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Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19 (2021)

Chapter: 4 Implementation of Non-Vaccine Control Measures

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Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 100
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 101
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 102
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 103
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 104
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 105
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 106
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 107
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 108
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 109
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 110
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 111
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 113
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 116
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 117
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 118
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 119
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 120
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 121
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 122
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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Page 123
Suggested Citation:"4 Implementation of Non-Vaccine Control Measures." National Academies of Sciences, Engineering, and Medicine and National Academy of Medicine. 2021. Public Health Lessons for Non-Vaccine Influenza Interventions: Looking Past COVID-19. Washington, DC: The National Academies Press. doi: 10.17226/26283.
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4 Implementation of Non- Vaccine Control Measures The coronavirus disease 2019 (COVID-19) pandemic has starkly il- lustrated the extent to which countries were underprepared to respond to a major pandemic, fostering an environment in which interventions to pre- vent and mitigate transmission of a viral respiratory pathogen were likely to fail from the outset. Interventions during the response to the pandemic could have been informed and strengthened by many lessons learned dur- ing the responses to previous epidemic and pandemic events, such as the Ebola virus disease outbreaks in sub-Saharan Africa (SSA) (2014–2016) and the global H1N1 influenza virus pandemic (2009). However, largely due to lack of funding, many of the gaps identified in those responses were never rectified (Afolabi et al., 2021). Additionally, for reasons unknown, many of the lessons learned during those epidemics were not translated into improvements in the COVID-19 responses. For example, the Ebola outbreaks highlighted the critical need for community engagement, clear and coordinated risk communications, and avoidance of contradictory mes- saging. But while countless reports were written about these experiences in the years following, those approaches were not immediately used when the COVID-19 pandemic began. Insufficient resources for public health systems persists as an ongoing issue that undermines countries’ preparedness and response capacities related to infectious disease threats (Edelman et al., 2020). Moreover, the limited international cooperation in responding to the pandemic—including the announcement in May 2020 that the United States would withdraw from the World Health Organization (WHO) (which was rescinded in 2021)—weakened the response efforts in countries and fractured the landscape of global diplomacy (Gostin et al., 2020). Drawing 97 PREPUBLICATION COPY—Uncorrected Proofs

98 NON-VACCINE INFLUENZA INTERVENTIONS on lessons learned during the pandemic, this chapter focuses on strategies for effectively implementing non-vaccine control measures by exploring (1) how community-specific social and cultural factors can aid or hinder implementation, (2) how evidence-based communication strategies can pro- mote population uptake of recommended measures, and (3) how a rapid, coordinated government response bolstered by strong and consistent leader- ship can catalyze a positive response to public health interventions. CONTEXTUAL FACTORS AFFECTING IMPLEMENTATION A host of social, cultural, and structural factors influenced the pub- lic’s reception and uptake of non-vaccine control measures during the COVID-19 pandemic. Understanding the interplay between these factors will help to inform more effective strategies for designing community- specific interventions that garner greater public support and higher rates of adherence during future outbreaks (see Box 4-1). Sociocultural Factors Public responses to non-vaccine interventions are profoundly shaped by a range of social and cultural values, beliefs, and norms that vary across communities around the world. A rapid systematic review of community- based interventions and practices during COVID-19 and previous out- breaks of respiratory infections implemented in low- and middle-income countries (LMICs) found that masks, hand hygiene, and physical distancing BOX 4-1 Examples of Research Topics Related to Contextual Factors Affecting Implementation • Tracking racial, ethnic, socioeconomic and similar data systematically during an outbreak. • Examining how the timing, duration, and intensity of interventions influence population uptake in various settings. • Exploring the influence of a community’s religious practices and institutions on its response to an epidemic and adherence to public health interventions. • Exploring the impacts of historical trauma experienced by certain popula- tions and how it affects their trust in government bodies and corresponding mandates or recommendations. • Analyzing ways of implementing public health interventions that do not stig- matize those with the disease. PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION OF NON-VACCINE CONTROL MEASURES 99 were effective in reducing virus transmission in the community. However, their overall effectiveness depended on people adhering to the interventions in different contexts; adherence is shaped by social norms and beliefs and economic and logistical factors. Understanding community-specific socio- cultural practices is thus critical in designing strategies and best practices to promote adherence, such as tailored communication to encourage behavior change (Abdullahi et al., 2020). An important aspect of a community’s values is the degree to which its members conceive of themselves as primarily either independent or inter- dependent beings. For instance, individualism and independence are highly valued in many cultures in Europe and North America. In contrast, cultures in Asian countries tend to be more interdependent, place higher value on community well-being, and prioritize adherence to social norms over per- sonal desires (Van Bavel et al., 2020). Differences in high-income countries’ uptake of interventions during the pandemic evidenced the influence of cultural variations of this sort. For example, in Japan, individuals are more likely to follow government advice for the benefit of the entire community, while in the United States, many people have deeply held libertarian values that prioritize personal liberties and are more prone to disregard govern- ment advice (Reich, 2020). Regional location, level of education, and beliefs about science have also affected how individuals have responded to interventions during the pandemic. A cross-sectional study was conducted in China to investigate differences in how residents of urban and rural areas responded to interven- tions that were intended to encourage behaviors to prevent transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Chen and Chen, 2020). Compared to urban populations, residents of rural areas were less likely to adopt preventive measures; they were also less likely to engage in the process of information appraisal1 in considering whether to do so. A study in the United States that used cell-phone location data to gauge adherence to physical distancing directives demonstrated the influence of belief in science on the adoption of COVID-19-containment measures; the researchers found that the proportion of people adhering to lockdown policies was significantly lower in areas with large proportions of climate change skeptics (Brzezinski et al., 2020). A community’s behavior is also affected by various practical con- siderations and expectations related to employment, school attendance, and other activities that are typically conducted in person. A review of the implementation of personal actions, such as physical distancing, that were recommended to mitigate the transmission of SARS-CoV-2 found 1  Information appraisal skills involve critical thinking and considering the application of health information to one’s own life. PREPUBLICATION COPY—Uncorrected Proofs

