COVID-19: Impact on Cardiovascular Research
|Take Home Messages|
The COVID-19 pandemic now requires little introduction. As the third lockdown is underway in England, many of us are grappling with the aftereffects of the SARS-COV-2 virus. “When you are thinking about a pandemic, you have to differentiate between what comes from being infected and what comes from being affected”, says Clare Wenham, Assistant Professor of Global Health Policy, London School of Economics and Political Science. Cardiology is a specialty that prides itself on its reputation for promoting research and therefore accumulating a vast evidence base on which to guide clinical decision making. However, the pandemic has meant that although research remains an important part of cardiology, it will require a different approach. This editorial explores the impact of the pandemic on research thus far, and future considerations.
Where we are now
The overall priority and message from University institutions and clinical centres of research is the safety of their staff and students first and foremost. A lack of understanding of the SARS-COV-2 virus at the start of the pandemic meant that very stringent safety measures were introduced and rightly so. Most centres aimed to create a safe environment by recommending the following1:
- Non-critical research and research related activities to be performed remotely where
- Strict adherence to social distancing and hand washing
- New projects that require in person presence not to be permitted, excluding all COVID-19 related basic and clinical research
Increasing understanding of the virus and more widespread availability of personal protective equipment mean that departments can now re-assess policies in view of new knowledge. The following paragraphs explore the implications of COVID-19 for different research activities.
Basic Science Research
This often includes the use of animals, commonly rodents such as mice. Changes in this setting mostly relate to animal handling procedures. These include longer cage-change intervals and ensuring a robust chain of supplies that is able to cater for frequent
disinfection of cages and maintaining animal welfare1. Animal care personnel have been classified as “essential” and have been reported to be utilising split schedules, staggered shifts, and restricted hours to maintain social distancing needs and keep personnel safe1. Enhanced sanitation is also necessary in common lab areas as a means of ensuring personnel safety. Timely and advance communication between the animal care staff and research personnel is needed to ensure a smooth operation.
Similar “rota” like procedures have been introduced for those pursuing other non-clinical “bench” laboratory research in order to minimise staff footfall and maintain social distancing.
At the peak of the pandemic all clinical research was placed in hiatus in order to allow redeployment of clinical staff to other areas including intensive care and COVID-19 wards as well as allow a focus on COVID-19 research in order to facilitate an understanding of the rapidly emerging SARS-CoV-2 virus. The latter allowed rapid recruitment of participants into various studies throughout the country including vaccine trials. An example of this was a healthcare worker (HCW) study at Barts NHS Trust in London, where at the peak of the pandemic a cohort of 400 HCWs were recruited in 7 working days2. This study highlighted that the rate of asymptomatic infection among HCWs more likely reflected general community transmission than inhospital exposure. These efforts were possible through not only multi-centre but multi-specialty collaboration to include virologists, immunologists, and cardiologists. The success of such projects in part was due to cardiology research teams being able to use years of knowledge of research infrastructure to mobilise teams and resources at short notice to rapidly deliver high quality studies2, 3. There are many similar success stories around the UK 4 and globally 5,6.
Whilst many of these studies have been well executed, others such as that by Valentina Puntman et al have led to concerns with regards to research undertaken under the constraints of COVID-19. This study investigating the potential long -term effects of coronavirus on cardiac function found cardiac involvement in 78% of participants and ongoing inflammation in 60% as identified by cardiac magnetic resonance imaging7. This has had important ramifications including for professional sport, where athletes were asked to stop sports indefinitely due to unknown risk of long-term inflammation. However, since its publication this study has attracted high media attention and controversy regarding whether the authors were over-stating the results and later had to issue a correction. This highlights the pressures researchers may be under currently to deliver high impact, novel research quickly.
It is becoming clear that we may be affected by COVID-19 for a while to come. There is therefore a need to understand and adapt to COVID-19 in the medium to long term. Banerjee et al8 proposed a simple stochastic model to determine clinical academic capacity in the UK8. From this they were able to identify 6 recommendations for science in the UK and globally in relation to COVID-19. These are described briefly as follows and summarised in Table 1 (adapted from Banerjee et al)8.
