Bjørn G. Iversen1, Jean-Claude Desenclos2,3, Atle Fretheim1, Anne-Catherine Viso2,3, Tanja Schmidt4, Jussi Sane4, Paula Virginia Vasconcelos Lopes4, Ihor Perehinets4, Trygve Ottersen1,2
1 Norwegian Institute of Public Health
2 International Association of National Public Health Institutes (IANPHI)
3 Santé Publique France (the French Public Health Agency)
4 World Health Organization (WHO) Regional Office for Europe, Health Emergency Programme
Introduction
This article covers two closely interrelated topics: the role of National Public Health Institutes (NPHIs) as knowledge providers during the COVID-19 pandemic and how to assess and evaluate the effects of public health and social measures (PHSM). We do not provide definite answers but rather raise some important questions on what should be done to develop NPHIs so that they can provide stronger evidence on the effectiveness and adverse effects of PHSM to better support decision making in emergency preparedness and response.
Role of National Public Health Institutes as knowledge providers in a pandemic
Most European countries have at least one NPHI that aims to provide scientific knowledge and independent advice to their government, society and populations. Yet how governments have utilised NPHIs during the pandemic varies greatly between countries. The societal missions of NPHIs vary by country and have also evolved during the pandemic in some countries, as documented in the IANPHI COVID-19 lessons learned exercise conducted in 2021 (to be published early in 2022). Based on this experience, a key question is how best to organise and develop NPHIs to support their governments during the ongoing pandemic and in preparedness and response to future public health emergencies and threats.
NPHIs vary in their organisational structure, size, functions, and roles. In many countries, they serve a dual role of being part of the governmental structure and at the same time having a research function. During the COVID-19 pandemic, some NPHIs have had a central role in governmental preparedness and response. This included some or several of the following activities: surveillance and investigations, contact-tracing, purchasing, stockpiling and distribution of medical equipment and goods (including vaccines, drugs, personal protective equipment like face masks, and other medical products), research, data analysis and modelling, providing knowledge and expert advice, health promotion interventions, advising on protective measures and vaccination. In other countries, the role of NPHIs has been more peripheral.
Definition and implementation of roles and functions are important to optimise the usefulness of NPHIs. Over the past years, and not least as a response to public health emergencies, the need to strengthen NPHIs has become more evident (Myhre et al. 2021), as well as the need to strengthen essential public health functions in general. Global collaboration has been highlighted as being important (Jakab et al. 2021, Bergh et al. 2019, Verrecchia et al. 2019), organisational issues such as legal frameworks are being discussed (Rosenfeld et al. 2020), and suggestions for strengthening preparedness have been presented (Khan et al. 2020).
The International Association for National Public Health Institutes (IANPHI) launched its new Strategy 2021-2025 in May 2021 in the midst of the COVID-19 pandemic. Its vision is of a global community of interdependent and trusted NPHIs as scientific advisors working together to protect and improve the public’s health and build a more equitable world, and IANPHI aims to be an inclusive and independent professional association which promotes an evidence-based approach to public health and scientific excellence. The emphasis here is on being trusted scientific advisors and using an evidence-based approach to promote best practices, protect and improve the public’s health.
One of the four strategic priorities of the IANPHI strategy is to harness the collective expertise of members to develop public health capacity globally, and one action point under this strategic priority is a review of the Framework for the Creation and Development of National Public Health Institutes and particularly its core functions and attributes. How best to organise national public health functions in a country, what they consist of, and what they are expected to deliver - are some of the key questions to be answered.
Another action point of the strategy is to develop an NPHI Code of Practice, in relation to the review of the Framework for the Creation and Development of NPHIs, which includes core values such as scientific independence to support members in their national remits. A Code of Practice can be defined as a set of written rules or principles that is set out by a professional association to guide its members towards compliance with the appropriate standards. Some of the core values to be explored for a Code of Practice are the scientific independence of an NPHI, the scientific excellence of their work, and the openness and transparency in the way they work.
NPHIs have played a decisive role in many countries – in particular in Europe – in responding to the pandemic in producing, summarising, and providing knowledge, advice and guidance to governments and other major stakeholders (Fretheim et al. 2020). IANPHI has held a series of network meetings for its members on lessons learned from COVID-19. The results from these meetings are now being harvested into a report that is scheduled to be published in the spring of 2022. An article for African NPHIs has been published (Binder et al. 2021).
However, COVID-19 has raised legitimate questions on the most effective ways of organising essential public health functions in responding to a pandemic and the roles and missions of NPHIs in this. Some of these include:
- Which are the essential public health functions in pandemics best handled by NPHIs?
- To what extent should NPHIs have a role in primary knowledge production?
- To what extent have NPHIs been able to advise and make recommendations, particularly for PHSM, given the knowledge gaps on their desirable and undesirable effects?
- What are the specific gaps for which research needs to provide new evidence on PHSM and what are the barriers to carrying it out?
- With the lack of evidence and the uncertainty on the effects of PHSM, how can NPHIs best advise policy and decision makers?
