How to Increase the Attractiveness of the Public Health Service in Germany as a Prospective Employer? Part II of the OeGD-Studisurvey.

The Public Health Service (PHS) in Germany has had difficulties in recruiting enough qualified staff for years, but there is limited research on what factors drive decisions to (not) join the PHS workforce. We explored reasons for this perceived (lack of) attractiveness. We conducted two cross-sectional surveys among medical students (MS), public health students and students from other PHS-relevant fields (PH&ONM) in Germany before (2019/2020) and during the COVID-19 pandemic (2021). Both waves surveyed self-reported reasons for why students did (not) consider working in the PHS as attractive and how this could be improved, using open-question items. Qualitative and quantitative content analyses were conducted according to Mayring. In total, 948 MS and 445 PH&ONM provided valid written responses. Reasons for considering the PHS as attractive were, among others, the perception of a good work-life balance, high impact, population health focus, and generally interesting occupations. Suggestions to increase attractiveness included reducing bureaucracy, modernization/digitalization, and more acknowledgement of non-medical professionals. Among MS, reasons against were too little clinical/patient-related activities, low salary, and occupations regarded as boring. Our findings indicate areas for improvement for image, working conditions in, and institutional structures of the PHS in Germany to increase its attractiveness as an employer among young professionals.

What Factors Influence the Interest in Working in the Public Health Service in Germany? Part I of the OeGD-Studisurvey.

As in many European countries, the Public Health Service (PHS) in Germany has had considerable difficulties in attracting well-qualified personnel for decades. Despite ongoing political and societal debate, limited empirical research on possible causes and explanations is available. To identify areas of action, we explored reasons for the (lack of) interest in working in the PHS by conducting two cross-sectional surveys among 3019 medical students (MS), public health students, and students from other PHS-relevant fields (PH&ONM) in Germany right before (wave 1, 2019/2020) and during the COVID-19 pandemic (wave 2, 2021). While interest in working in the PHS among MS was low, it was considerably higher among PH&ONM. The prevalent underestimation of the importance of public health and low levels of knowledge about the PHS were identified as potential barriers. Although core activities of the PHS were often considered attractive, they were repeatedly not attributed to the PHS. A negative perception of the PHS (e.g., it being too bureaucratic) was prevalent among students with and without PHS interest, indicating that both a negative image and potentially structural deficits need to be overcome to increase attractiveness. Based on the findings, we propose approaches on how to sustainably attract and retain qualified personnel.

Searching two or more databases decreased the risk of missing relevant studies: a metaresearch study.

BACKGROUND AND OBJECTIVES: Assessing changes in coverage, recall, review, conclusions and references not found when searching fewer databases. METHODS: In randomly selected 60 Cochrane reviews, we checked included study publications' coverage (indexation) and recall (findability) using different search approaches with MEDLINE, Embase, and CENTRAL and related them to authors' conclusions and certainty. We assessed characteristics of unfound references. RESULTS: Overall 1989/2080 included references, were indexed in ≥1 database (coverage = 96%). In reviews where using one of our search approaches would not change conclusions and certainty (n = 44-54), median coverage and recall were highest (range 87.9%-100.0% and 78.2%-93.3%, respectively). Here, searching ≥2 databases reached >95% coverage and ≥87.9% recall. In reviews with unchanged conclusions but less certainty (n = 2-8): 63.3%-79.3% coverage and 45.0%-75.0% recall. In reviews with opposite conclusions (n = 1-3): 63.3%-96.6% and 52.1%-78.7%. In reviews where a conclusion was no longer possible (n = 3-7): 60.6%-86.0% and 20.0%-53.8%. The 265 references that were indexed but unfound were more often abstractless (30% vs. 11%) and older (28% vs. 17% published before 1991) than found references. CONCLUSION: Searching ≥2 databases improves coverage and recall and decreases the risk of missing eligible studies. If researchers suspect that relevant articles are difficult to find, supplementary search methods should be used.

Barriers and facilitators to implementation of direct fruit and vegetables provision interventions in kindergartens and schools: a qualitative systematic review applying the consolidated framework for implementation research (CFIR).