100 NON-VACCINE INFLUENZA INTERVENTIONS that their effectiveness is largely contingent upon the specific culture and context. For example, in SSA, the applicability of and compliance with interventions used in other parts of the world would largely depend on the resources available and the timing, duration, and intensity of each interven- tion (Amaechi et al., 2020). This was also the case in Latin America, where an important proportion of the population, which had informal employ- ment with precarious income, was not able to follow stay-at-home orders or isolation without income support (Garcia et al., 2020). A community’s religious and family values can also impact health- related behaviors and undermine adherence to non-vaccine control inter- ventions. In Malaysia, cases of COVID-19 spiked after a series of large religious gatherings that were attended by thousands of people (Tan et al., 2021). Although religious leaders may advise congregants to practice physical distancing in other contexts during an outbreak, many individuals believe they enjoy divine protection while attending religious ceremonies. In many communities around the world, religion serves as the foundation and structure for virtually all dimensions of social life and shapes a broad range of private and public behaviors—including those related to the mitigation of infectious disease (Baker, M. G. et al., 2020). Early in March 2020, a Modern Orthodox Jewish community whose members reside in several New York City boroughs and beyond became the first community in the United States to be quarantined, based on the group’s tight-knit religious and educational institutions rather than geo- graphic proximity. The group’s strong communal links likely contributed to it becoming one of the most heavily impacted, first by the disease itself and then by the adverse psychosocial effects of interventions intended to mitigate the pandemic. For example, community members experienced el- evated levels of stress, anxiety, and perceived stigma directly associated with the lack of consistent communication from local public health departments (Weinberger-Litman et al., 2020). More research is warranted to inform decisions about which types of interventions should be implemented during future outbreak events and diminish their potential adverse consequences. This research could focus on the interplay between epidemics and religious groups and their gatherings and the positive and negative influences of re- ligion on a community’s response to an epidemic and adherence to public health interventions. Social and Structural Determinants of Health Along with social and cultural values, strategies for successful imple- mentation of non-vaccine control interventions should take into account the critical variables of community-specific social and structural determinants PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION OF NON-VACCINE CONTROL MEASURES 101 of health, including disparate treatment of certain racial and ethnic groups and socioeconomic inequalities. Racial and Ethnic Disparities It is now well established that racial and ethnic disparities underlie a range of barriers to accessing quality health care (NASEM, 2017). In all countries, the COVID-19 pandemic has made tragically apparent the existing inequities in access to resources and long-standing biases and prejudices that have long undermined the health of affected populations. The pandemic has also exacerbated the confluence of factors driving health inequities that some communities—typically defined by race, ethnicity, and socioeconomic status—have experienced for generations. During the pan- demic, this confluence of factors driving health inequities has heightened the risk of exposure to the virus due to occupational or living conditions and led to greater prevalence of noncommunicable diseases that increases the rates of severe disease and mortality due to COVID-19 in adversely affected groups (Maani et al., 2021). In the United States, historically marginalized racial and ethnic groups— including Black, Hispanic, Asian, American Indian, and Alaska Native populations—have been disproportionately impacted. Although many ju- risdictions failed to report racial and ethnic data early in the pandemic, by July 2020, researchers had documented this disproportionate impact—as seen in disparities in testing, infection rates, and outcomes, including hos- pitalization and death—in the nonwhite population. In the United States, the highest COVID-19-related fatality rates were among racial and ethnic minorities (CDC, 2021), even in states where racial and ethnic minorities only make up small percentages of the total population (KFF, 2021). An analysis of U.S. patient health record data found that hospitalization rates and death rates per 10,000 were substantially higher for Black (24.6 and 5.6, respectively), Hispanic (30.4 and 5.6), and Asian (15.9 and 4.3) people than for white people (7.4 and 2.3) (Lopez et al., 2021). Similar results exist on a global level among migrant and ethnic minor- ity groups, who experienced higher COVID-19 infection rates and disease severity (UN News, 2020). The United Kingdom, Sweden, Brazil, Spain, and South Africa have all reported higher rates of severe disease and death among those groups, who also tend to have limited access to testing and poor outcomes after recovering from the infection (Melchior et al., 2021). Despite these well-established disparities related to COVID-19, most coun- tries—even those with large immigrant populations—do not report their statistics by ethnicity or migrant status, highlighting the importance of research to develop systems for tracking such data during an outbreak. PREPUBLICATION COPY—Uncorrected Proofs