Although most of these steps have been utilised successfully, it does make it difficult to draw boundaries as it is unclear who gets to then decide which projects are worthwhile and continue, who is redeployed and therefore is at high risk of being seen as unjust by many.
|Table 1. Six steps of academic research (including basic and clinical) in the UK during the COVID-19 pandemic|
|Radical prioritisation||Simplifying research infrastructure|
|Leadership||Maintaining academic professionals in own roles without redeployment unless necessary|
|Rationalisation||Using existing systems procedures where necessary, e.g. for sample analysis|
|Resourcing||Using academic resources from multiple sources to allows|
delivery of large studies
|Careful site selection||Using centres experienced in delivery of studies with tried and tested methods|
|Dissemination||Multi-site collaboration in the UK and worldwide|
The Researcher’s Perspective
My experience of clinical research is only just beginning but even from my perspective the impact is palpable. There are constant anxieties with regards to being able to recruit participants for many of the non-COVID related studies, constant concerns about grants and the possibility of there not being as much support from funding bodies as previously. At times, there are feelings of guilt for not being on the front line whilst recognising that research is just as important in order to enable innovative care at the bedside. Most of my colleagues in clinical research during the pandemic were asked to resume their clinical duties and most did so without any hesitation and helped in the pandemic alongside their colleagues. However, as this crisis continues there are now concerns regarding matters such as time lost to being “re-deployed” to clinical medicine and income as many funding bodies such as the British Heart Foundation will not pay a basic salary beyond the original terms of contract. Consequently, there is a real worry with regards to self-funding higher degrees and balancing this with adult responsibilities such as mortgages and bills. For many this may mean having to make difficult choices such as shortening research plans and being awarded an MPhil or in some cases changing entire projects.
These concerns are mirrored by other groups of research staff including those in the basic sciences and post-doctoral students. A recent editorial in Nature9, highlights that funding appears to be the most pressing issue with many of these students living away from home in rental properties and facing eviction. There are also calls for immediate action from the government and the UK’s main research funding body United Kingdom Research and Innovation (UKRI), as the situation is now a source of “anxiety and depression” for many postdoctoral students. Although these sentiments are not new for those in post-doctoral positions10, the pandemic has heightened the sense of distress surrounding career prospects. These emerging concerns may thus ‘force the research world’ into becoming more resilient and supportive of all those involved.
Minority groups in research
Minority groups such as women and those from black and ethnic minority groups (BAME) are under-represented in research (including basic sciences and clinical). The pandemic once again has served to highlight and create a wider chiasm between research and these groups11. In a prepandemic US survey, “financial security” was one of the top factors influencing decisions with regards to perusing academia further by post-doctoral students. In addition, mentorship and forming strong bonds both within the immediate research environment and with those who share similar interests was found to be the main reason for maintaining research goals and pursuing a research career12. As research continues, it is different to pre-pandemic with social distancing limiting the number of people in a department at any one time. This therefore makes collaboration and mentoring difficult, especially for early career researchers, myself included, that are yet to really find their feet. Finance has also been impacted by the pandemic as already discussed.
COVID-19 research will likely embed itself into the current research infrastructure and will be required for at least the next few years, not only to keep informing us on emerging evidence and understanding of COVID-19 but likely to form models of understanding that can be mobilised in case of similar pandemics in years to come.
Non COVID-19 research is currently affected by a myriad of things including funding, recruitment, and staff availability. This makes a sustainable public health approach to COVID-19 even more important as stated by Gurdasani et al in a recent issue of the Lancet13 and by the European Commission14. The British Heart Foundation have also reported a fall in the amount they are able to invest in research grants from 100 to 50 million since the start of the pandemic15. Worryingly, in a survey of early career scientists funded by charity grants, 4 in 10 were considering leaving their current post for fears over funding and perceived instability and career progression due to the corona virus pandemic16.
The National Institute for Health Research has been actively involved in providing guidance for those in research since the start of the pandemic. Their current guidance for research in the second wave of the pandemic can be found as a document entitled “NIHR – Guidance for a “second wave” of COVID- 19 activity”17. This document outlines the priorities of the NIHR and stipulates that NIHR funded staff should only be re-deployed to the front line under exceptional circumstances. These measures will potentially aid the continuation of research despite further lockdown measures and protect resources ringfenced for research where possible.
The overwhelming message from various research bodies including NIHR and BHF is that during this pandemic the priority is maintaining one’s own safety, wellbeing and that of loved ones. However, research remains an important part of cardiology and that research bodies are fully supportive of restarting studies stopped due to the pandemic, whilst supporting ongoing COVID-19 studies.
The pandemic has had an undeniable impact on research. The impact of prolonged time out of a clinical training programme, not only has financial implications but also impacts confidence returning to clinical practice. In addition, the precarious funding and grant systems currently may further alienate minority groups such as women from pursuing academia. There may also be more of a focus on “big data” research that is less reliant on recruitment of participants. Resources such as UK biobanks will prove invaluable but for those already well into their research, a change in project may not be feasible18.
It is vital all research groups are recognised. and although the research world across all disciplines seems to be in crisis19, due to an unforeseen pandemic, the words of John F Kennedy seem apt and hopeful in the current climate: “When written in Chinese, the word “crisis” is composed of two characters. One represents danger and the other represents opportunity.”