BACKGROUND: Although children's intake of fruit and vegetables has seen a recent rise, almost half of adolescents do not eat even one piece of fruit or vegetables per day. One way to address this problem is through interventions that provide fruit and vegetables directly to children in kindergartens and schools. For such interventions to meet their intended goals, what is important to consider in addition to impact is implementation. Our objective is to systematically review qualitative results reporting on the determinants (barriers and facilitators) to implementation of interventions that entail direct provision of fruit and vegetables in kindergarten and school settings and conduct a framework analysis of those results using the Consolidated Framework for Implementation Research (CFIR). METHODS: A systematic search was designed and run in November 2019 for: MEDLINE (Ovid), Embase (Ovid), PsychINFO (Ovid), ERIC (Ovid), Cochrane Library Reviews and Cochrane Library Trials. A keyword search of the journal Implementation Science was completed. Screening of titles and abstracts (n = 5427) and full texts (n = 227), led to 14 included articles. Coding and analysis were done using the framework method and CFIR. RESULTS: The following CFIR constructs were found relevant: 1) intervention characteristics domain: 'design quality and packaging', 'adaptability' 'cost'; 2) outer setting: 'cosmopolitanism', 'external policy and incentives' 'patients' needs and resources'; 3) inner setting: 'implementation climate', 'readiness for implementation' and 'structural characteristics'; 4) characteristics of individuals: 'individual stage of change', 'knowledge and beliefs about the intervention' 5) process: 'engaging', 'executing' and 'reflecting and evaluating'. The review stresses the dual role of parents as both supporting the implementation and targets of the intervention, which could have implications for the design and implementation of future fruit and vegetables interventions. Positive child perceptions of the value of the intervention and perceived behavior change due to the intervention were reported as relevant facilitators to implementation across several studies, and should be taken into consideration in future design efforts. CONCLUSIONS: CFIR offers a systematic way to identify and organize barriers and facilitators to implementation of interventions in the kindergarten and school setting. Revisions are encouraged to allow adequate space for perceptions of various implementation actors and the target group. PROSPERO REGISTRATION: CRD42020167697.

Measures implemented in the school setting to contain the COVID-19 pandemic

BACKGROUND: In response to the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the impact of coronavirus disease 2019 (COVID-19), governments have implemented a variety of measures to control the spread of the virus and the associated disease. Among these, have been measures to control the pandemic in primary and secondary school settings. OBJECTIVES: To assess the effectiveness of measures implemented in the school setting to safely reopen schools, or keep schools open, or both, during the COVID-19 pandemic, with particular focus on the different types of measures implemented in school settings and the outcomes used to measure their impacts on transmission-related outcomes, healthcare utilisation outcomes, other health outcomes as well as societal, economic, and ecological outcomes.  SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and the Educational Resources Information Center, as well as COVID-19-specific databases, including the Cochrane COVID-19 Study Register and the WHO COVID-19 Global literature on coronavirus disease (indexing preprints) on 9 December 2020. We conducted backward-citation searches with existing reviews. SELECTION CRITERIA: We considered experimental (i.e. randomised controlled trials; RCTs), quasi-experimental, observational and modelling studies assessing the effects of measures implemented in the school setting to safely reopen schools, or keep schools open, or both, during the COVID-19 pandemic. Outcome categories were (i) transmission-related outcomes (e.g. number or proportion of cases); (ii) healthcare utilisation outcomes (e.g. number or proportion of hospitalisations); (iii) other health outcomes (e.g. physical, social and mental health); and (iv) societal, economic and ecological outcomes (e.g. costs, human resources and education). We considered studies that included any population at risk of becoming infected with SARS-CoV-2 and/or developing COVID-19 disease including students, teachers, other school staff, or members of the wider community.  DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles, abstracts and full texts. One review author extracted data and critically appraised each study. One additional review author validated the extracted data. To critically appraise included studies, we used the ROBINS-I tool for quasi-experimental and observational studies, the QUADAS-2 tool for observational screening studies, and a bespoke tool for modelling studies. We synthesised findings narratively. Three review authors made an initial assessment of the certainty of evidence with GRADE, and several review authors discussed and agreed on the ratings. MAIN RESULTS: We included 38 unique studies in the analysis, comprising 33 modelling studies, three observational studies, one quasi-experimental and one experimental study with modelling components. Measures fell into four broad categories: (i) measures reducing the opportunity for contacts; (ii) measures making contacts safer; (iii) surveillance and response measures; and (iv) multicomponent measures. As comparators, we encountered the operation of schools with no measures in place, less intense measures in place, single versus multicomponent measures in place, or closure of schools. Across all intervention categories and all study designs, very low- to low-certainty evidence ratings limit our confidence in the findings. Concerns with the quality of modelling studies related to potentially inappropriate assumptions about the model structure and input parameters, and an inadequate assessment of model uncertainty. Concerns with risk of bias in observational studies related to deviations from intended interventions or missing data. Across all categories, few studies reported on implementation or described how measures were implemented. Where we describe effects as 'positive', the direction of the point estimate of the effect favours the intervention(s); 'negative' effects do not favour the intervention.  We found 23 modelling studies assessing measures reducing the opportunity for contacts (i.e. alternating attendance, reduced class size). Most of these studies assessed transmission and healthcare utilisation outcomes, and all of these studies showed a reduction in transmission (e.g. a reduction in the number or proportion of cases, reproduction number) and healthcare utilisation (i.e. fewer hospitalisations) and mixed or negative effects on societal, economic and ecological outcomes (i.e. fewer number of days spent in school). We identified 11 modelling studies and two observational studies assessing measures making contacts safer (i.e. mask wearing, cleaning, handwashing, ventilation). Five studies assessed the impact of combined measures to make contacts safer. They assessed transmission-related, healthcare utilisation, other health, and societal, economic and ecological outcomes. Most of these studies showed a reduction in transmission, and a reduction in hospitalisations; however, studies showed mixed or negative effects on societal, economic and ecological outcomes (i.e. fewer number of days spent in school). We identified 13 modelling studies and one observational study assessing surveillance and response measures, including testing and isolation, and symptomatic screening and isolation. Twelve studies focused on mass testing and isolation measures, while two looked specifically at symptom-based screening and isolation. Outcomes included transmission, healthcare utilisation, other health, and societal, economic and ecological outcomes. Most of these studies showed effects in favour of the intervention in terms of reductions in transmission and hospitalisations, however some showed mixed or negative effects on societal, economic and ecological outcomes (e.g. fewer number of days spent in school). We found three studies that reported outcomes relating to multicomponent measures, where it was not possible to disaggregate the effects of each individual intervention, including one modelling, one observational and one quasi-experimental study. These studies employed interventions, such as physical distancing, modification of school activities, testing, and exemption of high-risk students, using measures such as hand hygiene and mask wearing. Most of these studies showed a reduction in transmission, however some showed mixed or no effects.   As the majority of studies included in the review were modelling studies, there was a lack of empirical, real-world data, which meant that there were very little data on the actual implementation of interventions. AUTHORS' CONCLUSIONS: Our review suggests that a broad range of measures implemented in the school setting can have positive impacts on the transmission of SARS-CoV-2, and on healthcare utilisation outcomes related to COVID-19. The certainty of the evidence for most intervention-outcome combinations is very low, and the true effects of these measures are likely to be substantially different from those reported here. Measures implemented in the school setting may limit the number or proportion of cases and deaths, and may delay the progression of the pandemic. However, they may also lead to negative unintended consequences, such as fewer days spent in school (beyond those intended by the intervention). Further, most studies assessed the effects of a combination of interventions, which could not be disentangled to estimate their specific effects. Studies assessing measures to reduce contacts and to make contacts safer consistently predicted positive effects on transmission and healthcare utilisation, but may reduce the number of days students spent at school. Studies assessing surveillance and response measures predicted reductions in hospitalisations and school days missed due to infection or quarantine, however, there was mixed evidence on resources needed for surveillance. Evidence on multicomponent measures was mixed, mostly due to comparators. The magnitude of effects depends on multiple factors. New studies published since the original search date might heavily influence the overall conclusions and interpretation of findings for this review.

