A multinational Delphi consensus to end the COVID-19 public health threat

Chief Researcher and Editor of the Portal

Joaquim Cardoso MSc.
the health transformation / portal

Novembeer 3, 2022


Jeffrey V. Lazarus, Diana Romero, Christopher J. Kopka, Salim Abdool Karim, Laith J. Abu-Raddad, Gisele Almeida, Ricardo Baptista-Leite, Joshua A. Barocas, Mauricio L. Barreto, Yaneer Bar-Yam, Quique Bassat, Carolina Batista, Morgan Bazilian, Shu-Ti Chiou, Carlos del Rio, Gregory J. Dore, George F. Gao, Lawrence O. Gostin, Margaret Hellard, Jose L. Jimenez, Gagandeep Kang, Nancy Lee, Mojca Matičič, Martin McKee, Sabin Nsanzimana, Miquel Oliu-Barton, Bary Pradelski, Oksana Pyzik, Kenneth Rabin, Sunil Raina, Sabina Faiz Rashid, Magdalena Rathe, Rocio Saenz, Sudhvir Singh, Malene Trock-Hempler, Sonia Villapol, Peiling Yap, Agnes Binagwaho, Adeeba Kamarulzaman, Ayman El-Mohandes

03 November 2022

EXECUTIVE SUMMARY [by the Editor of the Portal]


  • Despite notable scientific and medical advances, broader political, socioeconomic and behavioural factors continue to undercut the response to the COVID-19 pandemic1,2

  • Here we convened, as part of this Delphi study, a diverse, multidisciplinary panel of 386 academic, health, non-governmental organization, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global threat to public health. 

  • The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry and other key stakeholders across six domains: 
    (1) communication;
    (2) health systems; 
    (3) vaccination; 
    (4) prevention; 
    (5) treatment and care; and 
    (6) inequities. 

  • In the wake of nearly three years of fragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches1, …

  • … while maintaining proven prevention measures using a vaccines-plus approach2 that employs a range of public health and financial support measures to complement vaccination. 

  • Other recommendations with at least 99% combined agreement advise governments and other stakeholders to improve communication, rebuild public trust and engage communities3 in the management of pandemic responses. 

  • The findings of the study, which have been further endorsed by 184 organizations globally, include points of unanimous agreement, as well as six recommendations with >5% disagreement, that provide health and social policy actions to address inadequacies in the pandemic response and help to bring this public health threat to an end.

Key statements and recommendations

The following six domains summarize the main areas of agreement, with a particular focus on the recommendations.

  • 1.Communicate effectively

  • 2.Strengthen health systems

  • 3.Emphasize vaccination, but not exclusively so

  • 4.Promote preventive behaviours

  • 5.Expand treatments

  • 6.Eliminate inequities

The quantitative results on agreement and disagreement for the statements and recommendations are reflected in the tables and are further illustrated in Supplementary Discussion 1.

1.Communicate effectively

Substantial combined agreement among the panellists (range, 88–100%) indicates that communication issues remain a key area of risk and opportunity for ending COVID-19 as a public health threat. 

Policymakers and public health agencies should take special care when communicating the causation of and continuing accountability for the pandemic (Tables 2 (STMT1.7) and 4 (REC1.1)). The lowest level of agreement in this domain (agree, 57%; combined agreement, 88%) was found for a statement about government accountability receiving less attention when unvaccinated individuals are blamed for the pandemic’s continuation (Table 2 (STMT1.6)).

The panel focused primarily on the role of trust in government (Table 2 (STMT1.5)), the consequences of false information (Table 2 (STMT1.2, STMT1.3, STMT1.4)) and the rapid production of large volumes of new COVID-19-related information (Table 2 (STMT1.1)). 

That said, governments themselves may be a source of misinformation, for example, in the context of identifying transmission mechanisms (Table 6 (REC4.3)) and when stating that the COVID-19 pandemic has ended (Table 2 (STMT1.7)).

To counteract the infodemic and false information, governments should monitor false information (Table 4 (REC1.7)), expose networks of false information (Table 4 (REC1.9)) and consider holding publishers of false information liable (Table 4 (REC1.10)). 

