Research at the Ministry of Health

COVID-19 Health Research Priorities Framework

Purpose of the Framework:

The COVID-19 Health Research Priorities Framework (Framework) provides guidance on the key research priorities needed to support Ontario’s COVID-19 response.

The Framework elevates to the forefront topics where evidence and research are needed to inform policy and planning, and to create a better, faster, and more efficient response to COVID-19 in order to protect the health of Ontarians. It also considers where Ontario has a particular strength in, or need for, this type of research and where results can be generated in the short-term (<2yrs) to support Ontario’s COVID-19 response.

The Framework will continue to evolve over time and be refined as new information, gaps and priorities emerge.

This tool can be used to:

• Identify research/evidence projects of particular relevance for provincial funding;
• Map existing provincial/federal funding projects against MOH priorities to identify gaps in evidence needs; opportunities for collaboration, rapid learning and duplication of effort;
• Communicate ministry key priorities for research and consult key stakeholders on priority evidence needs;
• Inform how other research across Ontario aligns to the research priorities of the Ministry of Health;
• Understand how current research could support Ontario’s data infrastructure needs and inform internal ministry round tables, such as those related to the COVID-19 Health Data Platform; and
• Inform pandemic research and partnerships with external ministry initiatives, such as the Ontario SPOR (Strategy for Patient-Oriented Research) SUPPORT Unit; and, opportunities to partner on new federal research calls for COVID-19 related research, such as CIHR’s research calls.

How it was developed:

The Framework reflects collective input over time from the Ministry of Health, Ontario Health, Public Health Ontario and the COVID-19 tables.

Research Themes and Priority Research Questions:

Ten broad research themes were identified across the spectrum of COVID-19 related health research, with corresponding key questions developed for each area.

1. Understanding the Disease
2. Transmission
3. Case Testing and Surveillance
4. Disease Management
5. Health Equity and Vulnerable Populations
6. Public Health Measures
7. Infection, Prevention and Control in Specific Settings
8. Frontline Workers
9. Supply Chain
10. Data Analytics, Modelling and Measurement

Research Theme 1: Understanding the Disease

This research theme focuses on understanding the virus and the resulting disease, including severity (symptoms, mechanism of action, and resulting functional changes in the body), and the immune response.

Key Questions:

1. What are the key features of the virus (i.e., strains, symptoms, disease progression, and severity)? Do different strains have different severity?
2. How does the disease affect different people (e.g., risk factors based on medical history, genetic markers, underlying conditions [i.e., cancer, pregnancy], age, lifestyle factors?
3. What are the full range of symptoms for COVID-19?
4. How many people are asymptomatic or mildly symptomatic? What characteristics do they have (e.g., medical history, genetic markers, age, lifestyle factors, etc.)?
5. Which viral properties create good or neutralizing immune response and how long do those immune responses last?
6. Can individuals be re-infected with COVID-19?
7. How is the virus changing at the genomic level?
8. What are the determinants for antibody levels post-infection?
9. How does the virus adapt and change over time?

Research Theme 2: Transmission

This research theme focuses on understanding the virus’s incubation period and period of communicability (including asymptomatic, mildly symptomatic and pre-symptomatic transmission). This theme also focuses on understanding the transmissibility of the virus and specific modes of transmission (i.e., aerosol versus droplet).

Key Questions:

1. What are the risks, rates, and how is COVID-19 transmitted within particular environments/settings (e.g., indoor, outdoor, congregate living, long-term care sector, urban/rural, etc.) and different conditions?
2. What is the risk, rate, and how is COVID-19 transmitted during particular non-medical activities (e.g., running, biking, choir), medical procedures (directly and not related to disease management), and dental procedures?
3. How can the pandemic response be improved through better understanding of conditions for transmissibility, asymptomatic and pre-symptomatic transmission, incubation, characteristics associated with communicability, immunity and potential for reinfection, including looking to other jurisdictions?
4. Are you less likely to get COVID-19 if you have already had the illness? Does infection with COVID-19 result in immunity, and if so, for how long? Are any sub-populations immune to COVID-19? Will herd immunity offer protection against COVID-19?
5. What is the effectiveness of PPE (e.g., masks, reuse, gloves, disinfectant wipes, hand sanitizer, bodysuits) in terms of preventing transmission of COVID-19: 1) in health care settings, 2) workplaces (e.g. essential workers - grocery, pharmacy, and construction, etc.) and 3) for the general public in indoor and outdoor settings?
6. What is the effectiveness of sanitization (i.e., types of surface sanitizers/soaps/disinfectants that can kill the virus, surface exposure time, etc.) activities?
7. What are the most effective strategies for reducing transmission?
8. What difference would it make for household transmission if people self-isolated from their families 1) from the time of testing: 2) from return of result?
9. What is the actual transmission from completely asymptomatic individuals?

