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Inquiry Public health measures for covid-19Effectiveness of public health measures in reducing the incidence of covid-19, SARS-CoV-2 transmission, and covid-xix mortality: systematic review and meta-analysis
BMJ 2021; 375 doi: https://doi.org/10.1136/bmj-2021-068302 (Published eighteen November 2021) Cite this as: BMJ 2021;375:e068302 Linked Editorial
- Stella Talic , lecturer in clinical epidemiology and public health12,
- Shivangi Shah , honours studentane,
- Holly Wild , lecturer and honours studentthirteen,
- Danijela Gasevic , senior lecturer in epidemiology and chronic disease prevention14,
- Ashika Maharaj , lecturer quality and safety and cancer epidemiology1,
- Zanfina Ademi , acquaintance professor of medical outcomes and health economics12,
- Xue Li , assistant professor46,
- Wei Xu , research studentiv,
- Ines Mesa-Eguiagaray , statistical geneticist4,
- Jasmin Rostron , research studentfour,
- Evropi Theodoratou , professor of cancer epidemiology and global health45,
- Xiaomeng Zhang , research student4,
- Ashmika Motee , research student4,
- Danny Liew , professor of medical outcomes and wellness economic science12,
- Dragan Ilic , professor of medical education and public healthane
- 1School of Public Health and Preventive Medicine, Monash University, Melbourne, 3004 VIC, Australia
- 2Monash Outcomes Enquiry and health Economics (More than) Unit, Monash University, VIC, Australia
- 3Torrens University, VIC, Australia
- 4Heart for Global Health, The Usher Institute, University of Edinburgh, Edinburgh, U.k.
- 5Cancer Research UK Edinburgh Centre, MRC Institute of Genetics and Molecular Medicine, Academy of Edinburgh, Edinburgh, UK
- half dozenSchool of Public Health and The Second Affiliated Infirmary, Zhejiang University School of Medicine, Hangzhou, Communist china
- Correspondence to: S Talic stella.talic{at}monash.edu
- Accustomed 21 October 2021
Abstruse
Objective To review the bear witness on the effectiveness of public health measures in reducing the incidence of covid-19, SARS-CoV-2 transmission, and covid-19 mortality.
Design Systematic review and meta-analysis.
Data sources Medline, Embase, CINAHL, Biosis, Joanna Briggs, Global Health, and World Health Arrangement COVID-19 database (preprints).
Eligibility criteria for study selection Observational and interventional studies that assessed the effectiveness of public wellness measures in reducing the incidence of covid-19, SARS-CoV-2 manual, and covid-19 mortality.
Main outcome measures The main consequence measure was incidence of covid-19. Secondary outcomes included SARS-CoV-2 transmission and covid-19 mortality.
Information synthesis DerSimonian Laird random effects meta-analysis was performed to investigate the outcome of mask wearing, handwashing, and physical distancing measures on incidence of covid-xix. Pooled effect estimates with respective 95% confidence intervals were computed, and heterogeneity amidst studies was assessed using Cochran's Q test and the I2 metrics, with ii tailed P values.
Results 72 studies met the inclusion criteria, of which 35 evaluated individual public wellness measures and 37 assessed multiple public health measures equally a "package of interventions." 8 of 35 studies were included in the meta-analysis, which indicated a reduction in incidence of covid-19 associated with handwashing (relative risk 0.47, 95% confidence interval 0.nineteen to i.12, I2=12%), mask wearing (0.47, 0.29 to 0.75, Iii=84%), and physical distancing (0.75, 0.59 to 0.95, I2=87%). Owing to heterogeneity of the studies, meta-assay was not possible for the outcomes of quarantine and isolation, universal lockdowns, and closures of borders, schools, and workplaces. The effects of these interventions were synthesised descriptively.
Conclusions This systematic review and meta-assay suggests that several personal protective and social measures, including handwashing, mask wearing, and physical distancing are associated with reductions in the incidence covid-19. Public wellness efforts to implement public health measures should consider community wellness and sociocultural needs, and futurity research is needed to better empathize the effectiveness of public health measures in the context of covid-nineteen vaccination.
Systematic review registration PROSPERO CRD42020178692.
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Introduction
The impact of SARS-CoV-2 on global public health and economies has been profound.1 As of fourteen October 2021, there were 239 007 759 million cases of confirmed covid-19 and 4 871 841 million deaths with covid-19 worldwide.2
A variety of containment and mitigation strategies have been adopted to adequately respond to covid-xix, with the intention of deferring major surges of patients in hospitals and protecting the almost vulnerable people from infection, including elderly people and those with comorbidities.iii Strategies to reach these goals are diverse, commonly based on national risk assessments that include interpretation of numbers of patients requiring hospital access and availability of hospital beds and ventilation support.