102 NON-VACCINE INFLUENZA INTERVENTIONS Socioeconomic Inequalities Socioeconomic inequalities can severely impact health outcomes during an outbreak, which underscores the need for national and international ef- forts to prioritize vulnerable groups in response to a pandemic. For exam- ple, in Brazil, communities and individuals from socioeconomic and ethnic groups that suffer from inequality had less capacity to prevent and recover from COVID-19 infections (Tavares and Betti, 2021). A population-based seroepidemiological study conducted in Lima, Peru demonstrated that both lower socioeconomic status and overcrowding in households were linked with greater SARS-CoV-2 seroprevalence (Reyes-Vega et al., 2021). Simi- larly, an analysis that compared COVID-19 disease incidence and mortality in high- and low-income municipalities in Santiago, Chile, reported a strong association between socioeconomic status and COVID-19 outcomes, with a greater infection fatality rate among younger people living in lower-income municipalities (Mena et al., 2021). Furthermore, they found that people liv- ing in lower-income areas did not adhere to lockdown orders as stringently as those in higher-income areas. Housing conditions and location, and household composition can also intensify or ameliorate risks along socioeconomic lines during a viral re- spiratory outbreak. Across the world, an estimated one billion people live in high-density communities and informal settlements with overcrowded dwellings and poor sanitation—often referred to as “slums”—that inten- sify their existing vulnerabilities during outbreaks of infectious diseases (Friesen and Pelz, 2020). The COVID-19 pandemic has exposed the lack of robust data on the people in such communities, their health statuses, and their living conditions—all of which limit the effectiveness of non-vaccine interventions for infection prevention and control (Wamoyi et al., 2021). Moreover, people living in slum communities and crowded homes are less likely to have access to basic preventive measures, such as handwash- ing (World Bank, 2020b) or space where sick residents can be isolated. In Latin America, residents of these settlements also struggle with improved housing due to a “lack of land availability, affordable construction materi- als, infrastructure connections, access to urban amenities” (McTarnaghan et al., 2016, p. viii). Many townships in South Africa lack running water in homes, with many residents living in close quarters (Trenchard, 2020). Growing urbanization in countries such as Kenya, Uganda, and Tanzania increases the number of people per household; it is estimated that in 57 per- cent of urban households, residents share a single room and thus are unable to practice physical distancing and other prevention measures implemented in other countries (Lirri, 2020; Wayomi et al., 2021). The ability to comply with stay-at-home orders is likewise affected by income and occupation. Many wage-earners who work in the informal PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION OF NON-VACCINE CONTROL MEASURES 103 sector may not be able to comply with stay-at-home orders due to needing to provide for their families (Wamoyi et al., 2021). Data aggregated from 40 million mobile devices at the county level in the United States showed that households with higher incomes adhered more closely to stay-at-home orders during the COVID-19 pandemic, as evidenced by less mobility out- side the home, than did lower-income households. This could be attributed in part to broader options for working remotely compared to households whose income depends on jobs involving direct, in-person labor (Singh et al., 2021). Workarounds to Unchanging Social and Structural Factors While identifying the social and structural determinants of health is important, these often will not be resolved quickly, so many typical inter- ventions may not be effective for certain populations or in certain locations. Policy consideration of these factors is necessary, but so is creative research and documentation of best practices to have a more comprehensive under- standing of what non-vaccine measures can be reasonably implemented in difficult settings (i.e., in urban slums where quarantine of infected family members is not feasible or in schools with outdated or poorly functioning heating, ventilation, and air conditioning systems) to provide some level of protection. Locations where many in the population face these challenging factors and do not have equitable access to effective vaccines have had to depend on creative workarounds throughout the COVID-19 pandemic. For example, despite predictions that African health systems would be quickly overwhelmed when the outbreak spread, most countries have still reported relatively few cases compared to much wealthier and more industrialized countries. Binagwaho and colleagues (2020) outlined seven contextual factors as key facilitators or barriers to implementation of interventions: culture of accountability, national coordination, financial stability of the population, culture of innovation, culture and capacity of research, strength of the health sector, and cross-border economies. They also suggested po- tential strategies to address the factors, such as task shifting from clinicians to community health workers and community-based engagement to lessen the burden on the health sector. Numerous innovations developed in Africa, such as low-cost rapid test kits or locally manufactured ventilators, can be leveraged by putting them in the hands of the right workforce. Other workarounds to these structural and social factors may include encouraging mask wearing in every setting that lacks access to vaccines, conducting classes outside, or alternating which groups of students attend school in person on different days. However, it is unclear if any of these are effective or if and when they outweigh the societal burden. More research is needed on the ad hoc interventions to reduce the spread in different coun- PREPUBLICATION COPY—Uncorrected Proofs

104 NON-VACCINE INFLUENZA INTERVENTIONS tries, as this is an opportunity to learn more about which were effective or ineffective. These interventions should also be conducted within a frame- work of implementation research, allowing for adapting and improving the practices and informing future work examining real-world effectiveness. COMMUNICATION APPROACHES TO PROMOTE UPTAKE The methods by which evidence, policies, mandates, and other infor- mation related to COVID-19 are communicated significantly impact the public’s perceptions and uptake of public health interventions intended to prevent and mitigate transmission. Health care professionals have found that public communication strategies should be clear, credible, and consis- tent to promote compliance with recommended interventions (Hung and Lin, 2021). Science communication, “the art and technique of informing, influencing, and motivating individual, institutional, and public audiences about important health issues” (HHS, 2000), is critical to conveying how new research informs policy and individual behavior (Goldstein et al., 2020). However, recommendations inevitably may have to be revised based on research, which occurred frequently and rapidly with COVID-19 (Fra- ser et al., 2021). Thus, the public needs timely reminders that guidance and mandates may change to stay consistent with the best current evi- dence rather than being constant over time. Additionally, officials need to gather—and use—data on the public’s understanding of, and adherence to, public health guidance in order to formulate public health policies and com- munication strategies that will increase the uptake of non-vaccine control interventions (Timmons et al., 2021). Additional research to inform com- munication approaches are outlined at the end of this section in Box 4-2. BOX 4-2 Examples of Research and Programmatic Opportunities for Communication Approaches • Analyzing the positive and negative impacts of using mass media as a plat- form for public health communication. • Gathering data on the public’s understanding of, and adherence to, pub- lic health guidance to formulate public health policies and communication strategies. • Leveraging ways that community engagement can be most fully used to implement public health interventions during a pandemic. • Exploring the impact of the new communication modalities developed dur- ing the COVID-19 pandemic, with attention to inequalities in access to such modalities. PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION OF NON-VACCINE CONTROL MEASURES 105 Factors Impacting Public Perceptions and Compliance with Interventions Many modes of communication can be used to disseminate public health information to the public, which will have different effects on the responses of different groups. Receptivity to non-vaccine infection control measures is influenced by individual psychology and a range of sociode- mographic factors, such as age and gender. For example, warning is a key component of crisis communication, which focuses on rapidly providing the public with information about impending or ongoing hazards and how to respond to them (Rahn et al., 2021). A cross-sectional survey in Germany on compliance with warnings during the COVID-19 pandemic found that older adults were more likely to comply (Rahn et al., 2021). In another study of perceptions and behaviors related to COVID-19 public health measures in Canada, men, people in younger age groups, and members of the paid workforce were less likely to report that they considered the mea- sures to be effective and less confident in their ability to comply (Brankston et al., 2021). Other factors that impact compliance include communication style and the perceived psychological distance between the audience and the com- municator. Psychological distance is a multidimensional construct spanning four types of distance: spatial (i.e., physical proximity), social (i.e., friend versus stranger), temporal (i.e., now versus next year), and hypothetical (i.e., high-probability versus low-probability event). A multisite study in the United States looked at the impact of perceived distance on the effects of an aggressive public communication style used to convey scientific informa- tion about COVID-19 (Chu et al., 2021). The use of aggressive language and tactics, including name-calling or other personal attacks, was found to increase compliance if the recipients perceived the communicator as psy- chologically close to them. This suggests—somewhat counterintuitively— that aggressive communication can strengthen public health strategies if the communicator has developed a close connection with the audience. Furthermore, the framing of public health communication can influence compliance with measures, including use of “positive” communication and language or tone (Biroli et al., 2020; McGuire et al., 2020). For example, one study found that communication focused on individual victims of the pandemic had a more positive impact on compliance than communication about statistical cases, as is common in “flatten-the-curve” campaigns (Byrd and Białek, 2021). These findings suggest that the most effective strategies and channels of communication about public health measures vary according to a range of factors. Tailoring communication to specific sociodemographic groups could help bolster acceptance of, confidence in, and adherence to interven- tions in an outbreak context. For instance, communication about risks and PREPUBLICATION COPY—Uncorrected Proofs

