Effectiveness of non-pharmaceutical measures (NPIs) on COVID-19 in Europe: A systematic literature review

  1. Constantine I. Vardavas
  2. Katerina Nikitara
  3. Katerina Aslanoglou
  4. Michele Hilton-Boon
  5. Revati Phalkey
  6. Jo Leonardi-Bee
  7. Gkikas Magiorkinis
  8. Paraskevi Katsaounou
  9. Anastasia Pharris
  10. Ettore Severi
  11. Jonathan E. Suk

Reviewed by

Read the full article

Listed in

Log in to save this article

Abstract

Background

The study objective was to conduct a systematic review to assess the effectiveness of non-pharmaceutical interventions (NPIs) to reduce the transmission of SARS-CoV-2 in Europe during the first wave of the pandemic.

Methods

We searched OVID Medline, EMBASE, and the Cochrane and Campbell Databases for Systematic Reviews published up to April 15 th 2021. Focusing on community (meso-level) and society (macro-level) level NPIs, we included all study designs, while a geographic restriction was limited to the EU, UK and European Economic Area (EEA) countries. Using the PICO framework, two reviewers independently extracted data and assessed quality using appropriate quality appraisal tools. A qualitative synthesis was performed, with NPIs grouped initially by a) Physical Distancing measures, b) Case detection and management measures, and c) hygiene measures and subsequently by country.

Results

Of 17,692 studies initially assessed, 45 met all inclusion criteria. Most studies (n=30) had a modelling study design, while 13 were observational, one quasi-experimental and one experimental. Evidence from across the European continent, presented by country, indicates that the implementations of physical distancing measures (i.e., lockdowns/quarantines), preferably earlier in the pandemic, reduce the number of cases and hospitalisation across settings and for which the timing and duration are essential parameters. Case detection and management measures were also identified as effective measures at certain levels of testing and incidence, while hygiene and safety measures complemented the implementation of physical distancing measures.

Conclusions

This literature review represents a comprehensive assessment of the effectiveness of NPIs in Europe up to April 2021. Despite heterogeneity across studies, NPIs, as assessed within the context of this systematic review at the macro and meso level, are effective in reducing SARS-CoV-2 transmission rates and COVID-19 hospitalisation rates and deaths in the European Region and may be applied as response strategies to reduce the burden of COVID-19 in forthcoming waves.

Article activity feed

  1. ScreenIT

    SciScore for 10.1101/2021.11.11.21266216: (What is this?)

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

    Table 1: Rigor

    Ethicsnot detected.
    Sex as a biological variablenot detected.
    RandomizationStudy designs included peer-reviewed studies including but not limited to: Simulation studies using mathematical models or transmission models, cluster and parallel randomised controlled trials (RCTs), cluster and parallel non-RCTs, quasi-experimental studies (including controlled before-after studies, uncontrolled before-after studies, time series, and interrupted time series) that assess the effectiveness of community non-pharmaceutical measures.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Search Results and PICO: Relevant peer-reviewed studies were identified through systematic electronic searches using OVID Medline, EMBASE and the Cochrane and Campbell Databases for Systematic Reviews.
    Medline
    suggested: (MEDLINE, RRID:SCR_002185)
    EMBASE
    suggested: (EMBASE, RRID:SCR_001650)
    Cochrane
    suggested: (Cochrane Library, RRID:SCR_013000)

    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: Our systematic review has several strengths, including the systematic approach during study identification, data extraction and quality appraisal that was applied. Some limitations should also be acknowledged. We assessed peer-reviewed and published evidence available until April 2021, much of which included the period before December 2020, and hence the information provided does not adequately cover NPIs in place during the circulation of all variants of concern. As per our inclusion criteria, only studies based in EU/EEA and UK were assessed, and accordingly, the results may not reflect the effectiveness of NPI implementation in other contexts globally – although other systematic reviews of a broader scope indicate similar findings (66, 67). Furthermore, a significant percentage of identified studies were based on mathematical modelling studies that require many assumptions related to the model design, which may lead to variability in model predictions and uncertainty for decision-makers. There was, furthermore, significant heterogeneity in study designs and studied interventions/combination of interventions, which only allowed for a narrative presentation of the results. Also, given that NPI effectiveness depends on the implementation, the personal protective measures that are probably implemented in parallel, demographic characteristics, and compliance levels, direct comparisons across countries and across NPIs were not possible.

    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.

    Results from scite Reference Check: We found no unreliable references.

    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.

  2. Version published to 10.1101/2021.11.11.21266216v1 on medRxiv