Globally, vaccination programmes accept proved to be condom and constructive and relieve lives.45 However most vaccines do not confer 100% protection, and it is not known how vaccines will prevent future transmission of SARS-CoV-2,vi given emerging variants.789 The proportion of the population that must be vaccinated against covid-19 to reach herd immunity depends greatly on electric current and time to come variants.x This vaccination threshold varies according to the country and population'due south response, types of vaccines, groups prioritised for vaccination, and viral mutations, amidst other factors.6 Until herd immunity to covid-nineteen is reached, regardless of the already proven high vaccination rates,11 public health preventive strategies are likely to remain as first choice measures in disease prevention,12 particularly in places with a depression uptake of covid-19 vaccination. Measures such as lockdown (local and national variant), physical distancing, mandatory use of face masks, and mitt hygiene accept been implemented every bit primary preventive strategies to curb the covid-19 pandemic.13
Public health (or non-pharmaceutical) interventions have been shown to exist beneficial in fighting respiratory infections transmitted through contact, droplets, and aerosols.1415 Given that SARS-CoV-2 is highly transmissible, information technology is a challenge to determine which measures might exist more constructive and sustainable for further prevention.
Substantial benefits in reducing mortality were observed in countries with universal lockdowns in place, such as Australia, New Zealand, Singapore, and China. Universal lockdowns are non, nonetheless, sustainable, and more tailored interventions need to be considered; the ones that maintain social lives and keep economies functional while protecting high gamble individuals.1617 Substantial variation exists in how different countries and governments have applied public wellness measures,18 and it has proved a challenge for assessing the effectiveness of private public health measures, particularly in policy decision making.19
Previous systematic reviews on the effectiveness of public health measures to treat covid-19 lacked the inclusion of analytical studies,20 a comprehensive approach to data synthesis (focusing merely on one measure),21 a rigorous assessment of effectiveness of public wellness measures,22 an assessment of the certainty of the show,23 and robust methods for comparative analysis.24 To tackle these gaps, nosotros performed a systematic review of the evidence on the effectiveness of both individual and multiple public health measures in reducing the incidence of covid-19, SARS-CoV-ii transmission, and covid-19 mortality. When feasible nosotros too did a disquisitional appraisal of the testify and meta-analysis.
Methods
This systematic review and meta-analysis were conducted in accordance with PRISMA25 (supplementary material i, tabular array one) and with PROSPERO (supplementary cloth 1, table 2).
Eligibility criteria
Manufactures that met the population, intervention, comparison, effect, and study design criteria were eligible for inclusion in this systematic review (supplementary textile i, table 3). Specifically, preventive public health measures that were tested independently were included in the main analysis. Multiple measures, which generally incorporate a "parcel of interventions", were included as supplementary cloth owing to the disability to report on the private effectiveness of measures and comparisons on which packet led to enhanced outcomes. The public health measures were identified from published World Health Organization sources that reported on the effectiveness of such measures on a range of communicable diseases, mostly respiratory infections, such equally influenza.
Given that the scientific community is concerned about the ability of the numerous mathematical models, which are based on assumptions, to predict the course of virus transmission or effectiveness of interventions,26 this review focused just on empirical studies. Nosotros excluded case reports and instance studies, modelling and simulation studies, studies that provided a graphical summary of measures without clear statistical assessments or outputs, ecological studies that provided a descriptive summary of the measures without assessing linearity or having comparators, non‐empirical studies (eg, commentaries, editorials, government reports), other reviews, articles involving only individuals exposed to other pathogens that can crusade respiratory infections, such as severe astute respiratory syndrome or Middle Due east respiratory syndrome, and articles in a linguistic communication other than English.
Information sources
Nosotros carried out electronic searches of Medline, Embase, CINAHL (Cumulative Alphabetize to Nursing and Allied Health Literature, Ebsco), Global Wellness, Biosis, Joanna Briggs, and the WHO COVID-xix database (for preprints). A clinical epidemiologist (ST) developed the initial search strategy, which was validated by two senior medical librarians (LR and MD) (supplementary textile one, table 4). The updated search strategy was last performed on seven June 2021. All citations identified from the database searches were uploaded to Covidence, an online software designed for managing systematic reviews,27 for study choice.
Study selection
Authors ST, DG, SS, AM, ET, JR, Xl, WX, IME, and XZ independently screened the titles and abstracts and excluded studies that did not match the inclusion criteria. Discrepancies were resolved in discussion with the main author (ST). The same authors retrieved full text articles and determined whether to include or exclude studies on the footing of predetermined choice criteria. Using a pilot tested data extraction form, authors ST, SS, AM, JR, XL, WX, AM, IME, and XZ independently extracted data on study design, intervention, upshot measures, outcomes, results, and limitations. ST, SS, AM, and HW verified the extracted data. Tabular array 5 in supplementary material 1 provides the specific criteria used to assess study designs. Given the heterogeneity and diversity in how studies defined public health measures, we took a common approach to summarise evidence of these interventions (supplementary textile 1, table vi).
Risk of bias within individual studies
SS, JR, XL, WX, IME, and XZ independently assessed risk of bias for each study, which was cross checked by ST and HW. For non-interventional observational studies, a ROBINS-I (risk of bias in non-randomised studies of interventions) take a chance of bias tool was used.28 For interventional studies, a revised tool for assessing take chances of bias in randomised trials (RoB 2) tool was used.29 Reviewers rated each domain for overall run a risk of bias as depression, moderate, high, or serious/critical.
