manifestations. It is unlikely that a single definition will fit all needs. Consensus definitions that are optimized and empirically tested for various applications, including clinical care, epidemiological surveillance, and research, should be developed. Definitions must necessarily evolve to incorporate new understanding as the evidence base for long COVID grows.

Similarly, developing consensus on clinical endpoints for trials of long COVID is needed. Drug regulatory agencies in consultation with stakeholders, including patients and scientists, should lead in this arena and provide regulatory guidance on clinical endpoints for trials. These endpoints will also have to necessarily evolve as our understanding of long COVID expands.

Building consensus on definitions and clinical endpoints would catalyze progress in this field, remove barriers to entry for the pharmaceutical industry into long COVID trials and facilitate comparative analyses across studies.

Global coordination

The global nature of long COVID necessitates international cooperation in both research and policy. International bodies (for example, the WHO) should facilitate partnership and collaboration among countries across the globe. This collaboration is pivotal to coordinate and synergize efforts across the globe and accelerate progress on the different challenges posed by long COVID.

Professional societies for long COVID

Professional societies (national and global) should be established for long COVID. Because of the multisystemic nature of long COVID (and the other infection-associated chronic conditions), it does not fit neatly under any of the traditional organ-based organizational structures of medical care and research 284 , hence the need for professional home(s) for long COVID and associated conditions. Dedicated professional societies could provide strategic leadership and guidance in the clinical management of long COVID and associated conditions 284 . They could serve as hubs to coordinate education, research and advocacy efforts 284 . These professional societies could play a major role in organizing and hosting national and international conferences, spearheading efforts to provide periodic synthesis of evidence that distills existing research into actionable insights guiding care of people with long COVID. The newly established Clinical Post COVID Society in the United Kingdom may be a promising example of this 284 .

Preparedness for the next pandemic

We must reflect on our collective experience with COVID-19 to enhance resilience and preparedness for future pandemics 285 , 286 , 287 . A major lesson learned from long COVID is that pandemics leave in their wake a long tail of disease and disability 198 . This is not unique to the COVID-19 pandemic 198 ; historical accounts show similar phenomena following previous pandemics 198 , 199 , 255 . Due to climate change, deforestation, human encroachment on animal habitat, increased frequency of travel, a growing livestock industry and other anthropogenic factors, the risk of zoonotic spillover and novel viral sharing among species is likely higher in the twenty-first century than it was in the twentieth century 286 , 288 , 289 , 290 , 291 , 292 . Many of the geographic areas that are most prone to these changes are also projected to have high population density—creating ripe conditions for pandemics 289 , 291 . Future pandemics are likely to also produce long-term disability and disease 198 . Investment in systems to measure the population-level incidence and prevalence of post-acute and chronic disease caused by infectious agents, including SARS-CoV-2, will aid in the characterization of the epidemiology of long COVID and will position us to be better prepared to deal with post-acute and chronic illnesses that will emerge in future pandemics. Incorporating the potential emergence of long-term health effects into initiatives for pandemic preparedness and resilience (for example, the WHO Preparedness and Resilience for Emerging Threats Initiative) is essential to optimize response to the long-term consequences of future pandemics.

Conclusions

Considerable progress has been made in the past several years in characterizing the epidemiology, clinical course and biology of long COVID. But much remains to be done. The scale of long COVID and its far-reaching impacts necessitate a robust and coordinated research and policy response strategy. Addressing the research and care needs of people impacted by long COVID will have broad benefits, potentially unlocking a better understanding of infection-associated chronic illnesses (an ignored area for decades) and optimizing our preparedness for the next pandemic.

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Aug. 16, 2024

Researchers make breakthrough in fight against covid-19.

A team led by Jose Onuchic at Rice University and Paul Whitford at Northeastern University, both researchers at the National Science Foundation Physics Frontiers Center at the Center for Theoretical Biological Physics ( CTBP ) at Rice, has made a discovery in the fight against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the virus responsible for COVID-19.

The team, in partnership with an experimental effort led by Yale University researchers Walter Mothes and Wenwei Li, has uncovered new insights into how the virus infects human cells and how it can be neutralized. Their findings were published in the journal Science on Aug. 15.

SARS-CoV-2 uses its spike protein to attach to the angiotensin-converting enzyme 2 on human cells, initiating a process that allows it to enter the cell. The spike protein has two main parts: the S1 domain, which varies greatly among different strains of the virus, and the S2 domain, which is highly conserved across different coronaviruses. This similarity makes the S2 domain a promising target for vaccines and therapies that could work against many virus strains.

By combining simulations and theoretical predictions with structural information from their experimental collaborators, including initial and final configurations as well as intermediate states during the viral invasion, the researchers obtained a detailed picture of the infection process at an atomic level.

“Understanding these intermediate states of the spike protein creates new opportunities for treatment and prevention,” said Onuchic, the Harry C. and Olga K. Wiess Chair of Physics, professor of physics and astronomy, chemistry and biosciences and co-director of CTBP. “Our work demonstrates the importance of combining theoretical and experimental approaches to tackle complex problems such as viral infections.”

Using an advanced imaging technique called cryo-electron tomography, the experimental researchers at Yale captured detailed snapshots of the spike protein as it changes during the fusion process.