Research Theme 3: Case Testing and Surveillance

This research theme focuses on understanding the best mix of population level testing and surveillance strategies including symptomatic testing alongside passive, active, sentinel and syndromic surveillance approaches. This theme also focuses on understanding the impact of test turn-around time on contact tracing and disease spread. Areas of interest include analysis of various types of tests, testing levels and targeting strategies.

Key Questions:

1. How can we best identify those with COVID-19, using: a) screening, b) diagnostic testing, c) surveillance and d) contract tracing tools?
2. How can we optimize testing speed, availability, effectiveness and efficiency, and build a responsive testing infrastructure?
3. What are the most efficient strategies to perform surveillance testing (sentinel surveillance, cohorting, test pooling, etc.)?
4. How can we quickly identify different strains of COVID-19?
5. Do serology test results correlate with COVID-19 immunity?
6. What is the utility of COVID-19 serology testing?
7. How do we measure immune response in the community?
8. Can other health care professionals conduct COVID-19 testing and screening?
9. What are the differences in testing for the purposes of screening vs. diagnosis?
10. Can testing models incorporate strategies in different settings and demographics, such as schools, workplaces, long-term care homes, etc.?
11. What would be the impact of changing PCR test thresholds for screening asymptomatic low prevalence population vs. diagnostic testing in higher risk population (symptomatic, close contact)?

Research Theme 4: Disease Management

This research theme focuses on understanding disease symptoms, diagnostics (e.g., laboratory detection methods and their accuracy; radiology; co-infections and/or alternate diagnoses), the course of the disease and prognosis, including longer term effects. This theme also focuses on understanding how to triage patients and prioritize specific treatments and patient care (e.g., therapeutics and other medications, ventilators, respirators), the most effective models of care including specific treatment options and the outcomes associated with various disease management approaches.

Key Questions:

1. How can we best monitor and manage complications resulting from COVID-19 and optimize care pathways?
2. Which drug and/or non-drug interventions can be used to manage disease, and how effective are they? Which drugs should not be used?
3. What triage and prioritization frameworks for treatments or practices can be used in times of resource shortages to decide who gets what care?
4. What are the best care pathways to manage the disease?
5. How can we optimize hospital and ICU capacity? What are the strengths of ICU networks (e.g., drug treatment and ventilation, including ECMO)?
6. How has COVID-19 impacted access to health care services and interventions (e.g., surgeries, primary care, mental health and addictions services)?
7. What are the long-term health implications of COVID-19 (e.g., heart, respiratory system, mental health)? Who has had a relapse in symptoms?

Research Theme 5: Health Equity and Vulnerable Populations

This research theme focuses on understanding health equity considerations for vulnerable populations groups and the potential disproportionate impacts on populations vulnerable to COVID-19. Vulnerable populations in the context of the COVID-19 pandemic include consideration of population sub-groups (clinical characteristics, physical and developmental disabilities, socio-demographic (Indigenous peoples, age-related groups, immigrants and refugees, ethno-racial communities, Francophone, homeless, linguistic communities, low income, religious/faith communities, rural/remote or inner urban populations, drug use, sex and gender, sexual orientation, people receiving social assistance), employment, and geography).

Key Questions:

1. What are the rates, and how is COVID-19 transmitted within different populations?
2. What are the risks of COVID-19 on racialized and vulnerable population groups (i.e., ethnicity, low income, homelessness, Indigenous)?
3. How can employing an equity/vulnerable population lens help reduce transmissions?
4. What innovative/technological approaches and platforms can optimize testing and contact tracing across different populations and settings (e.g., rural, urban, low income, seniors, Indigenous, homeless, immigrant, Francophones, etc.)?
5. How can we support better care and outcomes in high risk groups or for populations with poor outcomes, or with particular vulnerabilities?
6. How can we cater to patients living in rural/isolated regions, given limited resources (hospital beds, drugs, etc.) available in those areas?
7. What are the most effective public health measures with consideration to the social determinants of health (e.g., age, sex/gender, ethno-racial, cultural background, language, regional location, socioeconomic status, discrimination, etc.)?
8. How can innovative technology be used for communication, surveillance, and to reduce harm for particular sub-populations (e.g., seniors, youth, people with pre-existing conditions, people living in remote communities, Indigenous etc.)?
9. How has racism, discrimination, and stigma impacted Ontarians within the pandemic response? And what is the impact of COVID-19 on health equity (e.g., distribution and availability of PPE, availability of and access to testing facilities)?
10. How have containment measures differently impacted different populations sub-groups?
11. What is the impact of COVID-19 on mental health for vulnerable population sub-groups (e.g., ethno-racial, low-income, Indigenous)?
12. To ensure equitable access to services, what supports should be available for vulnerable population sub-groups impacted by COVID-19?
13. What are the best practices for isolation and quarantine in different settings and environments (e.g., medical, non-medical, communal and non-communal), employing a health equity and vulnerable populations lens?

Research Theme 6: Public Health Measures

This research theme focuses on understanding the most efficient and effective containment and re-opening strategies, the interactions between various strategies, and compliance with containment strategies in different settings, and among different population groups. This theme also focuses on understanding the optimal COVID-19 vaccination strategies, including targeting, messaging, access and roll out across the population. Analysis should consider the required conditions for various stages of re-opening, the interdependencies, and the health and well-being impacts of closing and re-opening. Analysis should also consider the interaction with influenza and other respiratory viruses.

Key Questions:

1. What are the most effective public health measures?
2. How can innovative technology be used for communication, surveillance, and to reduce harm?
3. How can participation and compliance in response efforts be incentivized to reduce COVID-19 infection in the community?
4. How has the COVID-19 containment measures (e.g., work and school closures) affected health status, including mental health and general wellness of Ontarians (including child and youth well-being and impact on domestic violence)?
5. How has the COVID-19 pandemic and response affected health care access and health care quality?
6. How has the COVID-19 pandemic and response affected the social and economic situation?
7. What is the clinical presentation of Ontarians with mental health issues as a result of COVID-19?
8. What is the impact of COVID-19 on mental health of professions including caregivers and other essential workers?
9. What are the physical and psychological impacts on frontline workers (including mental health, attrition, burnout, wellness, workplace violence, WSIB claims, sick days and leave of absence, etc.), and what are the interventions that can be implemented to support their mental health?
10. What is the incremental benefit of public health measures (e.g., school closures, social distancing, quarantine, washing hands, masks, etc.)? Should other measures be considered instead?
11. What is the positive and negative effect of school closures on children, parents and caregivers, and what inequities are most pronounced?
12. What are the consequences of decisions that have been made (e.g., visitor restrictions in LTC homes, delayed surgeries, closure of safe consumption sites)?
13. How have public health measures impacted mental health and substance use (including problem gambling) of Ontarians?
14. To what size should we be encouraging people to try and keep their bubbles to keep growth manageable, under different circumstances?
15. If we see a resurgence, what level of controls will be required to get it back under control?
16. What are optimal strategies for vaccine implementation (including messaging around safety/effectiveness of vaccine)?
17. What are the impacts on the health, mental health and well-being of closing and opening of elements of society / economy (e.g., education)?

Research Theme 7: Infection, Prevention and Control in Specific Settings

This research theme focuses on approaches to prevent and control infections for patients and health care workers (medical and non-medical staff) (e.g., effective interventions and practices, best practices for isolation and quarantine, virtual care, mask wearing, etc.) in settings of interest, such as:

• Pre-Hospital Paramedical/ Ambulatory Services
• Hospitals
• Primary Care
• Long-Term Care
• Home Care
• Retirement Homes
• Corrections
• Medical Laboratories and specimen collection centres (SCCs)
• Congregate Living Communities (e.g., shelters, halfway homes, group homes, remote, rural and First Nations communities)

This theme also focuses on approaches to prevent and manage infections for the general population in non-health care settings (e.g., parks, restaurants, etc.).

Key Questions:

1. What are the most effective interventions and practices for infection prevention and control for staff and non-staff in specific settings and when moving between settings?
2. What unique considerations are needed in specific settings to manage risk, reduce and manage outbreaks, and minimize exposure?
3. What are the best practices for isolation and quarantine in different settings and environments (e.g., medical, non-medical, communal and non-communal)?
4. What role can primary care, nurse practitioners, and virtual care play to help keep people out of hospitals?
5. When moving between institutions, how to direct clients towards appropriate resources and connections and minimize risk of exposure?
6. What is the impact on local spread at the local level due to mask wearing?
7. For the LTC setting, what is the predicted impact of different timing of control measures applied (e.g., universal masking of staff; limiting staff to work at one place only)?