Furthermore, public health professionals and other authorities should use clear, culturally responsive messaging to combat false information (Table 4 (REC1.3)). In parallel, social media companies should implement controls that reduce the publication and dissemination of false health information (Table 4 (REC1.8)).

Institutions and individuals should advance public trust by seeking training on building trust and developing trust-oriented communication strategies (Table 4 (REC1.4)), expanding collaboration with community leaders and the scientific community (Table 4 (REC1.1)), and working with individuals and organizations that have established trust in communities (Table 4 (REC1.2)). Using the preferred means of communication for different populations was unanimously recommended to further earn trust (Table 4 (REC1.1)).

Multidisciplinary research should assess the impact of the COVID-19 infodemic on health behaviours and outcomes (Table 4 (REC1.5)). Research funders should commission more reviews that synthesize, evaluate and disseminate COVID-19-related evidence to inform needed interventions (Table 4 (REC1.6)).

2.Strengthen health systems

Health systems have experienced wide-ranging circumstances throughout the pandemic, from periods of relative calm to periods of near collapse. 

The broad agreement among panellists strongly suggests that, although many health systems will remain at risk of once again being overwhelmed, those risks can be mitigated. 

Certain sources of risk to health systems are essentially structural, such as the lack of implementation of an evidence-based, globally agreed-upon set of minimum COVID-19 pandemic response standards (Table 2 (STMT2.1)).

  • As noted above, health systems recommendations with respect to whole-of-society (Table 4 (REC2.5)) and whole-of-government approaches (for example, multiministry coordination) (Table 4 (REC2.6)) were among the most highly ranked by the panel.

  • As community transmission of SARS-CoV-2 continues to present a risk to health systems, particularly through variants of concern, extensive virological surveillance should be used (Table 5 (REC2.8)). 

  • Public health policies should take better account of the potential long-term impact of the unchecked spread of COVID-19 given the ongoing uncertainties about the prevalence, severity and duration of post-COVID-19 morbidity (long COVID) (Table 5 (REC2.9)). 

  • Member States should authorize the World Health Organization (WHO) to lead a large, inclusive, multistakeholder, global effort to provide public health and clinical targets pertaining to SARS-CoV-2 and COVID-19, with an emphasis on cases, vaccination, morbidity and mortality (Table 5 (REC2.17)).

Economic impacts, notably costs borne by consumers (Table 2 (STMT2.5)), create risks to health systems. 

  • To address these risks, structural and economic recommendations include removing economic barriers to SARS-CoV-2 tests, personal protective equipment, treatment and care (Table 4 (REC2.1)), supporting the development of regional manufacturing hubs for COVID-19 supplies, treatments and vaccines (Table 4 (REC2.2)), and considering legislative and regulatory reforms to address market failures (Table 5 (REC2.16)). 

  • Where access to PCR or antigen tests is limited, providers should consider adopting a syndromic approach (Table 5 (REC2.18)). Notably, REC2.18 is the health systems recommendation with the highest percentages of panellists disagreeing as well as panellists indicating ‘not qualified to respond’.

  • To reduce the burden on hospitals, the role of primary health care should be strengthened (Table 5 (REC2.10)), while health care workers’ physical, mental and social well-being should be supported (Table 4 (REC2.4)).

  • With respect to digital health, the recommendations — encourage increasing investments in digital health infrastructure (Table 5 (REC2.13)), adapting user interfaces and experience to expand access, particularly for vulnerable groups (Table 4 (REC2.3)), and leveraging implementation science to determine which digital health solutions can be quickly scaled (Table 5 (REC2.12)).

  • With respect to procurement practices, engaging continuous improvement disciplines for intercountry procurement, pooling and supply-chain management was urged (Table 5 (REC2.11)). 

  • To best leverage community-based interventions and services, community-based organizations and students pursuing degrees in health-related fields should be engaged in providing COVID-19 education, testing and vaccination services (Table 5 (REC2.14)).

  • As social, political and economic sector risks continue to have spillover effects on health systems, key multisectoral indicators for systemic risks to health systems should be identified and assessed (Table 5 (REC2.7)).

  • Finally, health systems should identify and, where possible, reduce diagnostic, treatment and care backlogs for non-COVID-19-related medical conditions (Table 5 (REC2.15)).

