The EU experience in the first phase of COVID-19: implications for measuring preparedness

In light of the challenges posed during the COVID-19 crisis, European Union (EU) legislation has been revised to strengthen the EU’s collective preparedness to respond to threats from communicable diseases in the future. Decision 1082/2013/EU on serious cross-border health threats is under revision in a regulation to be adopted in autumn 2022. The ECDC mandate is also under review and will enter into force once the Regulation on Serious Cross-Border Health Threats is adopted and published in the EU Official Journal. Measuring and assessing the performance of public health emergency preparedness (PHEP) systems is an essential part of the process of enhancing preparedness.

This technical report presents an analysis focused on three issues (testing and surveillance, healthcare sector coordination and emergency risk communication) during the first phase of the COVID-19 pandemic. The analysis identifies specific challenges experienced at this stage, as well as successful responses to them. The implications for measuring preparedness are also identified to inform future outbreak preparedness efforts in EU Member States.

This analysis is based on the experiences of five countries (Croatia, Finland, Germany, Italy and Spain) during the first phase of the pandemic, ie before the start of vaccination programs in December 2020. It is based on:

  1. pandemic preparedness and response plans, standard operating procedures and other documents related to COVID-19 response measures provided by the countries,
  2. interviews with country representatives, and
  3. other literature identified by performing quick literature reviews.

The analysis identifies the following overarching issues with existing readiness measurement systems:

  • The COVID-19 pandemic pressured EU Member States to develop new strategies, approaches and policies regarding their PHEP systems and structures. These also had to be reviewed and revised as the pandemic developed. Existing preparedness metrics did not take into account the level of revision and innovation needed.
  • Existing preparedness metrics are generally inconsistent with a country’s internal hierarchical structure of public health, healthcare, and other entities that influence emergency response.
  • Existing preparedness metrics generally do not reflect the required coordination between different parts of the healthcare system, especially at the hospital and community level.
  • Existing preparedness metrics generally lack the flexibility and resilience needed to address the challenges of scaling a country’s pandemic response.

Section 3.1 builds on these overarching themes with specific indicators of issues that are missing or not adequately addressed in existing preparedness measurement systems, in particular the ECDC Emergency Health Preparedness Tool (HEPSA) and the Joint External evaluation of the WHO (JEE), and for some parts, the Global Health Security Index (GHSI). The following conclusions are reached:

  • Preparedness metrics should include an indicator that refers to the ability to conduct testing at scale, which was critical in the early phase of the pandemic.
  • Preparedness metrics should include an indicator of the flexibility of the monitoring system.
  • In fact, existing testing and surveillance preparedness metrics cover key tasks, but do not address the ability of systems to scale up testing capacity, the importance and complexity of sub-national structures for surveillance and epidemiological research, or the challenges of adapting existing surveillance systems and developing new ones during the pandemic. These need to be addressed with accurate indicators.
  • While three capabilities in the ECDC PHEP logic model (Medical Countermeasures, Supplies, and Equipment Management; Medical Wave; and Hospital Infection Control Practices) have been shown to be critical, they are not represented with respective indicators in existing preparedness metrics.
  • The ECDC PHEP logic model’s capacity for ‘preventive services’ should include a new broader capacity for the ‘coordination of population-based medicine’, defined as ‘the ability to activate and strengthen coordination in a particular geographic area – during an outbreak high impact infectious disease – public health, ambulatory care, including primary care, mental health and community support agencies, public and private sector and inpatient health care, using integrated pathways between different levels of care (outpatient and inpatient care).’
  • The experience during the response to COVID-19 has shown that the risk communication capabilities identified in the ECDC PHEP logic model are valid and relevant, but are not fully reflected in the existing preparedness metrics. In addition, countries experienced difficulties in managing an information epidemic, which meant that the logical model had to be further extended with a fifth possibility, ‘infodemic management’, i.e. dealing with an abundance of information (some accurate and some not) .

In summary, taking into account several existing preparedness measurement systems, the analysis in this report suggests that the type of measurement approach and format used, for example, in the joint external evaluation process, could be useful in assessing the EU’s efforts in the field of of readiness. This involves first developing a set of metrics and indicators to address the areas identified as not so well developed in the analysis, and then creating a scoring system or scale for each domain. As with the JEE process, the assessment would begin with an analysis and preliminary score by national experts. This would be followed by a meeting where colleagues from other countries review the documentation of the internal analysis and meet national experts to reach consensus on the score. The evaluation process could include an analysis of existing systems, performance during the COVID-19 pandemic and the ‘stress tests’ mentioned in the proposed EU legislation on preparedness and response to health emergencies.

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