Lessons from past pandemics: a systematic review of evidence-based, cost-effective interventions to suppress COVID-19

  1. Carl-Etienne Juneau
  2. Tomas Pueyo
  3. Matt Bell
  4. Genevieve Gee
  5. Pablo Collazzo
  6. Louise Potvin

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Abstract

Background

In an unparalleled global response, during the COVID-19 pandemic, 90 countries asked 3.9 billion people to stay home. Yet other countries avoided lockdowns and focused on other strategies, like contact tracing. How effective and cost-effective are these strategies? We aimed to provide a comprehensive summary of the evidence on past pandemic controls, with a focus on cost-effectiveness.

Methods

Following PRISMA guidelines, MEDLINE (1946 to April week 2, 2020) and EMBASE (1974 to April 17, 2020) were searched using a range of terms related to pandemic control. Articles reporting on the effectiveness or cost-effectiveness of at least one intervention were included.

Results

We found 1653 papers; 62 were included. The effectiveness of hand-washing and face masks was supported by randomized trials. These measures were highly cost-effective. For other interventions, only observational and modelling studies were found. They suggested that (1) the most cost-effective interventions are swift contact tracing and case isolation, surveillance networks, protective equipment for healthcare workers, and early vaccination (when available); (2) home quarantines and stockpiling antivirals are less cost-effective; (3) social distancing measures like workplace and school closures are effective but costly, making them the least cost-effective options; (4) combinations are more cost-effective than single interventions; and (5) interventions are more cost-effective when adopted early. For 2009 H1N1 influenza, contact tracing was estimated to be 4363 times more cost-effective than school closure ($2260 vs. $9,860,000 per death prevented).

Conclusions and contributions

For COVID-19, a cautious interpretation suggests that (1) workplace and school closures are effective but costly, especially when adopted late, and (2) scaling up as early as possible a combination of interventions that includes hand-washing, face masks, ample protective equipment for healthcare workers, and swift contact tracing and case isolation is likely to be the most cost-effective strategy.

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  1. Version published to 10.1186/s13643-022-01958-9
  2. Version published to 10.1101/2020.04.20.20054726v2 on medRxiv
  3. ScreenIT

    SciScore for 10.1101/2020.04.20.20054726: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    RandomizationReviews (all types), randomized trials, observational studies, and modelling studies were included.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    MEDLINE (1946 to April week 2, 2020) and Embase (1974 to April 17, 2020) were searched using the terms “non-pharmaceutical interventions”, “outbreak control”, “outbreak interventions”, “epidemic control”, “epidemic interventions”, “pandemic control”, and “pandemic interventions” (last search: April 19, 2020).
    MEDLINE
    suggested: (MEDLINE, RRID:SCR_002185)
    Embase
    suggested: (EMBASE, RRID:SCR_001650)
    Reference lists and PubMed related articles of included studies were reviewed to find additional articles.
    PubMed
    suggested: (PubMed, RRID:SCR_004846)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Strengths and limitations: This review has one key strength: it included a broad range of study designs to provide a comprehensive summary of the evidence. This could however also be viewed as a limitation, as it includes evidence of both high and low quality. Lower-quality evidence should be interpreted with caution. Still, as randomized trial evidence was not available for most epidemic control interventions, and as COVID-19 forces urgent decision making, we submit that some evidence, even of lower quality, is better than no evidence at all. In addition, this review has a number of limitations. First, because of time constraints, our search was limited to two databases (MEDLINE and Embase) and we did not examine risk of bias. Second, most studies focused on H1N1 and other viruses, not SARS-CoV-2. Third, estimates of COVID-19 case fatality rate are subject to substantial uncertainties. They are likely to change as more data emerge. Should the true rate be high, all interventions would be more cost-effective. Conversely, should it be low, costly interventions such as school closures may not be cost-effective at all.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  4. Version published to 10.1101/2020.04.20.20054726v1 on medRxiv