3.Emphasize vaccination, but not exclusively so

Even assuming continued innovation of vaccines and interventions that reduce vaccine hesitancy, 97% of the panel agrees that vaccination alone is insufficient to end the COVID-19 pandemic as a public health threat (Table 2 (STMT3.6)). 

Thus, the panel places a strong emphasis on additional prevention measures, particularly, as noted above and in the ten highest-ranked recommendations (Table 8), for countries to adopt a vaccines-plus approach, as discussed in the next domain.

  • Regarding the key role of vaccines, the panel made a range of recommendations. Government, philanthropic and industry funding should invest in developing vaccines that provide long-lasting protection against multiple SARS-CoV-2 variants (Table 6 (REC3.4)). 

  • As waning immunity remains a risk, calculations for immunity should consider the time after the date of vaccination and/or infection and be regularly updated with new scientific evidence (Table 6 (REC3.5)).

Vaccine hesitancy, which ranges from delay to refusal despite availability of vaccine services, remains a major challenge (Table 2 (STMT3.3)). 

  • To reduce vaccine hesitancy and increase uptake, several interventions are recommended: 
    – engaging trusted local leaders and organizations in vaccination efforts (Table
    6 (REC3.2)), 
    – providing information that clearly explains the efficacy and limitations of current vaccines (Table
    6 (REC3.1)) and 
    – tailoring messages to address the underlying bases of various populations’ specific concerns through targeted public health communications (Table
    6 (REC3.3)). 
  • Vaccine hesitancy may also be associated with false information, which is addressed in the communication domain above.

On the one hand, panellists largely agree that medical autonomy of individuals with decision-making ability extends to the right to make one’s own decisions regarding vaccination (Table 2 (STMT3.2)). 

On the other hand, panellists also acknowledge that, when the risk of harm to others is sufficiently severe, governments may determine that the right of all individuals to good health overrides the autonomy of any one individual to choose not to be vaccinated (Table 2 (STMT3.1)). 

These statements reflect among the highest levels of combined disagreement (Table 2 (STMT3.1, 9%; STMT3.2, 16%)). Civil liberties implications are further discussed in the next domain.

4.Promote preventive behaviours

As noted above, vaccination alone will not end COVID-19 as a public health threat (Table 2 (STMT3.6)) for all people. Infection rates tend to increase when governments discontinue social measures, including non-pharmaceutical interventions, regardless of the level of vaccination (Table 3 (STMT4.5)). 

  • Thus, all countries should adopt a vaccines-plus approach, including a combination of COVID-19 vaccination, other prevention measures, treatment and possibly financial incentives (Table 6 (REC4.5)).

Although the nature and vectors of SARS-CoV-2 transmission were not clearly understood early in the pandemic, current evidence guided the panellists to near-unanimous agreement that SARS-CoV-2 is an airborne virus that presents the highest risk of transmission in indoor areas with poor ventilation (Table 3 (STMT4.1)). 

  • Risk-related communications from all actors should clearly emphasize that transmission of SARS-CoV-2 is primarily caused by inhalation of the virus (Table 6 (REC4.3)). 

  • Considering the airborne nature of transmission, governments should regulate and incentivise structural prevention measures, such as ventilation and air filtration (Table 6 (REC4.1)), and high priority should be given to preventing SARS-CoV-2 transmission in the workplace, educational institutions and commercial centres (Table 6 (REC4.6)).

Mammal-to-mammal transmission represents a reservoir for future zoonotic variants (Table 3 (STMT4.3)). 

  • Thus, substantial virological surveillance based on whole-genome sequencing of positive samples in human and high-risk mammal populations is an essential component of the continued pandemic response and preparedness (Table 5 (REC2.8)). 

  • National and international travel restrictions should be based on current scientific knowledge and prevailing transmission rates of all variants that consider relevant, health-based factors (Table 6 (REC4.4)). 

  • Measures that are no longer scientifically valid for COVID-19 prevention should be immediately removed from COVID-19 guidance and policy (Table 6 (REC4.2)). 

  • Going forward, governments should consider imposing broad restrictions on civil liberties only in the event of variants of concern presenting risk of high rates of transmission and severity, coupled with waning immunity or vaccine resistance (Table 6 (REC4.7)).