Advancing the WHO-INTEGRATE Framework as a Tool for Evidence-Informed, Deliberative Decision-Making Processes: Exploring the Views of Developers and Users of WHO Guidelines.

BACKGROUND: Decision-making on matters of public health and health policy is a deeply value-laden process. The World Health Organization (WHO)-INTEGRATE framework was proposed as a new evidence-to-decision (EtD) framework to support guideline development from a complexity perspective, notably in relation to public health and health system interventions, and with a foundation in WHO norms and values. This study was conducted as part of the development of the framework to assess its comprehensiveness and usefulness for public health and health policy decision-making. METHODS: We conducted a qualitative study comprising nine key informant interviews (KIIs) with experts involved in WHO guideline development and four focus group discussions (FGDs) with a total of forty health decision-makers from Brazil, Germany, Nepal and Uganda. Transcripts were analyzed using MAXQDA12 and qualitative content analysis. RESULTS: Most key informants and participants in the FGDs appreciated the framework for its relevance to real-world decision-making on four widely differing health topics. They praised its broad perspective and comprehensiveness with respect to new or expanded criteria, notably regarding societal implications, equity considerations, and acceptability. Some guideline developers questioned the value of the framework beyond current practice and were concerned with the complexity of applying such a broad range of criteria in guideline development processes. Participants made concrete suggestions for improving the wording and definitions of criteria as well as their grouping, for covering missing aspects, and for addressing overlap between criteria. CONCLUSION: The framework was well-received by health decision-makers as well as the developers of WHO guidelines and appears to capture all relevant considerations discussed in four distinct real-world decision processes that took place on four different continents. Guidance is needed on how to apply the framework in guideline processes that are both transparent and participatory. A set of suggestions for improvement provides a valuable starting point for advancing the framework towards version 2.0.

Dissemination of Evidence by Cochrane Public Health Europe in German-Speaking Countries: An Online Stakeholder Survey.

Objectives: To investigate the reach and impact of "Infomails", email summaries of Cochrane reviews in German, regularly disseminated by Cochrane Public Health Europe (CPHE) to stakeholders in Austria, Germany and Switzerland. Methods: We analysed email campaign reports from 15 Infomails delivered until November 2020. Furthermore, we invited all previous Infomail recipients to participate in an online survey on the impact and perceptions regarding our Infomails in November 2020. We analysed the results using descriptive statistics. Results: The Infomails' open rate ranged from 10.9% to 39.3% (median 26.0%), and the median click rate on the embedded links was 28.0% (range 8.6-53.8%), highest for nutrition and prevention topics. Out of 1259 recipients, 267 (21.2%) completed our survey. Infomails were most used in discussions, writing reports or statements, for policy or strategy development or programme or guideline development. Persons who remembered receiving Infomails rated them as useful, comprehensible or informative. Conclusion: Infomails summarising recent Cochrane reviews were considered useful for the daily work of public health stakeholders in German-speaking countries. Regular targeted messaging may increase the perceived usefulness.