Nothing to disclose
- Omary MB, Eswaraka J, Kimball SD, et al. The COVID-19 pandemic and research shutdown: staying safe and productive. J Clin Invest. 2020 Jun 1;130(6):2745-2748. Doi:10.1172/JCI138646. PMID: 32243259; PMCID: PMC7260012.The Covid-19 pandemic and research shutdown: staying safe and productive.
- Treibel AT, Manisty C, Burton M, et al. COVID-19: PCR screening of asymptomatic health-care workers at London hospital. May 8th 2020. Lancet; 395:10237: 1608-1610. Doi: https://doi.org/10.1016/S0140-6736(20)31100-4
- Augusto JB, Menacho K, Andiapen M et al. Healthcare Workers Bioresource: Study outline and baseline characteristics of a prospective healthcare worker cohort to study immune protection and pathogenesis in COVID-19 [version 1; peer review: 1 approved, 1 approved with reservations]. Wellcome Open Res 2020, 5:179
- Docherty Annemarie B, Harrison Ewen M, Green Christopher A, et al. Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study BMJ 2020; 369 :m1985. Doi: https://doi.org/10.1136/bmj.m1985
- Dweck MR, Bularga A, Hahn RT, et al. Global evaluation of echocardiography in patients with COVID-19. Eur Heart J Cardiovasc Imaging. 2020 Sep 1;21(9):949-958. Doi:10.1093/ehjci/jeaa178. PMID: 32556199; PMCID: PMC7337658.
- Yishay S, Yael L, Taieb P et al. (2020). The Spectrum of Cardiac Manifestations in Coronavirus Disease 2019 (COVID-19) – a Systematic Echocardiographic Study. Circulation. 142. 10.1161/CIRCULATIONAHA.120.047971.
- Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(11):1265–1273. Doi:10.1001/jamacardio.2020.3557
- A. Banerjee, M. Katsoulis, A. G. Lai, et al, “Clinical academic research in the time of corona: a simulation study in
England and a call for action,” medRxiv, 2020. [Online]. Available: https://www.medrxiv.org/content/early/2020/04/17/2020.04.14.20065417
- Nature editorial team. Postdocs need urgent financial support amid COVID conditions. Dec 2020. Nature.588(8). doi: https://doi.org/10.1038/d41586-020-03377-z
- Woolston C. Postdoc survey reveals disenchantment with working life. Nature. 2020. 587, 505-508. doi: https://doi.org/10.1038/d41586-020-03191-7
- Paton, A. Fairness, Ethnicity, and COVID-19 Ethics. Bioethical Inquiry 17, 595–600 (2020). https://doi.org/10.1007/s11673-020-09999-2
- Lambert MW, Wells MT, Cipriano MF, et al. Research culture: career choices of under represented and female postdocs in the biomedical sciences. January 2020. eLife 2020;9:e48774 DOI: 10.7554/eLife.48774
- Gurdasani D, Bear L, Bogaert D, et al. November 9th 2020. Lancet. Online first. doi: https://doi.org./10.1016/S0140-
6736(20)32350-3 [Last accessed 10/11/2020]
- Giovannini, E., Benczur, P., Campolongo, F., Cariboni, J. and Manca, A., Time for transformative resilience: the COVID-19 emergency, EUR 30179 EN, Publications Office of the European Union, Luxembourg, 2020, ISBN 978-92-76-18113-2 (online), doi:10.2760/062495 (online), JRC120489.
- The British Heart Foundation. British Heart Foundation Warns research investment could half this year due to coronavirus. 24th June 2020. Online only. https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2020/june/bhf-research-under-threat
- The British Heart Foundation. Pandemic threatens future of research as early career scientists look to leave. 28th October 2020. Online only. https://www.bhf.org.uk/what-we-do/newsfrom-the-bhf/news-archive/2020/october/funding-crisisthreatens-future-of-research
- National Institute for Health Research. NIHR Guidance for a “second wave” of COVID-19 activity. Oct 2020. Available online. https://www.nihr.ac.uk/documents/nihr-guidance-for-asecond-wave-of-covid-19-activity/25837?pr= [last accessed 10/11/2020}
- Climie RE, Marques FZ. Impact, Strategies, and Opportunities for Early and Midcareer Cardiovascular Researchers During the COVID-19 Pandemic. Circulation. 2020 Jun 9;141(23):1838-1840. doi: 10.1161/CIRCULATIONAHA.120.047394. Epub 2020 Apr 14. PMID: 32286082; PMCID: PMC7314496.
- Iacobucci Gareth. Covid-19 makes the future of UK clinical research uncertain BMJ 2020; 369 :m1619. doi: https://doi.org/10.1136/bmj.m1619