5.Expand treatments

Panellists had substantially high agreement regarding all aspects of treatment and care, indicating that treatment will continue to be an area of major importance both for ending COVID-19 as a public health threat and for individual patient care. 

Notably, a statement addressing the risk of prioritizing treatment over prevention (Table 3 (STMT5.1)) had the highest level of combined disagreement (7%) for this domain.

  • With current public health policies reflecting greater tolerance for community transmission and increased rates of infection, research into COVID-19 must adapt and develop further evidence to understand the cumulative effect of COVID reinfection (Table 7 (REC5.4)). 

Research is needed to determine whether infection from distinct variants of SARS-CoV-2 is associated with significant differences in long-term morbidity (Table 3 (STMT5.4)). 

  • Additional research funding, particularly for long COVID, should be prioritized (Table 7 (REC5.6)), and multisectoral collaboration should accelerate new therapies across all stages of COVID-19 (Table 7 (REC5.2)). 

  • Moreover, global case definitions should be standardized (Table 7 (REC5.1)).

Echoing some statements and recommendations in the pandemic inequities domain (discussed below), clinical trials and longitudinal cohorts should be more inclusive and statistically representative regarding age, gender and vulnerable populations (Table 7 (REC5.3)).

6.Eliminate inequities

The substantial agreement of the panellists suggests that addressing inequities remains a global challenge. 

  • Immediate efforts should be made to reduce vaccine wastage (Table 7 (REC6.8)), 

  • addressing the need for cold storage, transport and other infrastructure-based barriers in low-resource settings (Table 7 (REC6.4)), 

  • addressing the affordability of testing and treatment for people in all countries (Table 7 (REC6.2)), 

  • as well as accelerating efforts to distribute vaccines in low- and middle-income countries (Table 7 (REC6.10)).

  • Transfer agreements to increase production capacities in low- and middle-income countries should be expedited (Table 7 (REC6.6)). 

  • Pre-existing social and health inequities must be considered in pandemic preparedness and response going forward (Table 7 (REC6.7)).

  • The findings call special attention to two vulnerable populations: children (Table 7 (REC6.5)) and those living within or fleeing from conflict zones (Table 7 (REC6.9)).

The pandemic has illustrated the risk of over-reliance on experts from a small number of disciplines (Table 3 (STMT6.8)), often excluding the expertise of community members (Table 4 (REC1.2)) and vulnerable groups (Table 3 (STMT6.7)). 

  • Instead, vulnerable groups should be sought out and actively engaged (Table 7 (REC6.3)). 

  • As noted in the communication domain, community leaders should also be engaged (Table 4 (REC1.1)). 

  • Multidisciplinary experts who understand local contexts should be included in developing national operational plans for ending COVID-19 as a public health threat (Table 7 (REC6.1)). 

  • COVID-19 tests and treatments should be affordable for all people in all countries (Table 7 (REC6.2)).

Other sections

See original publication (this is an excerpted version only)


  • The multidisciplinary panel’s emphasis on actionable, near-term recommendations guided the Delphi consensus-building process and increased the relevance of the study’s findings to a broad group of stakeholders, including governments, public health authorities, NGOs, community-based organizations, industry, and social media platforms and other media. 

  • This consensus study advances a global vision of informed decision-making on how the world can end COVID-19 as a public health threat without a return to sweeping limitations on civil liberties, without risking the health and lives of vulnerable groups, and without exacerbating economic burdens.

About the authors 

About the Brazilian Authors & Affiliations

Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
Mauricio L. Barreto, Mauricio Barreto, Tania Araujo-Jorge, Fernando A. Bozza, Ligia Giovanella & Marcus V. Lacerda

University of Bahia, Salvador, Brazil
Mauricio L. Barreto, Mauricio Barreto & Luis Eugenio de Souza

University of Sao Paulo, Sao Paulo, Brazil
Lorena Barberia & Deisy Ventura

Aids Healthcare Foundation, São Paulo, Brazil
Adele Benzaken

National Institute of Infectology Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil
Beatriz Grinsztejn

Carolina Batista

Originally published at https://www.nature.com on November 3, 2022.

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