Data synthesis
The DerSimonian and Laird method was used for random furnishings meta-analysis, in which the standard error of the study specific estimates was adjusted to comprise a measure of the extent of variation, or heterogeneity, among the effects observed for public health measures beyond different studies. It was assumed that the differences between studies are a issue of dissimilar, yet related, intervention effects being estimated. If fewer than 5 studies were included in meta-analysis, we practical a recommended modified Hartung-Knapp-Sidik-Jonkman method.30
Statistical assay
Considering of the differences in the effect metrics reported by the included studies, we could simply perform quantitative information synthesis for three interventions: handwashing, face mask wearing, and concrete distancing. Odds ratios or relative risks with corresponding 95% conviction intervals were reported for the associations betwixt the public health measures and incidence of covid-xix. When necessary, we transformed effect metrics derived from different studies to permit pooled analysis. We used the Dersimonian Laird random furnishings model to gauge pooled event estimates forth with corresponding 95% conviction intervals for each mensurate. Heterogeneity among individual studies was assessed using the Cochran Q test and the I2 test.31 All statistical analyses were conducted in R (version 4.0.3) and all P values were two tailed, with P=0.05 considered to be pregnant. For the remaining studies, when meta-analysis was not viable, nosotros reported the results in a narrative synthesis.
Public and patient involvement
No patients or members of the public were straight involved in this study as no chief information were collected. A member of the public was, however, asked to read the manuscript afterwards submission.
Results
A full of 36 729 studies were initially screened, of which 36 079 were considered irrelevent. After exclusions, 650 studies were eligible for full text review and 72 met the inclusion criteria. Of these studies, 35 assessed individual interventions and were included in the terminal synthesis of results (fig 1) and 37 assessed multiple interventions as a parcel and are included in supplementary material three, tables 2 and 3. The included studies comprised 34 observational studies and ane interventional study, viii of which were included in the meta-analysis.
Take a chance of bias
According to the ROBINS-I tool,28 the risk of bias was rated as low in three studies,323334 moderate in 24 studies,353637383940414243444546474849505152535455565758 and high to serious in seven studies.59606162636465 One of import source of serious or disquisitional risk of bias in almost of the included studies was major confounding, which was difficult to control for because of the novel nature of the pandemic (ie, natural settings in which multiple interventions might have been enforced at one time, dissimilar levels of enforcement across regions, and uncaptured individual level interventions such every bit increased personal hygiene). Variations in testing capacity and coverage, changes to diagnostic criteria, and access to accurate and reliable upshot information on covid-19 incidence and covid-nineteen mortality, was a source of measurement bias for numerous studies (fig 2). These limitations were especially prominent early in the pandemic, and in depression income environments.4752626365 The randomised controlled trial66 was rated as moderate risk of bias according to the ROB-2 tool. Missing data, losses to follow-upwards, lack of blinding, and low adherence to intervention all contributed to the reported moderate risk. Tables 1 and 2 in supplementary material two summarise the risk of bias assessment for each study assessing individual measures.
Study characteristics
Studies assessing individual measures
Thirty 5 studies provided estimates on the effectiveness of an individual public health measures. The studies were conducted in Asia (n=11), the U.s.a. (n=9), Europe (n=7), the Middle East (n=3), Africa (northward=3), S America (due north=1), and Australia (n=1). 30 four of the studies were observational and one was a randomised controlled trial. The study designs of the observational studies comprised natural experiments (northward=11), quasi-experiments (n=3), a prospective accomplice (northward=1), retrospective cohorts (north=8), example-command (n=2), and cross exclusive (n=nine). Xx six studies assessed social measures,3234353738394041424446474852535556575859606163646567 12 studies assessed personal protective measures,3643454950575860636668 iii studies assessed travel related measures,545862 and 1 study assessed ecology measures57 (some interventions overlapped across studies). The most normally measured consequence was incidence of covid-19 (n=xviii), followed by SARS-CoV-two transmission, measured as reproductive number, growth number, or epidemic doubling time (northward=13), and covid-xix mortality (n=8). Table 1 in supplementary material iii provides detailed information on each study.
Furnishings of interventions
Personal protective measures
Handwashing and covid-19 incidence—3 studies with a full of 292 people infected with SARS-CoV-2 and 10 345 participants were included in the analysis of the effect of handwashing on incidence of covid-xix.366063 Overall pooled analysis suggested an estimated 53% non-statistically significant reduction in covid-xix incidence (relative run a risk 0.47, 95% conviction interval 0.nineteen to one.12, I2=12%) (fig 3). A sensitivity analysis without adjustment showed a significant reduction in covid-19 incidence (0.49, 0.33 to 0.72, I2=12%) (fig 4). Hazard of bias across the three studies ranged from moderate3660 to serious or critical63 (fig 2).