106 NON-VACCINE INFLUENZA INTERVENTIONS disease outcomes that is intended to engage young adults and dispel myths and misinformation might be most effectively delivered using technologies and social media platforms that they favor (Hung and Lin, 2021). Commu- nication about interventions should also be tailored to specific cultures and settings to effectively engage different segments of the public. Public strate- gies during the COVID-19 pandemic have tended to focus on individual risks rather than the community risks that are the consequence of existing inequities (Airhihenbuwa et al., 2020). Communication about physical or social distancing may impart differences in cultural contexts where com- munities are more collectivist than individualist, for example. Lastly, social and societal values and the population’s trust in leadership and science, as discussed later in this chapter, can greatly impact uptake of preventive public health measures. Understanding Public Perceptions of Interventions A wealth of data is available from online sources that could be lever- aged to better understand the public’s perceptions about interventions in order to inform and refine communication strategies. For example, evidence suggests that perception of non-vaccine interventions is largely dependent on their restrictiveness. Social media platforms can provide sources of timely data and feedback about the public’s responses to such interventions (Doogan et al., 2020). A topic modeling analysis of Twitter posts in six countries (Australia, Canada, Ireland, New Zealand, the United Kingdom, and the United States) looked at public perceptions of interventions such as masks and physical distancing. The study found that less restrictive mea- sures garnered more widespread support and that more restrictive measures were perceived in different ways across those countries. Four characteris- tics were identified as influencing public adherence to the interventions: (1) timely implementation, (2) style of campaign strategies, (3) prevalence of inconsistent information, and (4) use of enforcement strategies (Doogan et al., 2020). A qualitative assessment of social media posts in South Africa during the COVID-19 pandemic revealed that false information circulated on social media can have multiple effects. In addition to instigating fear, confusion, and panic, it contributed to othering and stigmatizing responses and misconceptions that could potentially be mitigated by community- specific strategies (Schmidt et al., 2021). Mass media have a substantial influence on the public’s knowledge about viral respiratory pathogens and their associated risks. This was dem- onstrated during the COVID-19 pandemic and other coronavirus outbreaks when inconsistencies in the public’s understanding of these pathogens af- fected the public’s response, level of concern, and uptake of preventive interventions (Yu et al., 2021). Additionally, the constant barrage of infor- PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION OF NON-VACCINE CONTROL MEASURES 107 mation led to what WHO called the “infodemic,” or an overabundance of information online and offline that sometimes included deliberate ef- forts to spread disinformation (WHO, 2021b). This has been exacerbated through social media, negatively influencing many around the world and affecting public health knowledge and response. Although media bias in various countries may have had deleterious effects on intervention uptake, the media can also be leveraged positively. A community-based study of knowledge, attitudes, and practices toward COVID-19 in Southern Ethio- pia found that media campaigns can promote knowledge, awareness, and uptake of preventive measures in rural areas (Yoseph et al., 2021). Search engine data can also offer rapid and location-specific information about the impact and perception of public health strategies and potentially conflicting communication being delivered via mass media. An analysis of the timing and relative volumes of search engine terms related to COVID-19 in Ger- many found that most searches for “protective masks” occurred early in the country’s first wave—a period with conflicting recommendations about whether to wear face masks—suggesting that the phrase had created a degree of confusion among the population (Kristensen et al., 2021). More positive examples of how to leverage tools such as social media to optimally benefit public health are needed. Developing Community-Focused Communication Strategies The community should play an active—rather than passive—role in the response to an infectious disease outbreak or other public health emer- gency. Developing community-focused communication strategies can help foster community engagement and encourage adherence to non-vaccine control interventions. WHO defines community engagement in the context of health as “a process of developing relationships that enable people of a community and organizations to work together to address health-related issues and promote well-being to achieve positive health impact and out- comes” (WHO, 2020). However, engaging communities in this type of active participation during lockdowns or when large gatherings are limited creates major challenges. For these efforts to be successful, much of the outreach and relationship building needs to be done before an outbreak begins. For the times that soliciting community input in real time is neces- sary, creative approaches on how to facilitate that participation should be developed beforehand as well, so they can quickly be put into practice when needed. Developing a bottom-up, community-specific communication strat- egy—for example, by eliminating language barriers and involving local leaders—during a public health crisis can help to build public trust and contribute to the success of prevention and response efforts. This was PREPUBLICATION COPY—Uncorrected Proofs

