After-action review of the Finnish advice-making process for school interventions during the COVID-19 pandemic

Assessment
Cite:

European Centre for Disease Prevention and Control. After-action review of the Finnish advice-making process for school interventions during the COVID-19 pandemic. Stockholm: ECDC; 2024.

This focused after-action review (AAR), conducted by ECDC in collaboration with the Finnish Institute for Health and Welfare (THL), investigated the use of evidence in the Finnish advice-making process for school interventions from December 2021 to January 2022, when the SARS-CoV-2 Omicron variant was circulating and schools remained open.

Executive summary

Background

From March to May 2021, the SARS-CoV-2 Alpha variant was circulating, and school closures were implemented in some areas for children over 12 years old. The Omicron variant reintroduced consideration of the policy option of closing schools for physical attendance at the beginning of 2022.

The purpose of this AAR was to shed light on the advice-making processes during these vital weeks, when varying perspectives on school interventions were considered, by asking the question: How did the different key actors use evidence to inform advice on school interventions during these periods?

Methods

The core methodology of this focused AAR was a process-driven learning exercise that built on a qualitative review of a delimitated case: the advice-making process for school interventions during the beginning of the Omicron wave (December 2021 to January 2022). Data were gathered through a two-day workshop with key stakeholders identified by THL, alongside semi-structured online interviews conducted separately from the workshop. Stakeholders that participated in the workshop included employees from THL, the Ministry of Education and Culture (OKM), the City of Helsinki, and the Hospital District of Helsinki and Uusimaa (HUS), as well as representatives from the Regional Coordination Groups (RGCs). Representatives from the Ministry of Social Affairs and Health (STM) and the Trade Union of Education (OAJ) were interviewed, as they were not able to attend the workshop. Primary and secondary documents (e.g. international reports, peer-reviewed articles, risk assessments, etc.) were used to facilitate the workshop, as well as to triangulate the qualitative findings obtained within the country.

Results

Although school closures were implemented during the two national states of emergency (16 March to 16 June 2020 and March to May 2021), THL was critical of school closures from the summer of 2020. Prior to the Omicron wave in late 2021, THL’s position on nationwide mandatory school closures was that they constituted an ineffective non-pharmaceutical intervention (NPI) for two reasons:

  • they were not needed to protect children against the virus;
  • they did not have any demonstrable impact on the spread of the virus.

Despite introducing new uncertainties to the advice-making process, the Omicron wave did not challenge this basic position. THL based its advice on several types of evidence that were mainly epidemiological in nature:

  • experience-based evidence from Norway and Denmark, which suggested high transmissibility but less severe symptoms (the Omicron wave occurred later in Finland);
  • daily information from the centralised paediatric units in Finland, which reported few hospitalised patients from the outbreak;
  • daily and disaggregated epidemiological data that suggested that schools were usually not hotspots for transmission; and
  • extensive experience from the previous school closure during the Alpha variant wave, where THL evaluations suggested that they were largely ineffective in reducing transmission.

THL did not systematically gather data on adverse effects of school closures (e.g. negative impacts on mental health, well-being, physical health, learning and learning gaps, domestic abuse/violence, increased inequity) because THL found school closures to be inadvisable from a purely epidemiological perspective.

However, other stakeholders had suggested school closures after the winter break in 2022, most notably the STM, the OAJ and some infectious disease experts that had national visibility in the media. For some weeks in December and January, there was discussion between THL and the STM about whether school closures were necessary to contain the Omicron wave. Part of the need for deliberation can be explained by different points of departure: where the THL focused solely on epidemiologically informed public health perspectives, the STM had multiple additional concerns, including uncertainties around the development of the Omicron epidemic, the rights of children and teachers to be protected against illness and issues related to constitutional rights and legal compliance. Suboptimal communication between the advice-making bodies also contributed to this disagreement. Ultimately, the government decided to keep schools open at the national level during the Omicron wave. This aligned with the recommendations from most of the key advice-making bodies at regional and national levels, such as RCGs, THL and the OKM.

Conclusions

Participants in the AAR process identified several lessons learned and examples of good practice from the Finnish experience with advice-making on school interventions during the Omicron wave. These included the following:

  • Access to regularly updated national epidemiological data was considered key in advice-making. Cross-sectoral and interdisciplinary collaborations, particularly with the regions and the OKM, were integral to the advice-making process.
  • From an organisational perspective, having institutionalised processes in place for dealing with external requests was considered good practice. This alleviated some of the pressures and uncertainties for key infectious disease experts, allowing them to engage more proactively in the advice-making process.
  • Integrating behavioural science and communications considerations into the advice-making process from the beginning was considered good practice.
  • A multifaceted crisis communication strategy where crisis communication specialists have the resources to engage on many different platforms and levels was emphasised as good practice.
  • The establishment and operation of RCGs should be continued as a good practice for related public health challenges, perhaps with some flexibility to include other types of expertise when needed.

Lessons learned from suboptimal processes and practices were also compiled to improve the advice-making processes for future health emergencies. These included:

  • THL and the STM had overlapping areas of authority and a perceived lack of transparency, both in the advice-making process and with respect to the evidence that recommended interventions were based on.
  • It was not always clear what THL’s role was in terms of making recommendations for pandemic response. THL was to collect and analyse data as well as give scientific advice, whereas the government could make decisions based on not just the epidemiological data, but also wider societal and legal perspectives.
  • Good practice would include making epidemiological evidence and other factors used in the advice- and decision-making processes explicit and subject to scrutiny. Similarly, the rationale underlying a decision should be made explicit together with a clear articulation of when the objective of the decision has been reached.
  • Clear procedures for how and when crisis measures should be scaled down and ended – not just legally or organisationally, but also in managerial practices – were highlighted as good practice. It was deemed important to return to more standard management procedures characterised by less urgency and more reliance on empirically proven or evidence-informed advice as soon as possible.
  • As it is very difficult to adjust pandemic preparedness capacity up and down according to short-term needs, effective pandemic preparedness and response requires long-term investments. These include continued training, improved disease surveillance, regularly updating pandemic plans, and regularly conducting interdisciplinary evaluations of crisis management processes and interventions to prepare for future public health crises.