Mask wearing and covid-19 incidence—6 studies with a full of 2627 people with covid-19 and 389 228 participants were included in the analysis examining the event of mask wearing on incidence of covid-19 (table i).364357606366 Overall pooled analysis showed a 53% reduction in covid-19 incidence (0.47, 0.29 to 0.75), although heterogeneity between studies was substantial (Iii=84%) (fig 5). Risk of bias beyond the six studies ranged from moderate36576066 to serious or critical4363 (fig two).
Table one
Written report characteristics and master results from studies that assessed private personal protective and environmental measures
Mask wearing and transmission of SARS-CoV-2, covid-19 incidence, and covid-19 bloodshed—The results of additional studies that assessed mask wearing (non included in the meta-analysis considering of substantial differences in the assessed outcomes) indicate a reduction in covid-19 incidence, SARS-CoV-two transmission, and covid-nineteen mortality. Specifically, a natural experiment across 200 countries showed 45.seven% fewer covid-nineteen related mortality in countries where mask wearing was mandatory (tabular array i).49 Another natural experiment study in the US reported a 29% reduction in SARS-CoV-2 manual (measured equally the fourth dimension varying reproductive number Rt) (risk ratio 0.71, 95% confidence interval 0.58 to 0.75) in states where mask wearing was mandatory.58
A comparative written report in the Hong Kong Special Authoritative Region reported a statistically meaning lower cumulative incidence of covid-xix associated with mask wearing than in selected countries where mask wearing was not mandatory (table 1).68 Similarly, another natural experiment involving 15 The states states reported a two% statistically significant daily decrease in covid-nineteen transmission (measured every bit case growth rate) at ≥21 days after mask wearing became mandatory,50 whereas a cross sectional study reported that a 10% increment in self-reported mask wearing was associated with greater odds for control of SARS-CoV-2 manual (adjusted odds ratio three.53, 95% confidence interval two.03 to 6.43).45 The five studies were rated at moderate risk of bias (fig 2).
Environmental measures
Disinfection in household and covid-nineteen incidence
Only one study, from People's republic of china, reported the association between disinfection of surfaces and risk of secondary manual of SARS-CoV-2 within households (table 1).57 The report assessed disinfection retrospectively past request participants about their "daily use of chlorine or ethanol-based disinfectant in households," and observed that utilise of disinfectant was 77% constructive at reducing SARS-CoV-2 transmission (odds ratio 0.23, 95% confidence interval 0.07 to 0.84). The study did not collect information on the concentration of the disinfectant used past participants and was rated at moderate risk of bias (fig 2).
Social measures
Physical distancing and covid-19 incidence
Five studies with a total of 2727 people with SARS-CoV-2 and 108 933 participants were included in the analysis that examined the effect of physical distancing on the incidence of covid-xix.3753576063 Overall pooled analysis indicated a 25% reduction in incidence of covid-19 (relative risk 0.75, 95% confidence interval 0.59 to 0.95, Iii=87%) (fig 6). Heterogeneity amongst studies was substantial, and risk of bias ranged from moderate37535760 to serious or critical63(fig ii).
Concrete distancing and transmission of SARS-CoV-2 and covid-nineteen mortality
Studies that assessed physical distancing but were not included in the meta-analysis considering of substantial differences in outcomes assessed, mostly reported a positive result of physical distancing (table ii). A natural experiment from the U.s.a. reported a 12% decrease in SARS-CoV-ii transmission (relative risk 0.88, 95% conviction interval 0.86 to 0.89),twoscore and a quasi-experimental written report from Iran reported a reduction in covid-19 related bloodshed (β −0.07, 95% confidence interval −0.05 to −0.10; P<0.001).47 Another comparative study in Republic of kenya also reported a reduction in manual of SARS-CoV-ii after physical distancing was implemented, reporting 62% reduction in overall physical contacts (reproductive number pre-intervention was two.64 and post-intervention was 0.60 (interquartile range 0.50 to 0.68)).61 These 3 studies were rated at moderate risk of bias4061 to serious or critical chance of bias47 (fig two).
Tabular array ii
Study characteristics and main results from studies assessing individual social measures
Stay at home or isolation and transmission of SARS-CoV-ii
All the studies that assessed stay at dwelling house or isolation measures reported reductions in transmission of SARS-CoV-two (table ii). A retrospective accomplice study from the US reported a significant reduction in the odds of having a positive reproductive number (R0) result (odds ratio 0.07, 95% confidence interval 0.01 to 0.37),41 and a natural experiment reported a 51% reduction in time varying reproductive number (Rt) (risk ratio 0.49, 95% confidence interval 0.43 to 0.54).58
A report from the UK reported a 74% reduction in the boilerplate daily number of contacts observed for each participant and estimated a subtract in reproductive number: the reproductive number pre-intervention was three.6 and mail-intervention was 0.60 (95% confidence interval 0.37 to 0.89).65 Similarly, an Iranian report projected the reproductive number using series interval distribution and the number of incidence cases and institute a significant decrease: the reproductive number pre-intervention was 2.70 and post-intervention was 1.13 (95% confidence interval 1.03 to i.25).55 Iii of the studies were rated at moderate to serious or critical risk of bias,555865 and one written report was rated at low adventure of bias41 (fig ii).