They discovered antibodies targeting a specific part of the S2 domain, called the stem-helix, which can bind to the spike protein and stop it from refolding into a shape necessary for fusion. This prevents the virus from entering human cells.

“Our study provides a detailed understanding of how the spike protein changes shape during infection and how antibodies can block this process,” Onuchic said. “This molecular insight opens up new possibilities for designing vaccines and therapies targeting a wide range of coronavirus strains.”

The researchers used a combination of theoretical modeling and experimental data to achieve their findings. By combining simulations of the spike protein with experimental images, they captured intermediate states of the protein that were previously unseen. This integrated approach allowed them to understand the infection process at an atomic level.

“The synergy between theoretical and experimental methods was crucial for our success,” said Whitford, a professor in the Department of Physics at Northeastern. “Our findings highlight new therapeutic targets and strategies for vaccine development that could be effective against most variants of the virus.”

The team’s discovery is significant in the ongoing efforts to combat COVID-19 and prepare for future outbreaks of related viruses. By targeting the conserved S2 domain, scientists can develop vaccines and therapies that remain effective even as the virus mutates.

“This research is a step forward in the fight against COVID-19 and other coronaviruses that may emerge in the future,” said Saul Gonzalez, director of the U.S. National Science Foundation’s Physics Division. “Understanding the fundamental physical workings within intricate biological mechanisms is essential for developing more effective and universal treatments that can protect our health and save lives.”

This work was supported by the National Science Foundation, National Institutes of Health, Canadian Institutes of Health Research, Canada Research Chairs and Welch Foundation.

Other researchers include Michael Grunst and Zhuan Qin at the Department of Microbial Pathogenesis and Shenping Wu at the Department of Pharmacology at Yale; Esteban Dodero-Rojas at CTPB; Shilei Ding, Jérémie Prévost and Andrés Finzi at the Centre de Recherche du CHUM; Yaozong Chen and Marzena Pazgier in the Infectious Disease Division in the F. Edward Hebert School of Medicine at Uniformed Services University of the Health Sciences; and Yanping Hu and Xuping Xie in the Department of Biochemistry and Molecular Biology at the University of Texas Medical Branch at Galveston.

• Open access
• Published: 17 August 2024

Epidemiology, ventilation management and outcomes of COVID–19 ARDS patients versus patients with ARDS due to pneumonia in the Pre–COVID era

• Fleur–Stefanie L. I. M. van der Ven 1 , 2   na1 ,
• Siebe G. Blok 1   na1 ,
• Luciano C. Azevedo 3 , 4 ,
• Giacomo Bellani 5 , 6 ,
• Michela Botta 1 ,
• Elisa Estenssoro 7 ,
• Eddy Fan 8 ,
• Juliana Carvalho Ferreira 9 , 10 , 11 ,
• John G. Laffey 12 , 13 ,
• Ignacio Martin–Loeches 14 , 15 ,
• Ana Motos 16 , 17 , 28 ,
• Tai Pham 18 , 19 ,
• Oscar Peñuelas 17 , 20 ,
• Antonio Pesenti 21 ,
• Luigi Pisani 1 , 22 , 24 ,
• Ary Serpa Neto 4 , 23 ,
• Marcus J. Schultz 1 , 24 , 25 , 26 , 27 ,
• Antoni Torres 16 , 17 , 28 , 29 ,
• Anissa M. Tsonas 1 ,
• Frederique Paulus 1 , 30 &
• David M. P. van Meenen 1 , 31

for the ERICC–, LUNG SAFE–, PRoVENT–COVID–, EPICCoV–, CIBERESUCICOVID–, SATI–COVID–19–investigators

Respiratory Research volume  25 , Article number:  312 ( 2024 ) Cite this article

Metrics details

Ventilation management may differ between COVID–19 ARDS (COVID–ARDS) patients and patients with pre–COVID ARDS (CLASSIC–ARDS); it is uncertain whether associations of ventilation management with outcomes for CLASSIC–ARDS also exist in COVID–ARDS.

Individual patient data analysis of COVID–ARDS and CLASSIC–ARDS patients in six observational studies of ventilation, four in the COVID–19 pandemic and two pre–pandemic. Descriptive statistics were used to compare epidemiology and ventilation characteristics. The primary endpoint were key ventilation parameters; other outcomes included mortality and ventilator–free days and alive (VFD–60) at day 60.

This analysis included 6702 COVID–ARDS patients and 1415 CLASSIC–ARDS patients. COVID–ARDS patients received lower median V T (6.6 [6.0 to 7.4] vs 7.3 [6.4 to 8.5] ml/kg PBW; p  < 0.001) and higher median PEEP (12.0 [10.0 to 14.0] vs 8.0 [6.0 to 10.0] cm H 2 O; p  < 0.001), at lower median ΔP (13.0 [10.0 to 15.0] vs 16.0 [IQR 12.0 to 20.0] cm H 2 O; p  < 0.001) and higher median Crs (33.5 [26.6 to 42.1] vs 28.1 [21.6 to 38.4] mL/cm H 2 O; p  < 0.001). Following multivariable adjustment, higher ΔP had an independent association with higher 60–day mortality and less VFD–60 in both groups. Higher PEEP had an association with less VFD–60, but only in COVID–ARDS patients.