108 NON-VACCINE INFLUENZA INTERVENTIONS demonstrated by the effectiveness of a community-adapted communication strategy implemented in Orthodox Jewish communities in Belgium during the first COVID-19 lockdown; however, stigmatization can be a potential drawback of this approach (Vanhamel et al., 2021). Although community engagement through bottom-up approaches is critical during an epidemic, and such approaches were robust during previous outbreaks, such as Ebola (2014–2016), they have not been fully optimized during the COVID-19 pandemic. A rapid review of evidence examined the use of community engagement in infection prevention and control during past epidemics, identifying five key functions: (1) entering communities and building trust, (2) communicating to drive social and behavior change, (3) communicating risks, (4) conducting surveillance and contact tracing, and (5) providing logistical and administrative support (Gilmore et al., 2020). A mixed approach to communication with the public may be the most effective in many contexts. In Malaysia, public communications by the Ministry of Health during the COVID-19 pandemic was divided by subject categories, including disease information, state-mandated lockdowns, pre- vention, reference information, standard operating procedures, and other key information. It developed infographics in languages spoken by the local population that were intended to raise awareness, change and chal- lenge attitudes, and present a call to action for the public to adopt healthy behaviors (Jerome et al., 2021). Similarly, to help reach vulnerable local populations, community-engaged research partnerships in southeast Min- nesota translated COVID-19-related communication into six languages; community leaders used multiple electronic platforms and networks to deliver the communication (Wieland et al., 2020). Community and opinion leaders (including “social influencers”) can affect public perception during a health emergency (Quinn, 2020). Spe- cific communities with a history of medical mistrust have previously used members and leaders of those communities to improve community engagement with public health strategies, such with HIV/AIDS testing and prevention in the United States (Kalichman et al., 2016; Li et al., 2013). Religious leaders can also have positive and negative effects on the community. In Nigeria, a small qualitative survey found that people were more likely to follow handwashing and mask-wearing strategies during COVID-19 if the information came from a church or religious leader (Nname-Okechukwu et al., 2020). On the other hand, some religious leaders and communities were committed to maintaining pre-COVID-19 practices and actively worked against public health prevention efforts (Levin, 2020) or aligned with government leaders whose partisan politics were openly hostile to public health efforts, such as in Brazil (Bandeira and Carranza, 2020). PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION OF NON-VACCINE CONTROL MEASURES 109 Research Gaps Related to Communication Approaches During the COVID-19 pandemic, many people relied on digital com- munication as their exclusive means of social connection for lengthy pe- riods, leading to changes in the patterns of how people use these digital channels—shaped by various demographic and socioeconomic factors— that will likely persist after the pandemic is over (Nguyen et al., 2020). Although digital communication has provided a valuable outlet for many people, access is unequally distributed across the world, contributing to the infodemic that has resulted in confusion among populations and growing distrust toward official sources of information. The post-pandemic impact of new communication modalities and patterns on such inequalities war- rants further research. One of the challenges throughout the pandemic has been trying to ensure coherent communication of public health and scien- tific knowledge in an environment where new information and research rapidly emerges. In some cases, the new information may conflict with the previous findings and guidance, challenging the public’s trust, but clear methods for communicating this have not been identified. Also lacking in research are the positive and negative impacts of using mass media as a platform for public health communications (Anwar et al., 2020). Such research could inform strategies to effectively communicate reliable health information and health education despite the large volume of parallel in- formation—some of which may be false and/or unsourced—being delivered through social and mass media (Mheidly and Fares, 2020). GOVERNMENT RESPONSE AND LEADERSHIP TO SUPPORT IMPLEMENTATION Governments are the primary actors in determining how non-vaccine interventions are created, communicated, and deployed in the context of an epidemic or pandemic. Although the committee took into account so- cial contexts, communication methods, and other factors that influence the implementation and uptake of such interventions, their effectiveness is ultimately contingent upon coordination that is spearheaded by strong leadership and governance. More research in this area could inform types of interventions, and examples of topics are listed in Box 4-3. Rapid and Coordinated Government Action Many lessons gleaned from effective pandemic response efforts around the world highlight the importance of swift, proactive government action and effective coordination within and across sectors. A well-coordinated, multisectoral response is key to success so that the epidemic or pandemic PREPUBLICATION COPY—Uncorrected Proofs

110 NON-VACCINE INFLUENZA INTERVENTIONS BOX 4-3 Examples of Research Topics Regarding Leadership and Governmental Response • Studying the potential long-term economic impact of restrictive public health interventions on various industries. • Determining the mix of mandated versus voluntary policies that most effec- tively optimizes the population’s uptake of interventions. • Developing knowledge about the effective implementation of policies by including this topic in major research agendas for respiratory viruses. • Discovering how to rapidly create, and sustainably implement, evidence- based public health policy in a pandemic. • Determining how governments can best communicate changes to policy and mandates as the available evidence evolves. is not seen and managed as simply a health issue. Both WHO’s Inde- pendent Panel for Pandemic Preparedness and Response and the Lancet COVID-19 Commission Task Force for Public Health Measures to Suppress the Pandemic found that in successful countries, governments acted early and were proactive, whereas those that were unsuccessful were delayed in their response or denied the severity of COVID-19 (Lee et al., 2021; Sirleaf and Clark, 2021). For instance, a critical component of New Zealand’s success in eliminating transmission nationwide was rapid, science-based risk assessment linked to early, decisive government action (Baker, J. O. et al., 2020). The Lancet COVID-19 Commission Task Force reported that countries where partnerships were forged across sectors and at various lev- els performed well, because communication was transparent and consistent (Sirleaf and Clark, 2021). Furthermore, the strength of the public health enterprise, both day to day and in times of crisis, depends on nonparti- san support. Political partisanship can—and does—undermine efforts to operationalize scientific knowledge by implementing evidence-based inter- ventions (Narayan et al., 2021). Weak political coordination, anti-science sentiments, and distrust of political leaders have also been documented as adversely impacting the uptake of non-vaccine control measures during the pandemic (Anttiroiko, 2021; Desson et al., 2020; Feachem et al., 2021; Ferigato et al., 2020; Lancet, 2020; Migone, 2020). Leadership and Trust With country governments at the forefront of the COVID-19 response— and varying reactions to the pandemic by leaders within both political and PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION OF NON-VACCINE CONTROL MEASURES 111 public health institutions—decisive leadership has emerged as a key factor in determining the success of non-vaccine control interventions. Unfor- tunately, several countries were also influenced by political campaigns or other political tensions, leading to noncompliance or failure to implement recommended health measures. As the Delta variant continues to surge in the United States at the time of this report, these challenges are still seen, with various state governors going against public health recommendations in hopes of garnering more support from constituents. The successful responses to the COVID-19 health crisis enacted in New Zealand, South Korea, and Vietnam have been attributed, in part, to their leadership (Bhalla, 2021). For instance, empathic leadership in New Zealand effectively used the rallying cry that combating the pandemic was the work of a unified “team of 5 million.” A high degree of public confi- dence and trust2 contributed substantially to high levels of adherence to a suite of relatively burdensome pandemic-control measures (Baker, M. G. et al., 2020). This resulted in overwhelmingly positive outcomes: by mid- June 2021, New Zealand had reported only 26 deaths (WHO, 2021a). In contrast, adherence to quarantine orders in Colombia was undermined by poor coordination between the national government and the mayors and governors at regional and local levels. This gave rise to political tensions at the government level, confusion among the population, and public resis- tance to curfews across the country (Garcia et al., 2020). Effective national responses facilitated by strong leadership, such as New Zealand’s, illustrate the importance of several key factors, including the rapidity of response, good coordination, an evidence-based approach that is communicated ef- fectively, and the partnership spirit (Al Saidi et al., 2020; Lee et al., 2021). In addition to strong leadership, building public trust is crucial to ensuring compliance with non-vaccine control interventions. A survey con- ducted in 11 countries evaluated public perceptions of more than 40 dif- ferent containment measures. Researchers found significant variations in perceived effectiveness, restrictiveness, and compliance (Georgieva et al., 2021). Such findings suggest that in environments with low levels of public trust in government, compliance can be improved by offering incentives, such as supplements for people who have lost their jobs. No single crisis communication strategy is appropriate for all contexts, but an analysis of government approaches during COVID-19 found that the most effective strategies for developing and maintaining public trust are bidirectional, 2  “In its broadest sense, political trust refers to citizens’ assessments of the core institutions of the polity and the most relevant attributes that make each political institution trustworthy, such as credibility, fairness, competence, transparency in its policy-making, and openness to competing views” (Zmerli, 2014). PREPUBLICATION COPY—Uncorrected Proofs