Quarantine and incidence and transmission of SARS-CoV-two
Quarantine was assessed in two studies (table 2).3459 A prospective cohort written report from Saudi Arabia reported a four.ix% subtract in the incidence of covid-xix at viii weeks after the implementation of quarantine.34 This report was rated at low risk of bias (fig 2). A retrospective cohort study from Republic of india reported a 14 times higher risk of SARS-CoV-2 transmission associated with no quarantine compared with strict quarantine (odds ratio 14.44, 95% confidence interval two.42 to 86.17).59 This report was rated at moderate run a risk of bias (fig ii).
School closures and covid-19 incidence and covid-19 mortality
Two studies assessed the effectiveness of schoolhouse closures on transmission of SARS-CoV-ii, incidence of covid-19, or covid-xix bloodshed (table two).4448 A US population based longitudinal study reported on the effectiveness of state-wide closure of primary and secondary schools and observed a 62% decrease (95% confidence interval −49% to −71%) in incidence of covid-19 and a 58% decrease (−46% to−68%) in covid-xix bloodshed.48 Conversely, a natural experiment from Nippon reported no outcome of schoolhouse closures on incidence of covid-19 (α coefficient 0.08, 95% confidence interval −0.36 to 0.65).44 Both studies were rated at moderate risk of bias (fig 2).
Schoolhouse closures and transmission of SARS-CoV-2
Two natural experiments from the The states reported a reduction in manual (ie, reproductive number); with one study reporting a reduction of thirteen% (relative take a chance 0.87, 95% confidence interval 0.86 to 0.89)40 and another reporting a 10% (0.90, 0.86 to 0.93) reduction (table 2).58 A Swedish study reported an association between school closures and a pocket-sized increment in confirmed SARS-CoV-2 infections in parents (odds ratio one.17, 95% conviction interval 1.03 to 1.32), but observed that teachers in lower secondary schools were twice equally likely to get infected than teachers in upper secondary schools (2.01, i.52 to ii.67).32 All three studies were rated at moderate chance of bias (fig 2).
Business closures and transmission of SARS-CoV-2
Ii natural experiment studies assessed concern closures across l Usa states and reported reductions in transmission of SARS-CoV-2 (table 2).4058 One of the studies observed a significant reduction in transmission of 12% (relative take a chance 0.88, 95% conviction interval 0.86 to 0.89)xl and the other reported a meaning 16% (risk ratio 0.84, 0.79 to 0.90) reduction.58 Both studies were rated at moderate risk of bias (fig two).
Lockdown and incidence of covid-19
A natural experiment involving 202 countries suggested that countries that implemented universal lockdown had fewer new cases of covid-19 than countries that did not (β coefficient −235.8 (standard fault −xi.04), P<0.01) (table 2).52 An Indian quasi-experimental study reported a 10.viii% reduction in incidence of covid-19 mail service-lockdown,56 whereas a South African retrospective cohort report observed a 14.1% reduction in risk after implementation of universal lockdown (table ii).46 These studies were rated at high chance of bias52 and moderate risk of bias4656 (fig 2).
Lockdown and covid-19 mortality
The three studies that assessed universal lockdown and covid-19 bloodshed more often than not reported a decrease in mortality (tabular array 2).353842 A natural experiment study involving 45 US states reported a decrease in covid-19 related mortality of ii.0% (95% conviction interval −3.0% to 0.9%) daily later lockdown had been made mandatory.35 A Brazilian quasi-experimental study reported a 27.4% average difference in covid-19 related mortality rates in the outset 25 days of lockdown.42 In addition, a natural experiment study reported near xxx% and sixty% reductions in covid-19 related mortality postal service-lockdown in Italian republic and Spain over four weeks post-intervention, respectively.38 All iii studies were rated at moderate gamble of bias (fig ii).
Lockdown and transmission of SARS-CoV-2
Four studies assessed universal lockdown and transmission of SARS-CoV-ii during the first few months of the pandemic (table 2). The subtract in reproductive number (R0) ranged from 1.27 in Italy (pre-intervention 2.03, post-intervention 0.76)39 to 2.09 in Republic of india (pre-intervention 3.36, post-intervention 1.27),64 and 3.97 in China (pre-intervention four.95, post-intervention 0.98).33 A natural experiment from the United states reported that lockdown was associated with an xi% reduction in manual of SARS-CoV-2 (relative run a risk 0.89, 95% confidence interval 0.88 to 0.91).40 All the studies were rated at low risk of bias3339 to moderate risk4064 (fig 2).