Conclusions

Our findings show important differences in key ventilation parameters and associations thereof with outcomes between COVID–ARDS and CLASSIC–ARDS.

Trial registration

Clinicaltrials.gov (identifier NCT05650957), December 14, 2022.

The high numbers of patients who needed invasive ventilation early in the unprecedented pandemic of coronavirus disease 2019 (COVID–19) has led to numerous studies of epidemiology, ventilation management and outcomes in patients with acute respiratory distress syndrome (ARDS) related to an infection with SARS–CoV–2. COVID–19 ARDS would differ from ARDS before the pandemic (CLASSIC–ARDS) in several aspects [ 1 , 2 ], and different phenotypes have even been suggested [ 3 , 4 ].

The number of studies that directly compared ventilation management of COVID–ARDS with CLASSIC–ARDS is limited [ 5 , 6 ]. It remains uncertain whether practice of invasive ventilation in COVID–ARDS patients really differed from that in CLASSIC–ARDS patients. It is also unknown whether associations of certain aspects of ventilation with outcomes found in CLASSIC–ARDS also exist in COVID–ARDS. This would have serious implications on how to set the ventilator in the two patient groups, as then certain recommendations in guidelines for ventilation in CLASSIC–ARDS may not apply in COVID–ARDS [ 7 ].

We performed an analysis of a conveniently–sized database that pooled the data of individual patients of six observational ventilation studies, four of which were conducted in the COVID–19 pandemic and two pre–pandemic, to compare epidemiology, ventilator management and associations of ventilation characteristics and outcome between COVID–ARDS and CLASSIC–ARDS patients. To have comparable patient groups, we only selected patients with ARDS from a respiratory infection from the two pre–pandemic studies. We hypothesized that key ventilator parameters would be different between the two groups, and used multivariable analyses to determine associations with outcomes.

Study design and participants

This is a meta–analysis using the individual patient data of patients in six preselected large observational studies focusing on a diverse representation of epidemiological features and ventilation management in both COVID–19 and pre–pandemic ARDS. The six studies were selected because they all contained detailed data on epidemiological features, ventilation data, and outcomes, originating from various regions worldwide, both in resource–limited and resource–rich settings.

The corresponding authors of the original studies accepted the invitation, after which the data dictionaries of the studies were compared to check whether the data could be harmonized. Then, the databases were transferred after local approval and agreement on the analysis plan of the current investigation.

The two pre–pandemic studies were the national ‘Epidemiology of Respiratory Insufficiency in Critical Care’ study (ERICC) conducted in 2011 in Brazil [ 8 ], and the international ‘Large Observational Study to UNderstand the Global Impact of Severe Acute Respiratory FailurE’ study (LUNG SAFE) conducted in 2014 in 50 countries worldwide [ 9 ]. All four studies were conducted during the COVID–19 pandemic, ranging from March 2020 to 2021 and included: the national ‘Practice of Ventilation in COVID–19 patients’ study (PRoVENT–COVID) from The Netherlands [ 10 ], the national ‘EPIdemiology of Critical COVID–19’ study (EPICCoV) from Brazil [ 11 , 12 ], the national ‘Centro de Investigación Biomédica en Red Enfermedades Respiratorias COVID–19 study’ (CIBERESUCICOVID) from Spain [ 13 ], and the national ‘Sociedad Argentina de Terapia Intensiva–COVID–19 study’ (SATI–COVID–19) from Argentina [ 14 ].

The study protocols of the original studies were approved by Institutional Review Boards if applicable, and need for individual patient informed consent was waived for all studies due to their observational designs. Details of all studies can be found in the original publications [ 8 , 9 , 10 , 12 , 13 , 14 ]. We invited the corresponding investigators of the original studies to provide us the case report forms and data dictionaries, and the data of all patients. The creation of the pooled database did not require additional ethical approval. The databases of the original studies were harmonised using the case report forms and data dictionaries, and finally merged. This current analysis is registered at clinicaltrials.gov (study identifier NCT05650957), and its statistical analysis plan was finalized before cleaning and closing of the database.

Patients in the merged database were eligible for participation in this current analysis if: (1) aged 18 years or higher; (2) having received invasive ventilation within the first 48 h of ICU admission, regardless of its duration; and (3) fulfilling the Berlin definition of ARDS. We excluded CLASSIC–ARDS patients when ARDS was reported not to be caused by a respiratory infection.

Data available for merging

The following baseline and demographic variables were available for merging into the new database—sex, age, body weight and height, comorbidities including hypertension and cardiac failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, kidney failure, liver failure, and cancer, date of hospital and intensive care unit (ICU) admission, and disease severity scores, including the Simplified Acute Physiology Score (SAPS) II at ICU admission and a daily Sequential Organ Failure Assessment (SOFA) scores.

Collected ventilation variables were––mode of ventilation, tidal volume (V T ), positive end–expiratory pressure (PEEP), fraction of inspired oxygen (FiO 2 ), respiratory rate (RR), peak pressure (Ppeak) in volume–controlled ventilation and plateau pressure (Pplat) in pressure–controlled ventilation, blood gas analyses results, and adjunctive therapies to improve oxygenation in case of refractory hypoxaemia. The first available measurement of the day was used. If multiple measurements were taken on the same day, we selected earliest one.