Research Theme 8: Frontline Workers

This research theme focuses on understanding the physical and psychological impact of COVID-19 on frontline workers (both health care and non-health care), including their needs and effective responses to meet those needs. This research theme also focuses on understanding the health frontline workers resourcing needs during surges and peaks.

Key Questions:

1. How can health care workforce capacity be adequately maintained and developed during pandemic response, including with existing workers as well as completing training of near-grads?
2. What are the physical and psychological impacts on frontline workers (including mental health, attrition, burnout, wellness, workplace violence, WSIB claims, sick days and leave of absence, etc.)?
3. What are best practices for frontline workers (PPE, hygiene, job supports, other)?

Research Theme 9: Supply Chain

This research theme focuses on understanding the processes and strategies needed to improve the allocation and supply of personal protective equipment (PPE), ventilators, and drugs to support the COVID-19 response.

Key Questions:

1. What processes would improve supply chain management, including drug shortages, PPE, testing capacity?
2. What alternative forms of PPE could be considered (e.g., fabric masks), and what are the best practices associated with non-medical grade PPE?
3. What innovative strategies can be used to improve availability and production of critical health supplies, or help with equipment shortages?
4. What are best practices regarding the optimization of use and equitable distribution of critical health care equipment, drugs, tests and other resources during shortages and high demand?

Research Theme 10: Data Analytics, Modeling and Measurement

This research theme focuses on leveraging data and mathematical models to help inform decisions in responding to COVID-19. This could include modelling: trajectory and waves of COVID-19, transmission (who and how people are infected); impacts of public health measures; impact of testing and surveillance, health system capacity (including time horizon for recovery and longer term impacts); mortality; and economics (direct (e.g., job loss) and indirect (borrowing and lending)).

Key Questions:

1. Are there other data models that can be used to determine the disease and intervention effects (e.g., infection rates, mortality rates, hospital capacity, testing, contact tracing etc.)?
2. How can we develop data models to forecast needs and availability of health care resources for the various levels of care?
3. What data models can be developed to predict risk of infection?
4. How can we improve data collection, standardization, aggregation, sharing and access?
5. How can we accelerate patient recruitment into research to collect, aggregate, and share patient level data in a secure, ethical, patient privacy protected, and accessible manner?
6. Which interventions and surveillance indicators can be used to measure the impact of pandemic-related policies and containment measures?
7. How can artificial intelligence (AI) help address COVID-19 research priorities?
8. How can AI be used to improve contact tracing activities?
9. What methods can be used to evaluate COVID-19 interventions?
10. What is the economic impact of COVID-19 (e.g. most cost effective vaccination program, decision analysis for re-opening, etc.)?
11. How can data from serology testing be used to inform re-opening and testing strategies?
12. How can data modeling and AI help balance surveillance testing with active testing?
13. What are the best data models to predict surge capacity needed for testing, especially during the influenza season? What are the best models to predict surge capacity needed for testing, especially during the influenza season?
14. When looking at child care models, what will be the impact of schools restarting and/or daycares restarting, under different circumstances?
15. How many missed imported cases (due to travel) can we tolerate to keep growth of cases manageable?
16. Taking into consideration socioeconomic factors, are there thresholds that should be considered when providing direction about travel across COVID-19 risk gradients? What is the “unit of analysis” geographically that makes sense (municipality, region, province)?
17. Would immediate contact notification make a difference in keeping growth of cases manageable?
18. How can we model the impacts on resources and outcomes of various testing approaches (e.g., diagnostic testing only, diagnostic testing with reactive/highly targeted screening, diagnostic testing and liberal screening etc.)?
19. Using a risk factor based decision matrix for testing, which asymptomatic persons need testing beyond known contacts?
20. What is the utility and cost of widespread asymptomatic COVID-19 PCR testing?
21. What is the impact of interventions on top of each other and what is the incremental benefit (i.e., distancing; distancing and hand hygiene; distancing, hand hygiene and masking)?
22. What are the comparisons and complex factors (modifiable and non-modifiable) between provinces that led to differential strategies to manage COVID-19?
23. What is the cost-effectiveness of surveillance vs. asymptomatic testing?