Nutrition policies in Germany: a systematic assessment with the Food Environment Policy Index.

OBJECTIVE: To systematically assess Germany's nutrition policies, to benchmark them against international best practices and to identify priority policy actions to improve population-level nutrition in Germany. DESIGN: We applied the Food Environment Policy Index (Food-EPI), a methodological framework developed by the International Network for Food and Obesity/non-communicable Diseases Research, Monitoring and Action Support (INFORMAS) network. Qualitative content analysis of laws, directives and other documents formed the basis of a multistaged, structured consultation process. SETTING: Germany. PARTICIPANTS: The expert consultation process included fifty-five experts from academia, public administration and civil society. RESULTS: Germany lags behind international best practices in several key policy areas. For eighteen policy indicators, the degree of implementation compared with international best practices was rated as very low, for twenty-one as low, for eight as intermediate and for none as high. In particular, indicators on food taxation, regulation of food marketing as well as retail and food service sector policies were rated as very low to low. Identified priority actions included the binding implementation of nutrition standards for schools and kindergartens, a reform of the value added tax on foods and beverages, a sugar-sweetened beverage tax and stricter regulation of food marketing directed at children. CONCLUSIONS: The results show that Germany makes insufficient use of the potential of evidence-informed health-promoting nutrition policies. Adopting international best practices in key policy areas could help to reduce the burden of nutrition-related chronic disease and related inequalities in nutrition and health in Germany. Implementation of relevant policies requires political leadership, a broad societal dialogue and evidence-informed advocacy by civil society, including the scientific community.

Non-pharmacological measures implemented in the setting of long-term care facilities to prevent SARS-CoV-2 infections and their consequences: a rapid review.

BACKGROUND: Starting in late 2019, COVID-19, caused by the novel coronavirus SARS-CoV-2, spread around the world. Long-term care facilities are at particularly high risk of outbreaks, and the burden of morbidity and mortality is very high among residents living in these facilities. OBJECTIVES: To assess the effects of non-pharmacological measures implemented in long-term care facilities to prevent or reduce the transmission of SARS-CoV-2 infection among residents, staff, and visitors. SEARCH METHODS: On 22 January 2021, we searched the Cochrane COVID-19 Study Register, WHO COVID-19 Global literature on coronavirus disease, Web of Science, and CINAHL. We also conducted backward citation searches of existing reviews. SELECTION CRITERIA: We considered experimental, quasi-experimental, observational and modelling studies that assessed the effects of the measures implemented in long-term care facilities to protect residents and staff against SARS-CoV-2 infection. Primary outcomes were infections, hospitalisations and deaths due to COVID-19, contaminations of and outbreaks in long-term care facilities, and adverse health effects. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles, abstracts and full texts. One review author performed data extractions, risk of bias assessments and quality appraisals, and at least one other author checked their accuracy. Risk of bias and quality assessments were conducted using the ROBINS-I tool for cohort and interrupted-time-series studies, the Joanna Briggs Institute (JBI) checklist for case-control studies, and a bespoke tool for modelling studies. We synthesised findings narratively, focusing on the direction of effect. One review author assessed certainty of evidence with GRADE, with the author team critically discussing the ratings. MAIN RESULTS: We included 11 observational studies and 11 modelling studies in the analysis. All studies were conducted in high-income countries. Most studies compared outcomes in long-term care facilities that implemented the measures with predicted or observed control scenarios without the measure (but often with baseline infection control measures also in place). Several modelling studies assessed additional comparator scenarios, such as comparing higher with lower rates of testing. There were serious concerns regarding risk of bias in almost all observational studies and major or critical concerns regarding the quality of many modelling studies. Most observational studies did not adequately control for confounding. Many modelling studies used inappropriate assumptions about the structure and input parameters of the models, and failed to adequately assess uncertainty. Overall, we identified five intervention domains, each including a number of specific measures. Entry regulation measures (4 observational studies; 4 modelling studies) Self-confinement of staff with residents may reduce the number of infections, probability of facility contamination, and number of deaths. Quarantine for new admissions may reduce the number of infections. Testing of new admissions and intensified testing of residents and of staff after holidays may reduce the number of infections, but the evidence is very uncertain. The evidence is very uncertain regarding whether restricting admissions of new residents reduces the number of infections, but the measure may reduce the probability of facility contamination. Visiting restrictions may reduce the number of infections and deaths. Furthermore, it may increase the probability of facility contamination, but the evidence is very uncertain. It is very uncertain how visiting restrictions may adversely affect the mental health of residents. Contact-regulating and transmission-reducing measures (6 observational studies; 2 modelling studies) Barrier nursing may increase the number of infections and the probability of outbreaks, but the evidence is very uncertain. Multicomponent cleaning and environmental hygiene measures may reduce the number of infections, but the evidence is very uncertain. It is unclear how contact reduction measures affect the probability of outbreaks. These measures may reduce the number of infections, but the evidence is very uncertain. Personal hygiene measures may reduce the probability of outbreaks, but the evidence is very uncertain.  Mask and personal protective equipment usage may reduce the number of infections, the probability of outbreaks, and the number of deaths, but the evidence is very uncertain. Cohorting residents and staff may reduce the number of infections, although evidence is very uncertain. Multicomponent contact -regulating and transmission -reducing measures may reduce the probability of outbreaks, but the evidence is very uncertain. Surveillance measures (2 observational studies; 6 modelling studies) Routine testing of residents and staff independent of symptoms may reduce the number of infections. It may reduce the probability of outbreaks, but the evidence is very uncertain. Evidence from one observational study suggests that the measure may reduce, while the evidence from one modelling study suggests that it probably reduces hospitalisations. The measure may reduce the number of deaths among residents, but the evidence on deaths among staff is unclear.  Symptom-based surveillance testing may reduce the number of infections and the probability of outbreaks, but the evidence is very uncertain. Outbreak control measures (4 observational studies; 3 modelling studies) Separating infected and non-infected residents or staff caring for them may reduce the number of infections. The measure may reduce the probability of outbreaks and may reduce the number of deaths, but the evidence for the latter is very uncertain. Isolation of cases may reduce the number of infections and the probability of outbreaks, but the evidence is very uncertain. Multicomponent measures (2 observational studies; 1 modelling study) A combination of multiple infection-control measures, including various combinations of the above categories, may reduce the number of infections and may reduce the number of deaths, but the evidence for the latter is very uncertain. AUTHORS' CONCLUSIONS: This review provides a comprehensive framework and synthesis of a range of non-pharmacological measures implemented in long-term care facilities. These may prevent SARS-CoV-2 infections and their consequences. However, the certainty of evidence is predominantly low to very low, due to the limited availability of evidence and the design and quality of available studies. Therefore, true effects may be substantially different from those reported here. Overall, more studies producing stronger evidence on the effects of non-pharmacological measures are needed, especially in low- and middle-income countries and on possible unintended consequences of these measures. Future research should explore the reasons behind the paucity of evidence to guide pandemic research priority setting in the future.