112 NON-VACCINE INFLUENZA INTERVENTIONS clear, tailored for diverse audiences, and delivered using appropriate plat- forms by trusted actors (Hyland-Wood et al., 2021). Trust as a component of the relationship between the population and its leadership is predicated on shared values and, in several countries, shared values along political divisions can undermine attempts at unified communication from scientists and leadership. An example is using public health measures that require physical distancing despite adverse impacts on the local retail economy (Evans and Hagittai, 2020; Pagliaro et al., 2021). A low level of public trust in a country’s government does not necessarily mean the population does not understand the scientific rationale or agree with countermeasures, as was found in Liberia during the Ebola outbreak (Blair et al., 2017). Additionally, a high level of public trust in a government does not always signal a high level of trust in science (Evans and Hagittai, 2020). This is further complicated when country leaders themselves do not comply with countermeasures, are openly hostile toward experts (Idrovo et al., 2021), or publicly display behavior that flouts public health mandates, such as not wearing masks in public or hosting large events that go beyond local mandates for physical distancing or limiting the capacity of venues (Lancet, 2020). Any scientific uncertainty—such as in the case of modeling mortality projections—can be politicized, which is particularly harmful in countries where partisan leadership is likely to promote information that lacks evidence (Kreps and Kriner, 2020). In a cross-sectional study of people in 23 countries, researchers found moral values can positively affect trust in government but negatively affect trust in science (Pagliaro et al., 2021). Building trust is also a critical tool for counteracting misinformation, which abounds worldwide about the origin and response to the COVID-19 pandemic. A qualitative study of social media posts in Iran related to COVID-19 identified several factors that contributed to the spread of mis- information: (1) cultural factors, (2) demand for information during the crisis, (3) the ease of disseminating information through social media net- works, (4) marketing incentives, and (5) poor regulation and legal review of online content (Bastani and Bahrami, 2020). An online survey looked at participants’ evaluations of the believability of several COVID-19 narra- tives, finding that simply disseminating scientifically sound narratives may not be able to attenuate the public’s beliefs in misinformation (Agley and Xiao, 2021). A more effective response to the proliferation of misinforma- tion could involve strategies to foster the public’s understanding and trust in science, scientists, and the scientific process. Policy Considerations In implementing stringent public health measures, a critical consider- ation for policy makers is how to strike the appropriate balance between PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION OF NON-VACCINE CONTROL MEASURES 113 voluntary and mandated compliance by the public. Relying too heavily on the latter can undercut public support for measures and reduce public mo- tivation to comply voluntarily (Schmelz, 2021). A survey conducted during the first COVID-19 lockdown in Germany found that a large proportion of respondents would be more likely to support voluntary measures (Schmelz, 2021). It has been suggested that at the outset of an outbreak, the least re- strictive and most effective public health measures should be implemented first, rather than restrictive measures that have an adverse effect on adher- ence and can undermine human rights (Georgieva et al., 2021). Prolonged, restrictive interventions to control disease outcomes have economic and social sequelae, such as increased unemployment and busi- ness bankruptcies (Chen and Qiu, 2020; Garcia et al., 2020). Individuals worried about losing income, for example, may be reluctant to comply with public health interventions, such as quarantining at home. A cross- sectional survey in Iran explored reasons for noncompliance with home quarantine during COVID-19; among the most frequently expressed were concerns about people’s livelihoods and lack of government planning to support low-income groups (Nazari et al., 2020). Governments can help by assuring their citizens that livelihoods will be maintained during peri- ods of restrictive measures. A cross-sectional study in Israel found that if respondents assumed they would be compensated for lost wages, compli- ance was 94 percent, but it decreased to 57 percent when compensation was removed (Bodas and Peleg, 2020). More research is needed on the potential long-term economic impacts of restrictive public health interven- tions on various industries. Additionally, regulatory governance strategies would benefit from integrating behavioral insights into a holistic outbreak response (OECD Policy Responses to Coronavirus, 2020). Behavior Change Strategies Governments and leadership should draw on experiences during the COVID-19 pandemic to inform the development and implementation of more effective behavior change strategies for use during future viral respira- tory pathogen outbreaks. Containment strategies and mitigation strategies are two routes for changing individual and collective behaviors in response to an outbreak in the absence of an effective treatment or vaccine. Contain- ment aims to reduce transmission by employing approaches such as early case detection, contact tracing, and confinement. Mitigation is intended to slow the spread and reduce the burden of demand on strained health care systems through measures such as physical distancing, lockdowns, and im- proved hygiene (OECD Policy Responses to Coronavirus, 2020). Evidence gathered during the COVID-19 pandemic should be used to inform the development of effective behavior change strategies for use PREPUBLICATION COPY—Uncorrected Proofs

