3.1 Non-Pharmaceutical Interventions

NPIs are actions that can be taken during a biological incident to slow the spread of disease. NPIs may be used as a stopgap measure to bridge the time between detection of the incident and the arrival of pharmaceuticals, or as the predominant intervention when pharmaceuticals to prevent/treat the disease do not currently exist.

3.1.1 Types of Non-Pharmaceutical Interventions

Public health authorities will determine when and which type of NPI measures should be implemented. Depending on the nature of the biological incident, controlling the spread of a pathogen may require personal, community, and/or environmental NPIs.⁴⁴

• Personal NPIs: Protective actions that can help individuals avoid exposure to pathogens, such as handwashing, covering of the mouth and nose when coughing and/or sneezing, wearing facemasks/face coverings, and voluntary home isolation for those with confirmed illness or quarantine for those who were exposed but are not yet ill.⁴⁵ In general, the use of these measures community-wide is recommended only during biological incidents involving contagious diseases that are of sufficiently large scale and scope. For vector-borne diseases, avoidance of vector habitat areas during peak vector activity times⁴⁶ can reduce exposure to vectors and lower the risk of disease transmission.
• Community NPIs: Strategies and policies that communities and organizations can implement to minimize the risk of an outbreak negatively impacting Community Lifelines. Most commonly, workplace and public/community environments, procedures, and policies are modified to prevent spread of disease in settings in which close human contact may be necessary. Modifications may include temperature and/or sign/symptom checks, limiting in-person capacities, and facility closures. Protective measures can be supported through:
  • Encouraging staff and public compliance with personal NPIs
  • Eliminating nonessential travel
  • Limiting workplace interactions by implementing telecommuting policies and developing staggered work schedules when feasible
  • Educating the community about proper PPE use⁴⁷
• Environmental NPIs: Engineering controls can be implemented in indoor or outdoor settings to protect community members from exposure. In a workplace setting, engineering controls protect workers from biological hazards by mitigating hazardous conditions and/or by isolating or separating workers in ways that will not interfere with productivity.⁴⁸ Examples of engineering controls include increasing air exchange and surface sanitization in addition to high-efficiency air filters; physical barriers such as clear plastic sneeze guards; ultraviolet lighting; drive-through windows for customer service; and specialized negative pressure ventilation in areas where aerosol generation is likely (e.g., airborne infection isolation rooms in healthcare settings, specialized autopsy suites in mortuary settings).⁴⁹ Environmental NPIs also include routine surface cleaning of frequently touched surfaces and objects, especially in childcare facilities, schools, workplaces, etc.

3.1.2 Repercussions and Challenges of Non-Pharmaceutical Interventions

While intended to support lifesaving measures in the context of biological incidents, the implementation of NPIs also can have serious repercussions on the community in both the short and long term. For example, school closures can have educational, developmental, behavioral/social, and other health and well-being impacts on children. Isolation, quarantine, and social distancing requirements can have adverse impacts on the mental health of the affected population, who may experience stress and anxiety (see KPF 4: Augment Provision of Mass Care and Human Services to the Affected Population, for further discussion of mental health needs). The transition of schools and businesses to a virtual environment may limit their operations, and the need for reliable broadband internet may preclude rural or poor communities from participating. Limited customer capacities or facility closures will cause financial hardships for businesses and have cascading impacts to employee and customer livelihoods. Travel restrictions (domestic and international), embargos, business restrictions and closures, and cancelation of mass gatherings/events can create further economic hardships for communities and local business owners.

With community buy-in, many personal and community NPIs are relatively easy to implement; however, for the reasons stated above and others, local authorities may experience strong opposition to widespread adherence to NPIs. Achieving widespread and persistent implementation of face mask use and voluntary home isolation can prove difficult, especially if access to supplies of face masks is limited; at-home isolation is difficult to enforce when called for. In fact, community-wide compliance with prophylactic regimens and isolation/quarantine restrictions has been problematic in biological incidents prior to COVID-19.⁵⁰ As demonstrated during the COVID-19 pandemic, isolation, quarantine, and stay-at-home orders can create feelings of frustration and anxiety due to the loss of routine and social interaction.⁵¹ These public health strategies, while effective, can also increase risk to persons already experiencing interpersonal violence at home.⁵²

The implementation of NPIs such as travel restrictions, school closures, and mandatory home isolation orders can also create ethical and legal concerns. For example, contact tracing combined with home quarantine may raise concerns regarding violations of privacy, equity, and freedom of movement, and infected individuals could become stigmatized. Similarly, school and other facility closures can disproportionately affect low-income families, including those experiencing homelessness, those relying on state or local food programs, people with disabilities, indigenous peoples, and other vulnerable populations.⁵³ Planners and local authorities will need to balance information on biological incident severity, spread, affected populations, and local response goals with a critical examination of the potential adverse effects of NPI measures.