Travel related measures
Restricted travel and border closures
Border closure was assessed in one natural experiment study involving nine African countries (table 3).62 Overall, the countries recorded an increase in the incidence of covid-19 after border closure. These studies ended that the implementation of border closures within African countries had minimal effect on the incidence of covid-19. The written report had important limitations and was rated at serious or critical chance of bias. In the US, a natural experiment study reported that restrictions on travel between states contributed about xi% to a reduction in SARS-CoV-2 manual (table iii).36 The report was rated at moderate risk of bias (fig 2).
Table three
Written report characteristics and main results from studies that assessed individual travel measures
Entry and exit screening (virus or symptom screening)
One retrospective cohort study assessed screening of symptoms, which involved testing 65 000 people for fever (table three).54 The study found that screening for fever lacked sensitivity (ranging from 18% to 24%) in detecting people with SARS-CoV-2 infection. This translated to 86% of the population with SARS-CoV-two remaining undetected when screening for fever. The study was rated at moderate risk of bias (fig ii).
Multiple public health measures
Study characteristics
Overall, 37 studies provided estimates on the effectiveness of multiple public health measures, assessed as a commonage group. Studies were mostly conducted in Asia (n=15), the US (n=11), Europe (n=vi), Africa (north=4), and South America (due north=1). All the studies were observational. The nearly commonly measured effect was transmission of illness (ie, measured as reproductive number, growth number, or epidemic doubling fourth dimension) (due north=23), followed by covid-19 incidence (due north=19) and covid-xix mortality (n=8). This review attempted to assess the overall effectiveness of the public health intervention packages by reporting the pct departure in outcome before and after implementation of measures or between regions or countries studied. Eleven of the 37 included studies noted a departure of between 26% and l% in transmission of SARS-CoV-2 and incidence of covid-nineteen,7071727374757677787980 nine noted a difference of betwixt 51% and 75% in SARS-CoV-2 transmission, covid-19 incidence, and covid-19 mortality,818283848586878889 and 14 noted a deviation of more than 75% in transmission of SARS-CoV-2, covid-19 incidence and covid-19 mortality.79808990919293949596979899100 For the remaining studies, the overall effectiveness was not assessed attributable to a lack of comparators (come across supplementary material three, tabular array three). Ii studies that assessed universal lockdown and physical distancing reported a decrease of betwixt 0% and 25% in SARS-CoV-2 transmission and covid-xix incidence.79101 Studies that included schoolhouse and workplace closures,919596 isolation or stay at habitation measures,8094 or a combination of both798993979899 reported decreases of more than 75% in SARS-CoV-ii transmission. Supplementary textile 3, table 2 provides detailed information on each study.
Discussion
Worldwide, authorities and public wellness organisations are mitigating the spread of SARS-CoV-2 past implementing various public health measures. This systematic review identified a statistically significant reduction in the incidence of covid-19 through the implementation of mask wearing and physical distancing. Handwashing interventions also indicated a substantial reduction in covid-xix incidence, admitting non statistically significant in the adjusted model. As the random furnishings model tends to underestimate confidence intervals when a meta-analysis includes a modest number of individual studies (<five), the adjusted model for handwashing showed a statistically non-significant association in reducing the incidence of covid-19 compared with the unadjusted model.
Overall effectiveness of these interventions was affected by clinical heterogeneity and methodological limitations, such every bit confounding and measurement bias. It was not possible to evaluate the impact of type of face maks (eg, surgical, fabric, N95 respirators) and compliance and frequency of wearing masks owing to a lack of information. Similarly, it was non feasible to assess the differences in upshot that different recommendations for physical distancing (ie, i.5 one thousand, 2m, or 3 m) take as preventive strategies.
The effectiveness of measures such equally universal lockdowns and closures of businesses and schools for the containment of covid-19 have largely been constructive, just depended on early implementation when incidence rates of covid-19 were notwithstanding low.425258 Only Japan reported no decrease in covid-19 incidence afterwards school closures,44 and other studies found that dissimilar public health measures were sometimes implemented simultaneously or soon later one another, thus the results should be interpreted with caution.324656
Isolation or stay at home was an effective mensurate in reducing the manual of SARS-CoV-two, simply the included studies used results for mobility to assess stay at dwelling or isolation and therefore could have been limited by potential flaws in publicly available telephone data,4158102 and variations in the enforcement of public wellness measures in different states or regions were not assessed.5558102 Quarantine was found to be every bit constructive in reducing the incidence of covid-19 and transmission of SARS-CoV-2, yet variation in testing and case detection in low income environments was substantial.599698 Another study reported that quarantine was effective in reducing the transmission of SARS-CoV-2 in a accomplice with a depression prevalence of the virus, yet it is unknown if the aforementioned outcome would be observed with higher prevalence.34
It was not possible to draw conclusions about the effectiveness of restricted travel and full edge closures because the number of empirical studies was insufficient. Unmarried studies identified that border closure in Africa had a minimal effect in reducing SARS-CoV-2 transmission, but the study was assessed as being at loftier run a risk of bias.62 Screening for fever was also identified to be ineffective, with but 24% of positive cases being captured by screening.54
Comparison with other studies
Previous literature reviews have identified mask wearing as an effective measure out for the containment of SARS-CoV-2103; the caveat being that more high level evidence is required to provide unequivocal back up for the effectiveness of the universal utilize of confront masks.104105 Boosted empirical evidence from a recent randomised controlled trial (originally published as a preprint) indicates that mask wearing accomplished a 9.3% reduction in seroprevalence of symptomatic SARS-CoV-2 infection and an 11.ix% reduction in the prevalence of covid-19-like symptoms.106 Another systematic review showed stronger effectiveness with the use of N95, or like, respirators than disposable surgical masks,107 and a study evaluating the protection offered by 18 different types of textile masks institute substantial heterogeneity in protection, with the most effective mask beingness multilayered and tight fitting.108 However, manual of SARS-CoV-two largely arises in hospital settings in which total personal protective measures are in place, which suggests that when viral load is at its highest, even the best performing face up masks might not provide acceptable protection.51 Additionally, nigh studies that assessed mask wearing were prone to of import confounding bias, which might accept contradistinct the conclusions drawn from this review (ie, effect estimates might have been underestimated or overestimated or can be related to other measures that were in place at the time the studies were conducted). Thus, the extent of such limitations on the conclusions drawn remain unknown.
