We propose a hierarchical framework based on our experience of systematically reviewing and synthesizing 378 primary studies for an evidence-based update of the modes of transmission for SARS-CoV-2. These studies revealed significant methodological shortcomings with a lack of standardization in the design, conduct, testing and reporting of SARS-CoV-2 transmission. While this situation is in part excusable at the outset of a pandemic, evidence rules of proof for assessing the transmission of this virus are needed for this and future pandemics of viral respiratory pathogens. We review the history of causality assessment related to microbial etiologies with a focus on respiratory viruses and suggest a hierarchy of evidence to integrate clinical, epidemiologic, molecular and laboratory perspectives on transmission. The hierarchy, if applied to future studies, should narrow the uncertainty over the twin concepts of causality and transmission of human respiratory viruses. We attempt to address the translational gap between the current research evidence and the assessment of causality in the transmission of respiratory viruses with a focus on SARS-CoV-2. Experimentation, consistency and independent replication of research alongside our proposed framework provide a chain of evidence that can reduce the uncertainty over the transmission of respiratory viruses and increase the level of confidence in specific modes of transmission and the measures that should be undertaken to prevent transmission

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Subject: Medicine and Pharmacology - Immunology and Allergy

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