The dynamic driving pressure (ΔP) was calculated by subtracting PEEP from the maximum airway pressure [ 15 , 16 ]. Respiratory system compliance (Crs) was calculated by dividing V T by ΔP. MP was calculated using the power Eq. (17), wherein MP (J/min) = 0.098 * V T * RR * (Ppeak − 0.5 * ΔP) [ 17 ]; a modified power equation was used if no Ppeak was available 0.098 * V T * RR * (Pplat − 0.5 * ΔP) [ 16 ]. The ventilatory ratio was calculated as (minute ventilation * PaCO 2 )/(predicted bodyweight * 100 * 37.5) [ 18 ]. The number of ventilator–free days at day 60 (VFD–60) was calculated by subtracting the number of calendar days a patient received invasive ventilation up to the day of successful extubation from 60, similar to the method used for calculating VFD–28. Patients that died before or at day 60 received zero VFD–60 [ 19 , 20 ].

The following follow–up data were available for merging—last day of ventilation, tracheostomy use, last day in ICU and hospital, and life status at day 60.

The primary endpoint of this analysis was a combination of the following key ventilation characteristics as done before [ 10 ]—V T , PEEP, ΔP, and Crs. Secondary outcomes were other ventilator parameters, the use of prone positioning, muscle paralysis or extracorporeal membrane oxygenation, and 60–day mortality and the number of VFD–60.

Power analysis

We did not perform a formal power analysis; instead, the number of available patients served as the sample size.

Statistical analysis

Baseline demographics were compared using Fisher’s exact tests for categorical variables and Wilcoxon rank–sum tests for continuous variables. Continuous distributed variables are presented as medians and interquartile ranges, categorical variables are presented as frequencies and proportions.

The first day a patient received invasive ventilation and the first full calendar day were combined into ‘day 1’, the next day was designated as ‘day 2’. Information on missing values for each ventilation parameters and other variable can be found in the Supplementary Material (eTable 1). Only SOFA scores were available for all patients, therefore, we chose to only report these instead of other severity scores.

To compare ventilation characteristics between COVID–ARDS and CLASSIC–ARDS patients, a Wilcoxon rank–sum test was used. Cumulative distribution plots were constructed to visualize cumulative distribution frequencies of each ventilation variable or parameter, wherein vertical dotted lines represent broadly accepted safety cutoffs for each variable, and horizontal dotted lines show the respective proportion of patients reaching that cutoff.

As a post–hoc analysis to identify whether V T , PEEP and ΔP have independent associations with 60–day mortality and the number of VFD–60, a multivariable mixed–effects model with centre as random effect was performed. A linear mixed–effects model was used for the number of VFD–60 and a logistic mixed–effects model for 60–day mortality.

The following covariates, with a known or suspected association with these two outcomes were included in the model, based on clinical relevance: (1) PaO 2 /FiO 2 ; and (2) demographic variables, including sex, age, BMI, history of heart failure, COPD, diabetes mellitus, kidney failure, liver failure and cancer.

In this mixed model analysis, when a covariate exhibited more than 10% missing data, we utilized multiple imputation techniques implemented through the MICE package in R. The model was checked for collinearity using variance–inflation factors, wherein a variance–inflation factor < 5 was deemed acceptable. The variance–inflation factor was < 2 for all included variables in our model.

The estimate refers to the average effect of the ventilation parameter, i.e., V T , PEEP or ΔP on the outcome of interest, i.e., 60–day mortality and VFD–60 while controlling for the other variables in the model. A positive estimate indicates that an increase in the predictor variable tends to lead to a corresponding increase in the response variable, indicating a proportional relationship between them. Conversely, a negative estimate suggests that an increase in the predictor variable tends to result in a decrease in the response variable, indicating an inverse proportional relationship between them.

All analyses were conducted in R v.4.0.3 (R Foundation for Statistical Computing, Vienna, Austria). A p value < 0.05 was considered statistically significant.

We received the individual data of a total of 8374 COVID–ARDS patients and 3795 CLASSIC–ARDS patients (Fig.  1 ). After exclusion of patients that did not fulfil the Berlin definition of ARDS, patients that did not receive invasive ventilation on the first and second day in the study, and patients included in the two pre–pandemic studies who did not have a respiratory infection as the cause for ARDS, we had 6702 fully–analysable COVID–ARDS patients and 1415 fully–analysable CLASSIC–ARDS. COVID–ARDS patients were more often male, had higher median BMI, a history of diabetes more often, and a history of COPD or chronic kidney disease less often (Table  1 ). COVID–ARDS patients had lower median SOFA scores, and ARDS severity was more often classified as moderate or severe.

Flowchart of included studies. Abbreviations: ARDS = acute respiratory distress syndrome; COVID–19 = coronavirus disease 2019

COVID–ARDS patients were ventilated with volume–controlled ventilation more often than CLASSIC–ARDS patients (Table  2 ) and received ventilation with lower V T (6.6 [6.0 to 7.4] vs 7.3 [6.4 to 8.5] ml/kg PBW; p  < 0.001), higher PEEP (12.0 [10.0 to 14.0] vs 8.0 [6.0 to 10.0] cm H 2 O; p  < 0.001), at lower ΔP (13.0 [10.0 to 15.0] vs 16.0 [IQR 12.0 to 20.0] cm H 2 O; p  < 0.001) and higher Crs (33.5 [26.6 to 42.1] vs 28.1 [21.6 to 38.4] mL/cm H 2 O; p  < 0.001) (Fig.  2 ) COVID–ARDS patients received higher PEEP than CLASSIC–ARDS patients at any FiO 2 level (eFigure 2). Within each group, the ventilation characteristics were not different between day 1 and 2 (eTable 2 and eFigure 1 and 2).