- Have NPHIs been able to deliver scientific advice and carry out their missions with the required scientific independence to the evidence from political pressure?
Lack of knowledge on the effectiveness of individual public health and social measures
During the COVID-19 pandemic, national governments have introduced a wide variety of strict and sometimes long-lasting measures heavily affecting social life and individual freedoms. Evidence gathered and experience indicate that many of the measures implemented together have had some effect on the dynamics of the pandemic. A recent meta-analysis by Talic et al. (2021), found some evidence, although with a high degree of uncertainty, for the effectiveness of handwashing, mask-wearing, and physical distancing. The authors also concluded that more stringent measures, such as lockdowns and closures of borders, schools, and workplaces need to be carefully assessed by weighing their effectiveness versus the potential negative effects of these measures on general populations. In Europe, Vardavas et al. (2021) undertook a systematic review and found that, despite heterogeneity across studies, non-pharmaceutical interventions that include PHSM were effective in reducing SARS-CoV-2 transmission, COVID-19 hospitalisations and deaths, and may be applied as response strategies to reduce the burden of COVID-19 in forthcoming waves.
We must also recognise that most often the true effect of each measure is not precisely known, since many measures were implemented at the same time (Enria et al. 2021). Most importantly, there have been practically no randomized controlled studies carried out to assess the effectiveness of specific PHSM. For instance, the level of evidence gathered by Vardavas et al. (2021) remains very modest, since most assessments were done through modelling or observational design of heterogeneous quality, with only one study out of 45 that had an experimental design. Furthermore, the BESSI Collaboration (https://www.bessi-collab.net/) found that, as of 5 December 2021, only 15 randomised trials of behavioural, environmental, social, and systems interventions for pandemic preparedness had been reported. In comparison, the corresponding figure for drug trials was 789. The lack of experimental designs to assess PHSM may partly be due to ethical issues. On the one hand, how acceptable (and feasible) is it to randomize the introduction of interventions such as lockdowns or curfews in a country or a region? On the other hand, the implementation of such interventions with low or modest evidence raises ethical questions as well. It is, however, important to recognise that several randomized controlled trials of PHSM have been recently published, including an intervention during large live indoor gatherings (Delaugerre et al. 2021), daily contact testing as a safe alternative to home isolation when cases are identified in elementary schools (Young et al. 2021), and recommendations to use of face masks in the community (Abaluck et al. 2021).
There has been a large and rapid increase in planned and executed research on COVID-19 in many fields of science and medicine, but some key insufficiencies remain. One of these relates to the evaluation of the efficacy, effectiveness, adverse effects and impact of PHSM at population level (Glasziou et al. 2021). This is an area of specific interest to NPHIs, since PHSM constitute core elements in the response to epidemics and pandemics. Examples of PHSM include border closures, trade and travel restrictions, national or regional restrictions on movement, the mandatory wearing of face masks, physical distancing, hand hygiene measures, ventilation requirements, school closures, various types of lockdowns, curfews, closures of shops, restaurants, culture events, and other restrictions on public and private gatherings. Research exploring risk perception, community uptake and other behavioural aspects of implementing PHSM is also greatly needed.
NPHIs typically advise governments on the choice of PHSM, e.g. whether to issue stay-at-home orders, close businesses or schools, or introduce travel restrictions. To provide evidence-informed advice, public health institutions are dependent on the availability of research findings on which to base their recommendations. Such evidence remains limited for PHSM, and therefore neither their effectiveness nor their adverse effects and economic consequences have been sufficiently and reliably estimated.
Almost two years into the COVID-19 pandemic, the evidence base for various PHSM has only marginally improved. In this situation, given that NPHIs either carry out research or interact with research institutions to initiate applied research to inform decision and policy, they have an important and active role to play to reduce the knowledge gap on the effectiveness and adverse effects of PHSM.
Conclusion
NPHIs have played an important role in many European countries in responding to the pandemic by providing knowledge, advice, and guidance to governments. This has been done in a variety of ways, depending on the role and mission of the individual NPHI. The roles, functions, and attributes of NPHIs need to be developed further, drawing on the experiences from the pandemic, and especially their role as a knowledge provider to improve the public’s health. IANPHI coordinates knowledge exchange between NPHIs and encourages NPHIs to support decision making by developing more and better evidence on the effects and consequences of public health and social measures on epidemics.
Almost two years into the pandemic, there is still a great lack of knowledge on the effects of PHSM. Too little is known about border closures, trade and travel restrictions, the mandatory wearing of face masks, school closures, and various types of lockdowns. The evidence base has only marginally improved, and few trials are planned. We need to identify the obstacles to research of this kind, and whether they are of a legal, ethical, conceptual, or methodological nature, to be able to mitigate them and carry out the needed research.
Because of their unique missions, functions, and institutional situations, NPHIs play an important role as providers of science-based knowledge and advice to decision-makers. They have a key role to play in filling the knowledge gap that remains on the impact of PHSM on the COVID-19 dynamic, as well as on wider public health and societal consequences.
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