A 2020 rapid review ended that quarantine is largely effective in reducing the incidence of covid-19 and covid-19 mortality. All the same, uncertainty over the magnitude of such an upshot still remains,109 with enhanced management of quality quarantine facilities for improved effective command of the epidemics urgently needed.110 In addition, findings on the application of school and workplace closures are still inconclusive. Policy makers should be aware of the ambiguous evidence when considering school closures, as other potentially less disruptive physical distancing interventions might be more advisable.21 Numerous findings from studies on the efficacy of school closures showed that the take a chance of transmission within the educational environment often strongly depends on the incidence of covid-19 in the customs, and that school closures are most successfully associated with control of SARS-CoV-2 transmission when other mitigation strategies are in place in the community.111112113114115116117 School closures have been reported to be disruptive to students globally and are likely to impair children's social, psychological, and educational development118119 and to issue in loss of income and productivity in adults who cannot piece of work because of childcare responsibilities.120
Speculation remains equally how best to implement physical distancing measures.121 Studies that assess concrete distancing measures might interchangeably study physical distancing with lockdown35525664 and other measures and thus directly associations are hard to assess.
Empirical evidence from restricted travel and full border closures is also limited, as information technology is almost impossible to study these strategies as unmarried measures. Current prove from a recent narrative literature review suggested that control of motility, along with mandated quarantine, travel restrictions, and restricting nationals from inbound areas of high infection, are effective measures, just only with skilful compliance.122 A narrative literature review of travel bans, partial lockdowns, and quarantine too suggested effectiveness of these measures,123 and another rapid review further supported travel restrictions and cross border restrictions to stop the spread of SARS-CoV-2.124 It was incommunicable to make such observations in the current review considering of limited evidence. A German review, even so, suggested that entry, exit, and symptom screening measures to prevent transmission of SARS-CoV-2 are not effective at detecting a meaningful proportion of cases,125 and another review using real world data from multiple countries found that edge closures had minimal impact on the control of covid-19.126
Although universal lockdowns have shown a protective effect in lowering the incidence of covid-nineteen, SARS-CoV-2 transmission, and covid-19 mortality, these measures are also disruptive to the psychosocial and mental health of children and adolescents,127 global economies,128 and societies.129 Partial lockdowns could be an culling, as the associated effectiveness can exist loftier,125 specially when implemented early in an outbreak,85 and such measures would be less confusing to the general population.
Information technology is important to also consider numerous sociopolitical and socioeconomic factors that have been shown to increase SARS-CoV-two infection130131 and covid-nineteen mortality.132 Immigration status,82 economic status,81101 and poverty and rurality98 tin influence private and community compliance with public health measures. Poverty can impact the ability of communities to physically distance,133 specially in crowded living environments,134135 as well as reduce admission to personal protective measures.134135 A recent study highlights that "a one size fits all" arroyo to public wellness measures might not be constructive at reducing the spread of SARS-CoV-two in vulnerable communities136 and could exacerbate social and economic inequalities.135137 As such, a more than nuanced and community specific approach might be required. Even though screening is highly recommended past WHO138 because a proportion of patients with covid-xix tin be asymptomatic,138 screening for symptoms might miss a larger proportion of the population with covid-nineteen. Hence, temperature screening technologies might need to be reconsidered and evaluated for cost effectiveness, given such measures are largely depended on symptomatic fever cases.
Strengths and limitations of this review
The main strength of this systematic review was the utilize of a comprehensive search strategy to identify and select studies for review and thereby minimise selection bias. A clinical epidemiologist adult the search strategy, which was validated by 2 senior medical librarians. This review followed a comprehensive appraisal process that is recommended by the Cochrane Collaboration31 to appraise the effectiveness of public health measures, with specifically validated tools used to independently and individually appraise the run a risk of bias in each report by report design.