[COVID-19 and Its Potential for Disruption and Transformation in Public Health: Lessons Learned from the Perspective of Young Professionals]. / COVID-19 zwischen Disruption und Transformation der öffentlichen Gesundheit: Erste Lehren aus Perspektive des Nachwuchses.

The COVID-19 pandemic has both exposed and intensified various challenges for Public Health and the Public Health service (ÖGD) in Germany. However, it also offers a window of opportunity for effective long-term transformation of the country's Public Health system. Against this backdrop, an online survey was carried out among the members of the German Network of Young Professionals in Public Health (Nachwuchsnetzwerk Öffentliche Gesundheit (NÖG)) in October and November 2020. It sought to elicit members' experiences and views related to Public Health during the COVID-19 pandemic. The resulting preliminary "lessons learned" for the German Public Health context are presented in this article. Based on the results of the survey, recommendations were formulated which are intended to provide targeted and concrete advice for the strengthening and transformation of Public Health in Germany. The main issues that preoccupied the young professionals were the increased public and political attention to Public Health and the narrow focus on infectious disease control, the standing of Public Health in Germany and the strengths and weaknesses of Public Health structures and workforce. The recommendations are aimed at promoting long-term and holistic strengthening of Public Health, with the training of an interdisciplinary workforce of young professionals presenting a key focus.

[Expert committees in German public health policymaking during the SARS-CoV-2 pandemic: a document analysis]. / Politikberatung durch Expert*innenräte in der SARS-CoV-2-Pandemie in Deutschland: Eine Dokumentenanalyse aus Public-Health-Perspektive.