Key ventilation parameters. Cumulative frequency distribution of V T , PEEP, ΔP, and respiratory system compliance on the first calendar day for each variable. Vertical dotted lines represent broadly accepted safety cutoffs for each variable, and horizontal dotted lines show the respective proportion of patients reaching that cutoff. Abbreviations: V T  = tidal volume; PBW = predicted bodyweight; PEEP = positive end–expiratory pressure; ΔP = driving pressure; C RS  = respiratory system compliance

Prone positioning and neuromuscular blocking agents were more often used in COVID–ARDS patients than in CLASSIC–ARDS patients (Table  2 ). COVID–ARDS patients received a tracheostomy more often than CLASSIC–ARDS patients.

Mortality at day 60 was higher in COVID–ARDS patients compared to CLASSIC–ARDS patients (Table  2 and Fig.  3 ), and COVID–ARDS patients had significantly less VFD–60. Following multivariable adjustment, higher ΔP had an association with higher 60–day mortality and less VFD–60 in both groups. Higher PEEP also had an association with less VFD–60, but only in COVID–ARDS patients and not in CLASSIC–ARDS patients. In both groups, V T neither had an association with 60–day mortality nor with VFD–60 (eFigure 3 and eFigure 4).

Mortality and ventilator–free days and Alive at day–60, and associations with ventilator parameters. The estimate is the average effect of the predictor variable on the response variable, while controlling for the other variables in the model. A positive estimate suggests a proportional effect, whereas a negative estimate suggests an inversely proportional effect. Abbreviations: ARDS = acute respiratory distress syndrome; VFD = ventilator–free days and alive; IQR = interquartile range; N = number; CI = confidence interval; V T  = tidal volume; PBW = predicted bodyweight; PEEP = positive end–expiratory pressure; ΔP = driving pressure

We pooled the individual data of patients from six observational studies of ventilation and compared ventilation characteristics and associations with outcomes between COVID–ARDS with CLASSIC–ARDS. The main findings were: (1) compared to CLASSIC–ARDS patients, COVID–ARDS patients were ventilated with lower V T and higher PEEP, at lower ΔP and higher Crs, however with a higher MP; (2) 60–day mortality was not different between COVID–ARDS and CLASSIC–ARDS, but COVID–ARDS patients had less VFD–60; (3) higher ΔP had an association with higher 60–day mortality and less VFD–60 in COVID–ARDS and CLASSIC–ARDS; and (4) higher PEEP also had an association with less VFD–60, but only in COVID–ARDS.

Our findings add to the current understanding of differences and similarities between COVID–19 ARDS patients and pre–COVID ARDS patients. The international design of our study increases the generalizability of the findings across diverse healthcare systems, both in ARDS patients caused by COVID–19 and in patients with ARDS due to pneumonia from before the pandemic. The large sample size and high quality of the collected data allowed for sophisticated analyses of epidemiology, respiratory support strategies, and outcomes. Additionally, we found associations between key ventilator settings and patient outcomes.

Several studies have compared COVID–19 ARDS with pre–COVID ARDS. The epidemiological differences between COVID–19 ARDS and pre–COVID ARDS patients in our study align with previous findings [ 21 ]. As with other studies [ 22 , 23 ], we also found significant differences in ventilator variables like V T , PEEP, and ΔP, and in the use of adjunctive therapies. Our study contributes by demonstrating these differences specifically among ARDS patients and comparing COVID–19 ARDS to pre–COVID ARDS due to respiratory infections. Differences in outcomes found in our study are, at least in part, in line with prior research findings [ 21 , 23 ]. Our findings confirm that there are differences in mortality and the number of VFD–60 between COVID–19 ARDS and pre–COVID ARDS patients. However, these difference disappeared after propensity matching. This is important as it shows that, at least when comparing outcomes in ARDS patients from an infectious cause, outcomes are not different, opposite to what was thought at the start of the pandemic.

We observed more frequent use of lower V T in COVID–ARDS compared to CLASSIC–ARDS. Indeed, proportions of COVID–ARDS patients that received ventilation with a V T  < 6 or between 6 and 8 ml/kg PBW was higher than in CLASSIC–ARDS patients. This finding can be explained in several ways––e.g., it could be that the use of lung–protective ventilation with a lower V T has improved in the last decade [ 15 ]. It is also conceivable that, at least early in the pandemic care for COVID–ARDS patients was provided by inexperienced ICU staff which could have been more adherent to existing guidelines for management of patients with ARDS [ 10 , 24 ]. It is also possible that use of low V T in COVID–ARDS is easier to control––these patients were often deeply sedated and paralyzed allowing a stricter adherence to lower V T . Of note, especially in those patients, ventilation with a lower V T might be more beneficial than in spontaneous breathing patients [ 25 ].