This review has some limitations. Firstly, loftier quality evidence on SARS CoV-2 and the effectiveness of public health measures is still limited, with almost studies having different underlying target variables. Secondly, information provided in this review is based on current evidence, and so will be modified equally additional data become available, specially from more prospective and randomised studies. Also, we excluded studies that did not provide certainty over the upshot measure out, which might accept introduced selection bias and limited the interpretation of effectiveness. Thirdly, numerous studies measured interventions only once and others multiple times over short time frames (days five calendar month, or no timeframe). Additionally, the meta-analytical portion of this report was limited by significant heterogeneity observed across studies, which could neither be explored nor explained by subgroup analyses or meta-regression. Finally, we quantitatively assessed only publications that reported individual measures; studies that assessed multiple measures simultaneously were narratively analysed with a broader level of effectiveness (see supplementary fabric 3, table 3). Likewise, nosotros excluded studies in languages other than English.
Methodological limitations of studies included in the review
Several studies failed to define and assess for potential confounders, which made it difficult for our review to draw a i directional or causal determination. This trouble was mainly considering we were unable to study only i intervention, given that many countries implemented several public health measures simultaneously; thus information technology is a challenge to uncrease the touch on of individual interventions (ie, physical distancing when other interventions could exist contributing to the effect). Additionally, studies measured different primary outcomes and in varied ways, which limited the ability to statistically analyse other measures and compare effectiveness.
Further pragmatic randomised controlled trials and natural experiment studies are needed to amend inform the evidence and guide the future implementation of public health measures. Given that most measures depend on a population's adherence and compliance, it is important to understand and consider how these might be affected by factors. A lack of data in the assessed studies meant information technology was not possible to understand or determine the level of compliance and adherence to whatever of the measures.
Conclusions and policy implications
Current show from quantitative analyses indicates a benefit associated with handwashing, mask wearing, and physical distancing in reducing the incidence of covid-nineteen. The narrative results of this review point an effectiveness of both individual or packages of public health measures on the transmission of SARS-CoV-2 and incidence of covid-nineteen. Some of the public wellness measures seem to be more stringent than others and have a greater bear on on economies and the health of populations. When implementing public health measures, it is important to consider specific health and sociocultural needs of the communities and to weigh the potential negative effects of the public health measures against the positive effects for general populations. Farther research is needed to appraise the effectiveness of public health measures after adequate vaccination coverage has been achieved. It is likely that further control of the covid-19 pandemic depends non only on high vaccination coverage and its effectiveness but also on ongoing adherence to effective and sustainable public health measures.
What is already known on this topic
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Public health measures accept been identified as a preventive strategy for influenza pandemics
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The effectiveness of such interventions in reducing the transmission of SARS-CoV-ii is unknown
What this study adds
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The findings of this review suggest that personal and social measures, including handwashing, mask wearing, and physical distancing are effective at reducing the incidence of covid-19
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More stringent measures, such equally lockdowns and closures of borders, schools, and workplaces need to be carefully assessed by weighing the potential negative effects of these measures on general populations
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Further research is needed to appraise the effectiveness of public wellness measures later adequate vaccination coverage
Ethics statements
Ethical approving
Not required.
Data availability statement
No boosted information bachelor.
Acknowledgments
Nosotros give thanks medical discipline librarians Lorena Romero (LR) and Marshall Dozier (MD) for their expert advice and assistance with the study search strategy.
Footnotes
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Contributors: ST, DG, DI, DL, and ZA conceived and designed the study. ST, DG, SS, AM, HW, WX, JR, ET, AM, Forty, XZ, and IME collected and screened the data. ST, DG, and DI acquired, analysed, or interpreted the data. ST, HW, and SS drafted the manuscript. All authors critically revised the manuscript for important intellectual content.. XL and ST did the statistical assay. NA obtained funding. LR and MD provided administrative, technical, or textile support. ST and DI supervised the study. ST and DI had total access to all the information in the study and take responsibility for the integrity of the information and the accurateness of the data analysis. ST is the guarantor. The corresponding writer attests that all listed authors meet authorship criteria and that no others coming together the criteria have been omitted.
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Funding: No funding was bachelor for this inquiry. ET is supported by a Cancer Research UK Career Development Fellowship (grant No C31250/A22804). XZ is supported by The Darwin Trust of Edinburgh.
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Competing interests: All authors have completed the ICMJE uniform disclosure form at world wide web.icmje.org/disclosure-of-interest/and declare: ET is supported by a Cancer Research United kingdom Career Development Fellowship and XZ is supported by The Darwin Trust of Edinburgh; no fiscal relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to take influenced the submitted work.
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The lead writer (ST) affirms that the manuscript is an honest, accurate, and transparent account of the study reported; no important aspects of the report have been omitted. Dissemination to participants and related patient and public communities: It is predictable to disseminate the results of this research to wider customs via press release and social media platforms.
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Provenance and peer review: Non commissioned; externally peer reviewed.
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View Abstract
Source: https://www.bmj.com/content/375/bmj-2021-068302
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