INTRODUCTION: During the SARS-CoV-2 pandemic, policymakers have to make far-reaching decisions that should be supported by scientific evidence. This presents a major challenge, given the limited availability of evidence, especially in the early phases of the pandemic. Decision-makers thus turned to scientific experts to help to convey and contextualize the evidence for public health policymaking. The way in which these experts were consulted varied widely. Some decision-makers called on expert committees in which they convened multiple experts from different disciplines. However, the composition and role of these committees have raised questions of transparency and representation. This study examines whether and how expert committees in Germany were convened at the federal and national level to advise governments and ministries during the SARS-CoV-2 pandemic. We investigated the disciplinary composition, gender representation and the transparency related to the convening of these bodies, work processes and the accessibility of results. METHODS: We performed a multi-stage document analysis. Between May and July 2020, we submitted freedom-of-information requests to the governmental institutions at both a federal and a national level. In addition to analysing the responses to these requests, we conducted a thorough search and analysis of the i) pandemic preparedness plans, (ii) official press releases and (iii) minor interpellations ("Kleine Anfragen") at the federal and state level. We included documents on expert committees in the SARS-CoV-2 context for the period from January to the beginning of December 2020 and carried out a qualitative content analysis. RESULTS: We identified a total of 21 expert committees that were established in ten federal states and four federal ministries. In eleven committees, the members were known by name, with women making up 26 % of the members. Biomedical disciplines such as virology, hygiene, medicine, and biology were the most commonly represented. Other disciplines including economics, law and sociology, and non-scientific experts were represented in seven federal states. The members of ten committees were not known by name. These committees covered different thematic areas (school and day-care, civil participation, medicine and care, economic topics), and their members were more commonly practitioners or came from affected populations. DISCUSSION: The SARS-CoV-2 pandemic has led to an increased consultation of experts in public health policymaking. However, expert committees in Germany are not sufficiently representative and interdisciplinary to take different perspectives into account and ultimately advise politicians in complex pandemic situations. Furthermore, the work of these committees is not sufficiently transparent because access to information is limited. CONCLUSION: Due to this lack of transparency, it is unclear whether and how the expert committees exerted an influence on politics. Transparency of political decision-making processes and the consideration of pluralistic perspectives are considered essential for the legitimation and quality of political decisions in a pandemic and should therefore be strengthened in pandemic management in Germany.

Unintended health and societal consequences of international travel measures during the COVID-19 pandemic: a scoping review.

BACKGROUND/OBJECTIVE: International travel measures to contain the coronavirus disease of 2019 (COVID-19) pandemic represent a relatively intrusive form of non-pharmaceutical intervention. To inform decision-making on the (re)implementation, adaptation, relaxation or suspension of such measures, it is essential to not only assess their effectiveness but also their unintended effects. METHODS: This scoping review maps existing empirical studies on the unintended consequences, both predicted and unforeseen, and beneficial or harmful, of international travel measures. We searched multiple health, non-health and COVID-19-specific databases. The evidence was charted in a map in relation to the study design, intervention and outcome categories identified and discussed narratively. RESULTS: Twenty-three studies met our inclusion criteria-nine quasi-experimental, two observational, two mathematical modelling, six qualitative and four mixed-methods studies. Studies addressed different population groups across various countries worldwide. Seven studies provided information on unintended consequences of the closure of national borders, six looked at international travel restrictions and three investigated mandatory quarantine of international travellers. No studies looked at entry and/or exit screening at national borders exclusively, however six studies considered this intervention in combination with other international travel measures. In total, 11 studies assessed various combinations of the aforementioned interventions. The outcomes were mostly referred to by the authors as harmful. Fifteen studies identified a variety of economic consequences, six reported on aspects related to quality of life, well-being, and mental health and five on social consequences. One study each provided information on equity, equality, and the fair distribution of benefits and burdens, environmental consequences and health system consequences. CONCLUSION: This scoping review represents the first step towards a systematic assessment of the unintended benefits and harms of international travel measures during COVID-19. The key research gaps identified might be filled with targeted primary research, as well as the additional consideration of gray literature and non-empirical studies.

SARS-Cov-2 prevalence, transmission, health-related outcomes and control strategies in homeless shelters: Systematic review and meta-analysis.

BACKGROUND: People experiencing homelessness (PEH) may be at risk for COVID19. We synthesised evidence on SARS-Cov-2 infection, transmission, outcomes of disease, effects of non-pharmaceutical interventions (NPI), and the effectiveness of strategies for infection prevention and control (IPC). METHODS: Systematic review of articles, indexed in electronic databases (EMBASE, WHO-Covid19, Web of Science), institutional websites and the Norwegian Institute of Public Health's live map of COVID-19 evidence, and published from December 1st, 2019, to March 3rd, 2021. Empirical papers of any study design addressing Covid-19 and health(-related) outcomes in PEH or shelters' staff were included. (PROSPERO-2020-CRD42020187033). FINDINGS: Of 536 publications, 37 studies were included (two modelling, 31 observational, four qualitative studies). Random-effect meta-analysis yields a baseline SARS-Cov-2 prevalence of 2•32% (95% Confidence-Interval, 95%CI=1•30-3•34) in PEH and 1•55% (95%CI=0•79-2•31) in staff. In outbreaks, the pooled prevalence increases to 31•59% (95%CI=20•48-42•71) in PEH and 14•80% (95%CI=10•73-18•87) in staff. Main IPC strategies were universal rapid testing, expansion of non-congregate housing, and in-shelter measures (bed spacing, limited staff rotation, reduction in number of residents). INTERPRETATION: 32% of PEH and 15% staff are infected during outbreaks of SARS-Cov-2 in homeless shelters. Most studies were conducted in the USA. No studies were found quantifying health-related outcomes of NPI. Overview and evaluation of IPC strategies for PEH, a better understanding of disease transmission, and reliable data on PEH within Covid-19 notification systems are needed. Qualitative studies may serve to voice PEH and shelter staff experiences, and guide future evaluations and IPC strategies. FUNDING: None.