114 NON-VACCINE INFLUENZA INTERVENTIONS during future events. While many prior major influenza research agendas and initiatives, such as the WHO Global Influenza Strategy (WHO, 2019), did not recognize this evidence-gathering need, highlighting a research gap (see Box 4-3), a number of smaller studies have examined such behavior change elements. A cross-sectional survey of the social and behavioral consequences of mask-related measures during the COVID-19 pandemic in Germany found that a mandatory face mask policy was associated with increased compliance despite only moderate levels of acceptance; mask wearing was also correlated with other positive preventive behaviors (Betsch et al., 2020). In another cross-sectional study that surveyed adults in North America and Europe about barriers and facilitators of adher- ence to physical distancing measures, the most frequently stated barriers included (1) streets being crowded with pedestrians, preventing efforts to keep a distance (31 percent), (2) needing to run errands for friends and family (25 percent), (3) lack of trust in government communication about the pandemic (13 percent), and (4) feeling stressed when alone or in isola- tion (13 percent) (Coroiu et al., 2020). Commonly endorsed motivations to engage in distancing included wanting to protect others (86 percent) or oneself (84 percent) and a sense of responsibility to protect the community (84 percent). Compliance with non-vaccine control interventions is largely contin- gent upon widespread agreement that the health of a community is a public and shared good. From an evolutionary game theory perspective, the COVID-19 pandemic can be construed as a dilemma in which people are acting as “free riders” if they fail to comply. That is, they experience the benefit of their own decreased health risk as a result of other people’s efforts, without actually contributing to public safety themselves and, in some cases, by actually undermining public safety (Yong and Choy, 2021). Physical distancing is a public good with an especially severe free-rider problem. The evolved human psychological tendency to eschew free-riding behaviors among others in the community could be leveraged in develop- ing strategies to promote adherence to interventions. These might include imposing penalties for noncompliance, nurturing social norms that promote community-level cooperation (Yong and Choy, 2021), and encouraging pro-social behavior that takes advantage of the loss of social capital (Costa et al., 2021). A survey in Japan has suggested that people who have greater altruistic concerns and are more sensitive to shaming are more likely to adhere to physical distancing measures (Cato et al., 2020). In developing strategies to overcome the free-rider problem, public health officials need to consider the potential unintended consequences; for example, inducing negative feelings, such as shame, can be harmful because they also lead to self-harm, including suicide. PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION OF NON-VACCINE CONTROL MEASURES 115 STRATEGIES FOR OPTIMIZING POPULATION UPTAKE OF NON-VACCINE CONTROL MEASURES National and international responses to the COVID-19 pandemic— both successful and unsuccessful—have yielded valuable evidence and insights about potential strategies for optimizing population uptake of non-vaccine control measures during an epidemic or pandemic caused by a viral respiratory pathogen. For instance, lessons learned from social mobilization during COVID-19 include the importance of incorporating behavioral psychology principles into communication, using a trauma- responsive approach to communication, and recognizing the influence of context (e.g., no strategy is “one size fits all”) (Skouteris, 2021). However, even in a public health emergency, abiding by the Siracusa Principles3 that safeguard human rights can be a potential facilitator for uptake of control measures. In certain societies, it is important for people to be explicitly assured of the protection of their rights before they consider mandated interventions. When public health measures are enacted, certain core hu- man rights and basic needs must still be ensured. This has been a challenge in many countries that have undergone strict lockdowns and business closures in the face of COVID-19. During and after the acute phases of a crisis, a retroactive analysis and discussion of the measures used should be conducted to ensure they were based in evidence and proportionate to the need (Sun, 2020). The application of implementation science and frameworks could en- hance the creation and uptake of non-vaccine control interventions and the management of the resource shortages that have hampered public health interventions worldwide during the COVID-19 pandemic. For example, shortages of masks made it difficult to control the spread of infections by health care workers in nursing homes in the Netherlands (Wensing et al., 2020) and in Costa Rica (Garcia et al., 2020). Challenges resulting from resource shortages could potentially have been mitigated by using implementation science principles and frameworks to enhance emergency preparedness planning. Examples include process mapping with consensus building, microplanning with simulation, and stakeholder engagement techniques (Means et al., 2020). Implementation science has also been identified as having potential to support COVID-19 mitigation efforts by evaluating an implementation context, identifying context-specific barri- ers, selecting strategies to increase effective delivery of an evidence-based 3  For more on the Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights, see https://www.icj.org/wp-content/ uploads/1984/07/Siracusa-principles-ICCPR-legal-submission-1985-eng.pdf (accessed August 23, 2021). PREPUBLICATION COPY—Uncorrected Proofs