Higher PEEP was more often used in COVID–ARDS patients than in CLASSIC–ARDS patients, at any FiO 2 level. Indeed, proportions of COVID–ARDS patients that received ventilation with a PEEP between 8 and 12 cmH 2 O and even between 12 and 16 cmH 2 O was higher than in CLASSIC–ARDS patients. This finding can also be explained in several ways––e.g., a preference for use of higher PEEP in COVID–ARDS patients may have been triggered by the severity of ARDS, as COVID–ARDS was more often classified as moderate or severe, and more severe hypoxaemia naturally triggers the use of higher PEEP if PEEP/FiO 2 tables are used. It is also possible that higher PEEP was used in the assumption that lung lesions with COVID–ARDS are more recruitable than in CLASSIC–ARDS. This may at least explain the lower ΔP and higher Crs in COVID–ARDS patients.

In COVID–ARDS patients, mechanical power exceeded that of CLASSIC–ARDS, even though the driving pressure was lower. This observation marks the significance of considering factors beyond driving pressure, such as respiratory rate and PEEP, when evaluating the protective nature of invasive ventilation. These findings emphasize the complexity of respiratory management in COVID–ARDS and the need for a comprehensive approach to optimize lungprotective ventilation strategies.

COVID–ARDS patients received prone positioning more often than CLASSIC–ARDS patients. Before the pandemic, prone positioning remained underused, probably because it was more considered a rescue therapy for refractory hypoxaemia [ 26 ]. While we cannot rule out that use of prone positioning increased already before the pandemic, we favour the idea that the higher use of prone positioning in COVID–ARDS patients was triggered by the more severe hypoxaemia in COVID–ARDS patients.

Our analysis found several associations between ventilation parameters and outcome. The association of higher ΔP with higher 60–day mortality and less VFD–60 is in line with previous studies [ 27 , 28 , 29 ]. The association of higher PEEP with worse outcome confirms the findings of earlier studies [ 30 , 31 ]. Of note, this association was only found for COVID–ARDS. This may have been caused by the more frequent use of higher PEEP in COVID–ARDS than in CLASSIC–ARDS. One reason for the association between higher PEEP and worse outcome may be that sicker patients, with a higher chance of dying and prolonged ventilation, received higher PEEP than patients that were less sick. Nonetheless, a high PEEP is suggested to have detrimental effects [ 32 ], emphasizing the need to determine the optimal PEEP level based on lung recruitability rather than hypoxemia alone. Actually, one analysis of PRoVENT–COVID suggested worse outcomes if patients received ventilation according to a higher PEEP/lower FiO 2 table as compared to ventilation according to a lower PEEP/higher FiO 2 [ 30 ]. A post–hoc Bayesian analysis of a randomised clinical study, named the ‘Alveolar Recruitment for ARDS Trial’ (ART), wherein patients were randomized to receive ventilation with PEEP titrated to the best Crs and aggressive recruitment manoeuvres versus ventilation with a low PEEP strategy, suggested that higher PEEP with recruitment manoeuvres worsens the outcome of ARDS from pneumonia, while it may be beneficial in ARDS from another cause [ 33 ]. A posthoc analysis of a randomised clinical study named ‘Lung Imaging for Ventilator Setting in ARDS trial’ (LIFE), suggest that higher PEEP worsens outcomes in patients with ARDS with lesions that may not be recruitable with higher PEEP [ 34 ].

The findings of this pooled analysis extend the existing knowledge of the epidemiology, management of invasive ventilation and outcomes in COVID–ARDS. Our study shows that lung–protective ventilation was applied well in COVID–ARDS, and was comparable to best practice used in management for patients with CLASSIC–ARDS. Additionally, the effect of PEEP on major outcomes may have implications for care. At least it should trigger new studies that directly compare different PEEP strategies. Meanwhile, it could be more attractive to not use higher PEEP by default.

Our study has several strengths. We managed to receive and merge the datasets of four large observational studies of ventilation conducted in the COVID–19 pandemic with two well–performed pre–pandemic observational studies of ventilation––these six studies all focused on ventilation management and reported outcomes of invasively ventilated ARDS patients, allowing a robust analysis of ventilation management and the impact of certain ventilation parameters on outcome. While the COVID–19 studies were all national investigations, they are from different regions worldwide and were conducted in different types of hospitals, which increases the generalizability of our findings. The datasets from the original studies were rich and comprehensive, encompassing baseline and demographic data, granular ventilator settings and ventilation variables, and key clinical outcomes. All data could be harmonized and merged into one database.

We had an analysis plan in place before cleaning and closing of the new database, and this plan was strictly followed. The large numbers of patients allowed us to perform sophisticated statistical analyses of associations with outcomes.