Travel-related control measures to contain the COVID-19 pandemic: an evidence map.

OBJECTIVES: To comprehensively map the existing evidence assessing the impact of travel-related control measures for containment of the SARS-CoV-2/COVID-19 pandemic. DESIGN: Rapid evidence map. DATA SOURCES: MEDLINE, Embase and Web of Science, and COVID-19 specific databases offered by the US Centers for Disease Control and Prevention and the WHO. ELIGIBILITY CRITERIA: We included studies in human populations susceptible to SARS-CoV-2/COVID-19, SARS-CoV-1/severe acute respiratory syndrome, Middle East respiratory syndrome coronavirus/Middle East respiratory syndrome or influenza. Interventions of interest were travel-related control measures affecting travel across national or subnational borders. Outcomes of interest included infectious disease, screening, other health, economic and social outcomes. We considered all empirical studies that quantitatively evaluate impact available in Armenian, English, French, German, Italian and Russian based on the team's language capacities. DATA EXTRACTION AND SYNTHESIS: We extracted data from included studies in a standardised manner and mapped them to a priori and (one) post hoc defined categories. RESULTS: We included 122 studies assessing travel-related control measures. These studies were undertaken across the globe, most in the Western Pacific region (n=71). A large proportion of studies focused on COVID-19 (n=59), but a number of studies also examined SARS, MERS and influenza. We identified studies on border closures (n=3), entry/exit screening (n=31), travel-related quarantine (n=6), travel bans (n=8) and travel restrictions (n=25). Many addressed a bundle of travel-related control measures (n=49). Most studies assessed infectious disease (n=98) and/or screening-related (n=25) outcomes; we found only limited evidence on economic and social outcomes. Studies applied numerous methods, both inferential and descriptive in nature, ranging from simple observational methods to complex modelling techniques. CONCLUSIONS: We identified a heterogeneous and complex evidence base on travel-related control measures. While this map is not sufficient to assess the effectiveness of different measures, it outlines aspects regarding interventions and outcomes, as well as study methodology and reporting that could inform future research and evidence synthesis.

[Strategy for a Risk-stratified Use of Rapid Antigen Testing: Containing the SARS-CoV-2 Pandemic by Integrating Rapid Testing into Case and Contact Tracing Management]. / Strategie zum risikostratifizierten Einsatz von Antigen-Schnelltests: Eindämmung der SARS-CoV-2-Pandemie durch die Integration von Schnelltests in das Fall- und Kontaktpersonenmanagement.

The use of rapid testing offers an opportunity to contain the SARS-CoV-2 pandemic; however, the impact of false-positive and false-negative test results and population response must be anticipated and taken into consideration to avoid or mitigate harm. Untargeted use of rapid testing is associated with high direct and indirect costs and will have limited impact on the pandemic if resources are used inefficiently. We suggest using a risk-stratified testing strategy, based on targeted testing directly integrated with the Public Health Service's case and contact tracing management. According to the proposed targeted testing strategy stratified by risk of infection, all persons with acute symptoms of a respiratory infection as well as other population groups with an elevated probability of being infected with SARS-CoV-2 infection should be specifically tested to identify "hidden" infection networks. The strategy should include a uniform communication strategy for dealing with positive and negative test results, a targeted expansion of access to low-threshold testing opportunities, ensuring timely and free access to the results of confirmatory tests, and integration into an overarching documentation system for evaluation. This integration of a risk-stratified targeted testing strategy into case and contact tracing management embedded in a comprehensive strategy can help to reduce infection rates in a resource-efficient and sustainable manner.

International travel-related control measures to contain the COVID-19 pandemic: a rapid review.