116 NON-VACCINE INFLUENZA INTERVENTIONS intervention, and evaluating implementation in terms of uptake, coverage, resource efficiency, or other key measures (Chambers, 2020; Hirschhorn et al., 2020; Means et al., 2020; Wagner and Means, 2021; Wensing et al., 2020). Ideally, policies for implementing interventions should be based on quality evidence—including testing to see how the intended audience responds, though there are limitations to the speed with which scientific evidence can be aggregated and appropriately translated into policy dur- ing a pandemic with a rapidly spreading pathogen (Williams et al., 2020). Consequently, governance and public health leadership often rely on modeling projects to inform policy development (McBryde et al., 2020), including lessons from past pandemics. More research is needed on how to rapidly create and sustainably implement evidence-based public health policy in pandemic scenarios that pose barriers to the typical process for policy development by virtue of their uncertainty and potential for loss of human health and life (Yang, 2020). Developing such policies needs to be inclusive of all relevant stakeholders and flexible enough to adapt to evolving knowledge about the pathogen and pandemic (World Bank, 2020a). CONCLUSIONS AND RECOMMENDATIONS Optimizing Intervention Adherence Conclusion: The COVID-19 pandemic demonstrated that a number of contextual factors, political systems and leadership styles, culture, in- dividual norms and beliefs, and the methods used to implement public health policies influenced the uptake and optimal execution of public health interventions. This suggests a need to conduct research to ascer- tain how all these factors affected public acceptance. Recommendation 4-1: Global and regional public health agencies (e.g., World Health Organization, Pan American Health Organization, Africa Centres for Disease Control and Prevention) and national governments, including their local and state health agencies, should adopt policies that are tailored to each affected population, taking into account its social, economic and cultural characteristics, needs and resources, and other contextual factors, including norms, values and beliefs, in order to optimize the implementation of public health interventions, espe- cially those that rely on individual behaviors. PREPUBLICATION COPY—Uncorrected Proofs

IMPLEMENTATION OF NON-VACCINE CONTROL MEASURES 117 Leadership and Community Engagement Conclusion: Public trust in government officials, community leaders, scientists and other experts, and other people who influence public opinion has affected—both positively and negatively—public response to governmental policy announcements and mandates as well as the uptake of non-vaccine interventions to slow the spread of COVID-19. Trust in such persons and confidence in what they said about interven- tions was undermined when the policies were shown not to rest on a strong evidence base, when the reasoning behind the policies was not well communicated, and when the personal behavior of such persons did not coherently and consistently adhere to the practices that they had recommended or required. Recommendation 4-2: Governments, leaders of departments of health at local, state, and national levels, and elected and appointed govern- ment leaders should: • Take the systemic factors, such as race and socioeconomic dis- advantages that affect the health of affected populations into consideration and leverage behavioral health research and mar- keting tactics when developing and implementing public health interventions; • Demonstrate, in their behavior, adherence to non-vaccine mea- sures to prevent influenza in order to promote public trust in, and uptake of these measures; • Engage the community—including grassroots organizations, spiritual leaders, teachers, and sports coaches—in making and communication decisions about public health measures; and • Choose words to convey communications positively (e.g., “physical distancing,” “social solidarity,” and “stay at home” rather than “social distancing,” “individual isolation,” and “lockdown”). Data and Frameworks Conclusion: The variety of interventions implemented in response to the COVID-19 pandemic has not always been informed by evidence of effectiveness but, in some cases, has been based on contextual factors and policy makers’ individual views. This experience highlights a need to both generate evidence that is relevant across a wide range of settings and use this evidence when implementing non-vaccine control measures. PREPUBLICATION COPY—Uncorrected Proofs

118 NON-VACCINE INFLUENZA INTERVENTIONS Conclusion: Historically, investments in research to evaluate strategies and means of implementing non-therapeutic and non-vaccine control measures have not been sustained over the long term. The boom-bust cycle of interest in these topics, which peaks with the onset of an epidemic or pandemic, needs to be replaced by longer-term vision and infrastructure building to enable research on all aspects of prevention and response, including non-vaccine and non-therapeutic measures. Recommendation 4-3: Funding agencies should create mechanisms to support the rapid application of data and implementation frameworks during an influenza pandemic as well as to enhance similar mecha- nisms during interepidemic periods. Such mechanisms can be used to support implementation research on non-vaccine control measures for influenza. Recommendation 4-4: National governments—as well as local, state, and global public health agencies—should develop readily imple- mentable intervention plans for outbreaks of influenza and other diseases. Such plans should specify how, from the beginning of an outbreak, the government will • Take into consideration the needs of the population affected, with special attention to the needs of marginalized groups; • Iteratively collect and use data about the implementation and effectiveness of non-vaccine control measures to adapt plans where needed; and • Use proven scientific frameworks to guide and improve such measures. REFERENCES Abdullahi, L., J. J. Onyango, C. Mukiira, J. Wamicwe, R. Githiomi, D. Kariuki, C. Mu- gambi, P. Wanjohi, G. Githuka, C. Nzioka, J. Orwa, R. Oronje, J. Kariuki, and L. Mayieka. 2020. Community interventions in low- and middle-income countries to inform COVID-19 control implementation decisions in Kenya: A rapid systematic review. PLOS ONE 15(12):e0242403. Afolabi, M. O., M. O. Folayan, N. S. Munung, A. Yakubu, G. Ndow, A. Jegede, J. Ambe, and F. Kombe. 2021. Lessons from the Ebola epidemics and their applications for COVID-19 pandemic response in sub-Saharan Africa. Developing World Bioethics 21(1):25–30. Agley, J., and Y. Xiao. 2021. Misinformation about COVID-19: Evidence for differential latent profiles and a strong association with trust in science. BMC Public Health 21(1). Airhihenbuwa, C. O., J. Iwelunmor, D. Munodawafa, C. L. Ford, T. Oni, C. Agyemang, C. Mota, O. B. Ikuomola, L. Simbayi, M. P. Fallah, Z. Qian, B. Makinwa, C. Niang, and I. Okosun. 2020. Culture matters in communicating the global response to COVID-19. Preventing Chronic Disease 17. PREPUBLICATION COPY—Uncorrected Proofs

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The COVID-19 pandemic has challenged the world's preparedness for a respiratory virus event. While the world has been combating COVID-19, seasonal and pandemic influenza remain imminent global health threats. Non-vaccine public health control measures can combat emerging and ongoing influenza outbreaks by mitigating viral spread.

Public Health Lessons for Non-Vaccine Influenza Interventions examines provides conclusions and recommendations from an expert committee on how to leverage the knowledge gained from the COVID-19 pandemic to optimize the use of public health interventions other than vaccines to decrease the toll of future seasonal and potentially pandemic influenza. It considers the effectiveness of public health efforts such as use of masks and indoor spacing, use of treatments such as monoclonal antibodies, and public health communication campaigns.

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