This study has limitations. First, individual data was obtained from observational studies, which limits the ability to establish causality. Additionally, the willingness of data sharing could have led to selection bias towards the inclusion of ICUs with an interest in invasive ventilation and management of ARDS in the original studies. Second, studies in COVID–ARDS were conducted early in the COVID–19 pandemic, during which inexperienced staff and resource limitations could have influenced clinical decision making. Third, data was collected early in the pandemic when patient care took priority over data collection, resulting in more missing data than in previous studies. This affects the completeness and may impact the accuracy of our analysis. Fourth, we only reported on ventilation characteristics on day 1 and 2, because not all studies collected ventilation data beyond this timepoint. Therefore we were not able to compare ventilation management beyond day 2. Nevertheless, previous studies have shown ventilation characteristics don’t significantly change in the first four days after initiation of invasive ventilation [ 10 ]. Fifth, it is imperative to acknowledge the temporal distance between comparator cohorts. For the pre–COVID ARDS group we used patients of which data was collected between seven to nine years before the pandemic. We cannot exclude temporal differences, for instance due to studies that showed the importance of limiting liberal use of oxygen, and reducing the intensity of ventilation, e.g., by targeting a low driving pressure or a low mechanical power of ventilation, as well as the importance of early use of prone positioning. Sixth, is the lack of detailed subgroup analyses, particularly in patients with chronic respiratory comorbidities such as COPD. Although recent findings from a post–hoc analysis of the PRoVENT–COVID study by Tripipitsiriwat et al. [ 35 ] indicated that ventilation parameters did not show significant differences between COPD and non–COPD patients, it could be interesting to explore these subgroups. However, it was beyond the scope of our primary endpoint. Conducting such detailed subgroup investigations would require careful consideration to ensure the data from all included studies are appropriate for this type of analysis.

Finally, all COVID–19 ARDS patients, by definition, had a viral pneumonia, while patients in the classic ARDS group had respiratory infections of which the pathogen was not collected. This is an important limitation, as ARDS from a viral respiratory infection may differ from ARDS due to bacterial pneumonia. Consistent with other studies comparing COVID–19 ARDS to ARDS caused by other viruses, we found that the duration of ventilation was longer, and mortality was higher [ 21 , 36 , 37 ].

Epidemiology and key ventilation characteristics were different in patients with COVID–ARDS compared to CLASSIC–ARDS, also ΔP was lower in COVID––ARDS patients. ΔP had an independent association with outcome in both groups, whereas PEEP had an independent association with outcome only in COVID–ARDS patients.

Availability of data and materials

Data sharing: A de–identified dataset can be made available upon request to the corresponding authors one year after publication of this study, but only after permission of the principal investigators of all original studies. The request must include a statistical analysis plan.

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Acknowledgements

for the ERICC a –,LUNG SAFE b –, PRoVENT–COVID c –, EPICCoV d –, CIBERESUCICOVID e – and SATI–COVID–19 f –investigators

a ERICC, ‘Epidemiology of Respiratory Insufficiency in Critical Care’

b LUNG SAFE, ‘Large Observational Study to UNderstand the Global Impact of Severe Acute Respiratory FailurE’

c PRoVENT–COVID, ‘Practice of Ventilation in COVID–19 patients’

d EPICCoV, EPIdemiology of Critical COVID–19

e CIBERESUCICOVID, ‘Centro de Investigación Biomédica en Red Enfermedades Respiratorias COVID–19’

f SATI–COVID–19, ‘Sociedad Argentina de Terapia Intensiva–COVID–19’

No additional funding was received for this analysis.

Author information

Fleur–Stefanie L. I. M. van der Ven and Siebe G. Blok contributed equally to this work.

Authors and Affiliations

Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands

Fleur–Stefanie L. I. M. van der Ven, Siebe G. Blok, Michela Botta, Luigi Pisani, Marcus J. Schultz, Anissa M. Tsonas, Frederique Paulus & David M. P. van Meenen

Department of Intensive Care, Rode Kruis Ziekenhuis, Beverwijk, The Netherlands

Fleur–Stefanie L. I. M. van der Ven

Department of Emergency Medicine, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil

Luciano C. Azevedo

Department of Intensive Care, Hospital Israelita Albert Einstein, São Paulo, Brazil

Luciano C. Azevedo & Ary Serpa Neto

Centre for Medical Sciences (CISMed), University of Trento, Trento, Italy

Giacomo Bellani

Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy

Department of Intensive Care, Hospital Interzonal de Agudos General San Martin La Plata, Buenos Aires, Argentina

Elisa Estenssoro

Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

Department of Pulmonology, Instituto Do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil

Juliana Carvalho Ferreira

Department of Intensive Care, AC Camargo Cancer Center, São Paulo, Brazil

Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil

Department of Anaesthesiology and Intensive Care, Galway University Hospital, Saolta Hospital Group, Galway, Ireland

John G. Laffey

School of Medicine, University of Galway, Galway, Ireland

Department of Intensive Care, Multidisciplinary Intensive Care Research Organization (MICRO), St James’ Hospital, Dublin, Ireland

Ignacio Martin–Loeches

Department of Intensive Care, Hospital Clínic de Barcelona, Barcelona, Spain

Departement of Pulmonology, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain

Ana Motos & Antoni Torres

Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Institute of Health Carlos III, Madrid, Spain

Ana Motos, Oscar Peñuelas & Antoni Torres

Equipe d’Epidémiologie Respiratoire Integrative, Université Paris–Saclay, Paris, France

Service de Médecine Intensive-Réanimation, DMU CORREVE, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Hôpital de Bicêtre, Paris, France

Department of Intensive Care, Hospital Universitario de Getafe, Getafe, Spain

Oscar Peñuelas

Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy

Antonio Pesenti

Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva Delle Fonti, Italy

Luigi Pisani

Australian and New Zealand Intensive Care Research Centre (ANZIC–RC), Monash University, Melbourne, Australia