BACKGROUND: In late 2019, the first cases of coronavirus disease 2019 (COVID-19) were reported in Wuhan, China, followed by a worldwide spread. Numerous countries have implemented control measures related to international travel, including border closures, travel restrictions, screening at borders, and quarantine of travellers. OBJECTIVES: To assess the effectiveness of international travel-related control measures during the COVID-19 pandemic on infectious disease transmission and screening-related outcomes. SEARCH METHODS: We searched MEDLINE, Embase and COVID-19-specific databases, including the Cochrane COVID-19 Study Register and the WHO Global Database on COVID-19 Research to 13 November 2020. SELECTION CRITERIA: We considered experimental, quasi-experimental, observational and modelling studies assessing the effects of travel-related control measures affecting human travel across international borders during the COVID-19 pandemic. In the original review, we also considered evidence on severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). In this version we decided to focus on COVID-19 evidence only. Primary outcome categories were (i) cases avoided, (ii) cases detected, and (iii) a shift in epidemic development. Secondary outcomes were other infectious disease transmission outcomes, healthcare utilisation, resource requirements and adverse effects if identified in studies assessing at least one primary outcome. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts and subsequently full texts. For studies included in the analysis, one review author extracted data and appraised the study. At least one additional review author checked for correctness of data. To assess the risk of bias and quality of included studies, we used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool for observational studies concerned with screening, and a bespoke tool for modelling studies. We synthesised findings narratively. One review author assessed the certainty of evidence with GRADE, and several review authors discussed these GRADE judgements. MAIN RESULTS: Overall, we included 62 unique studies in the analysis; 49 were modelling studies and 13 were observational studies. Studies covered a variety of settings and levels of community transmission. Most studies compared travel-related control measures against a counterfactual scenario in which the measure was not implemented. However, some modelling studies described additional comparator scenarios, such as different levels of stringency of the measures (including relaxation of restrictions), or a combination of measures. Concerns with the quality of modelling studies related to potentially inappropriate assumptions about the structure and input parameters, and an inadequate assessment of model uncertainty. Concerns with risk of bias in observational studies related to the selection of travellers and the reference test, and unclear reporting of certain methodological aspects. Below we outline the results for each intervention category by illustrating the findings from selected outcomes. Travel restrictions reducing or stopping cross-border travel (31 modelling studies) The studies assessed cases avoided and shift in epidemic development. We found very low-certainty evidence for a reduction in COVID-19 cases in the community (13 studies) and cases exported or imported (9 studies). Most studies reported positive effects, with effect sizes varying widely; only a few studies showed no effect. There was very low-certainty evidence that cross-border travel controls can slow the spread of COVID-19. Most studies predicted positive effects, however, results from individual studies varied from a delay of less than one day to a delay of 85 days; very few studies predicted no effect of the measure. Screening at borders (13 modelling studies; 13 observational studies) Screening measures covered symptom/exposure-based screening or test-based screening (commonly specifying polymerase chain reaction (PCR) testing), or both, before departure or upon or within a few days of arrival. Studies assessed cases avoided, shift in epidemic development and cases detected. Studies generally predicted or observed some benefit from screening at borders, however these varied widely. For symptom/exposure-based screening, one modelling study reported that global implementation of screening measures would reduce the number of cases exported per day from another country by 82% (95% confidence interval (CI) 72% to 95%) (moderate-certainty evidence). Four modelling studies predicted delays in epidemic development, although there was wide variation in the results between the studies (very low-certainty evidence). Four modelling studies predicted that the proportion of cases detected would range from 1% to 53% (very low-certainty evidence). Nine observational studies observed the detected proportion to range from 0% to 100% (very low-certainty evidence), although all but one study observed this proportion to be less than 54%. For test-based screening, one modelling study provided very low-certainty evidence for the number of cases avoided. It reported that testing travellers reduced imported or exported cases as well as secondary cases. Five observational studies observed that the proportion of cases detected varied from 58% to 90% (very low-certainty evidence). Quarantine (12 modelling studies) The studies assessed cases avoided, shift in epidemic development and cases detected. All studies suggested some benefit of quarantine, however the magnitude of the effect ranged from small to large across the different outcomes (very low- to low-certainty evidence). Three modelling studies predicted that the reduction in the number of cases in the community ranged from 450 to over 64,000 fewer cases (very low-certainty evidence). The variation in effect was possibly related to the duration of quarantine and compliance. Quarantine and screening at borders (7 modelling studies; 4 observational studies) The studies assessed shift in epidemic development and cases detected. Most studies predicted positive effects for the combined measures with varying magnitudes (very low- to low-certainty evidence). Four observational studies observed that the proportion of cases detected for quarantine and screening at borders ranged from 68% to 92% (low-certainty evidence). The variation may depend on how the measures were combined, including the length of the quarantine period and days when the test was conducted in quarantine. AUTHORS' CONCLUSIONS: With much of the evidence derived from modelling studies, notably for travel restrictions reducing or stopping cross-border travel and quarantine of travellers, there is a lack of 'real-world' evidence. The certainty of the evidence for most travel-related control measures and outcomes is very low and the true effects are likely to be substantially different from those reported here. Broadly, travel restrictions may limit the spread of disease across national borders. Symptom/exposure-based screening measures at borders on their own are likely not effective; PCR testing at borders as a screening measure likely detects more cases than symptom/exposure-based screening at borders, although if performed only upon arrival this will likely also miss a meaningful proportion of cases. Quarantine, based on a sufficiently long quarantine period and high compliance is likely to largely avoid further transmission from travellers. Combining quarantine with PCR testing at borders will likely improve effectiveness. Many studies suggest that effects depend on factors, such as levels of community transmission, travel volumes and duration, other public health measures in place, and the exact specification and timing of the measure. Future research should be better reported, employ a range of designs beyond modelling and assess potential benefits and harms of the travel-related control measures from a societal perspective.