Ary Serpa Neto

Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand

Luigi Pisani & Marcus J. Schultz

Nuffield Department of Medicine, University of Oxford, Oxford, UK

Marcus J. Schultz

Department of Anesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Medical University of Vienna, Vienna, Austria

Laboratory of Experimental Intensive Care & Anaesthesiology (L·E·I·C·A), Amsterdam UMC, Location AMC, Amsterdam, The Netherlands

University of Barcelona, Barcelona, Spain

Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain

Antoni Torres

Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands

Frederique Paulus

Department of Anaesthesiology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands

David M. P. van Meenen

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Contributions

Author contribution: FV, SB, MS, FP and DM had full access to all the data and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: All authors Acquisition, analysis, or interpretation of data: FV, SB, MS, FP and DM Drafting of the manuscript: FV, SB, MS, FP and DM Critical revision of the manuscript for important intellectual content: All authors Statistical analysis and data verification: FV, SB, and DM Obtained funding: Not applicable; the original studies were performed with funding as stated in the original reports. Administrative, technical, or material support: LA, GB, MB, EE, JF, JL, TP, AT Supervision: MS, FP and DM.

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Correspondence to Fleur–Stefanie L. I. M. van der Ven .

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van der Ven, F.L.I.M., Blok, S.G., Azevedo, L.C. et al. Epidemiology, ventilation management and outcomes of COVID–19 ARDS patients versus patients with ARDS due to pneumonia in the Pre–COVID era. Respir Res 25 , 312 (2024). https://doi.org/10.1186/s12931-024-02910-2

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Received : 24 December 2023

Accepted : 07 July 2024

Published : 17 August 2024

DOI : https://doi.org/10.1186/s12931-024-02910-2

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New insight into antibody shows how it could offer sweeping protection against evolving SARS-CoV-2 virus

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New insight into antibody shows how it could offer sweeping protection against evolving SARS-CoV-2 virus

The results suggest that the neutralizing antibody could hold the key to manufacturing a vaccine that protects against a rapidly evolving virus.

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Researchers at Northeastern say they’ve discovered how an antibody could provide broad protection against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the virus responsible for COVID-19 — even as it evolves to outwit other of the body’s chemical defenses.  

Researchers studied the structure of the spike protein of SARS-CoV-2 — the outer projections of the virus’ membrane that is responsible for viral entry into a human cell. Following the outbreak of the COVID-19 pandemic, scientists were quick to identify how the spike protein helps hook the virus on to a cell, binding to an enzyme called the ACE-2 receptor . 

But it wasn’t until researchers began studying the structure of the spike protein that they began to learn more about its somewhat limb-like design — that these protruding strands undergo a rearrangement as they “pull” a cell toward it and initiate fusion. 

“For an infection to occur, the spike protein must jump out and grab a human cell,” says Paul Whitford , an associate professor of physics at Northeastern, who co-led the theoretical aspects of the study, published Thursday in Science . 

What the researchers showed was that a specific antibody — known as CV3-25 — disrupts the cell infection process by targeting a particular site on the spike protein that is largely conserved across the different viral strains, according to the study. 

The receptor binding domain, the critical portion of the spike protein that lets the virus “bind” and ultimately enter the cell, typically changes as the virus evolves, Whitford says. The region that often remains the same is vulnerable to CV3-25. 

Think of it as like the virus’ Achilles heel. 

The results suggest that the broadly neutralizing antibody could hold the key to manufacturing a vaccine that protects against a rapidly evolving virus. 

“This is a naturally occurring antibody that was found in specimens taken from people,” Whitford says. 

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The computational work was a joint effort undertaken by the Center for Theoretical Biological Physics at Northeastern and Rice University, a National Science Foundation Physics Frontiers Center. The multi-university team also partnered with a group of experimentalists at Yale University as part of the overall study. 

Whitford’s background is in using theoretical models to study “large molecular assemblies” — chemical structures that include viruses and their surface structures. In the vast world of the infinitely small, Whitford has focused primarily on studying the workings of the ribosome, a biomolecular machine responsible for producing the proteins that make up living organisms. 

Earlier this month, U.S. health officials said that COVID-19 is no longer a pandemic, but is now “endemic.” That means the virus is likely to stick around, only now it’s well-managed. But Whitford says more contagious and potentially deadly strains of the virus may still emerge.

“It is still a very significant problem, but one that can now be managed against the backdrop of many public health threats and not as sort of a singular pandemic threat,” Aron Hall, deputy director for science at the Centers for Disease Control and Prevention’s coronavirus and other respiratory viruses division, said recently, according to NPR . “And so how we approach COVID-19 is very similar to how we approach other endemic diseases.”

The findings are significant because scientists have yet to produce a vaccine that protects against all current and future variants of the virus, Whitford says.

“Currently, we’re keeping the virus at bay, but it keeps mutating,” Whitford says.

Whitford says the antibody could be “the next big target” for the design of new vaccines. 

“It opens up a new vaccine strategy,” he says. “While current vaccines try to block the arms, our results show how you can tie the legs instead, which gives us a new weapon for combating this ever-changing virus.”

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