Institute for Medical Information Processing, Biometry and Epidemiology, IBE, LMU Munich, Munich, Germany.
Pettenkofer School of Public Health, Munich, Germany.
Cochrane Database Syst Rev. 2020 Oct 5;10:CD013717. doi: 10.1002/14651858.CD013717.
BACKGROUND: In late 2019, first cases of coronavirus disease 2019, or COVID-19, caused by the novel coronavirus SARS-CoV-2, were reported in Wuhan, China. Subsequently COVID-19 spread rapidly around the world. To contain the ensuing pandemic, numerous countries have implemented control measures related to international travel, including border closures, partial travel restrictions, entry or exit screening, and quarantine of travellers. OBJECTIVES: To assess the effectiveness of travel-related control measures during the COVID-19 pandemic on infectious disease and screening-related outcomes. SEARCH METHODS: We searched MEDLINE, Embase and COVID-19-specific databases, including the WHO Global Database on COVID-19 Research, the Cochrane COVID-19 Study Register, and the CDC COVID-19 Research Database on 26 June 2020. We also conducted backward-citation searches with existing reviews. SELECTION CRITERIA: We considered experimental, quasi-experimental, observational and modelling studies assessing the effects of travel-related control measures affecting human travel across national borders during the COVID-19 pandemic. We also included studies concerned with severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) as indirect evidence. Primary outcomes were cases avoided, cases detected and a shift in epidemic development due to the measures. Secondary outcomes were other infectious disease transmission outcomes, healthcare utilisation, resource requirements and adverse effects if identified in studies assessing at least one primary outcome. DATA COLLECTION AND ANALYSIS: One review author screened titles and abstracts; all excluded abstracts were screened in duplicate. Two review authors independently screened full texts. One review author extracted data, assessed risk of bias and appraised study quality. At least one additional review author checked for correctness of all data reported in the 'Risk of bias' assessment, quality appraisal and data synthesis. For assessing the risk of bias and quality of included studies, we used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool for observational studies concerned with screening, ROBINS-I for observational ecological studies and a bespoke tool for modelling studies. We synthesised findings narratively. One review author assessed certainty of evidence with GRADE, and the review author team discussed ratings. MAIN RESULTS: We included 40 records reporting on 36 unique studies. We found 17 modelling studies, 7 observational screening studies and one observational ecological study on COVID-19, four modelling and six observational studies on SARS, and one modelling study on SARS and MERS, covering a variety of settings and epidemic stages. Most studies compared travel-related control measures against a counterfactual scenario in which the intervention measure was not implemented. However, some modelling studies described additional comparator scenarios, such as different levels of travel restrictions, or a combination of measures. There were concerns with the quality of many modelling studies and the risk of bias of observational studies. Many modelling studies used potentially inappropriate assumptions about the structure and input parameters of models, and failed to adequately assess uncertainty. Concerns with observational screening studies commonly related to the reference test and the flow of the screening process. Studies on COVID-19 Travel restrictions reducing cross-border travel Eleven studies employed models to simulate a reduction in travel volume; one observational ecological study assessed travel restrictions in response to the COVID-19 pandemic. Very low-certainty evidence from modelling studies suggests that when implemented at the beginning of the outbreak, cross-border travel restrictions may lead to a reduction in the number of new cases of between 26% to 90% (4 studies), the number of deaths (1 study), the time to outbreak of between 2 and 26 days (2 studies), the risk of outbreak of between 1% to 37% (2 studies), and the effective reproduction number (1 modelling and 1 observational ecological study). Low-certainty evidence from modelling studies suggests a reduction in the number of imported or exported cases of between 70% to 81% (5 studies), and in the growth acceleration of epidemic progression (1 study). Screening at borders with or without quarantine Evidence from three modelling studies of entry and exit symptom screening without quarantine suggests delays in the time to outbreak of between 1 to 183 days (very low-certainty evidence) and a detection rate of infected travellers of between 10% to 53% (low-certainty evidence). Six observational studies of entry and exit screening were conducted in specific settings such as evacuation flights and cruise ship outbreaks. Screening approaches varied but followed a similar structure, involving symptom screening of all individuals at departure or upon arrival, followed by quarantine, and different procedures for observation and PCR testing over a period of at least 14 days. The proportion of cases detected ranged from 0% to 91% (depending on the screening approach), and the positive predictive value ranged from 0% to 100% (very low-certainty evidence). The outcomes, however, should be interpreted in relation to both the screening approach used and the prevalence of infection among the travellers screened; for example, symptom-based screening alone generally performed worse than a combination of symptom-based and PCR screening with subsequent observation during quarantine. Quarantine of travellers Evidence from one modelling study simulating a 14-day quarantine suggests a reduction in the number of cases seeded by imported cases; larger reductions were seen with increasing levels of quarantine compliance ranging from 277 to 19 cases with rates of compliance modelled between 70% to 100% (very low-certainty evidence). AUTHORS' CONCLUSIONS: With much of the evidence deriving from modelling studies, notably for travel restrictions reducing cross-border travel and quarantine of travellers, there is a lack of 'real-life' evidence for many of these measures. The certainty of the evidence for most travel-related control measures is very low and the true effects may be substantially different from those reported here. Nevertheless, some travel-related control measures during the COVID-19 pandemic may have a positive impact on infectious disease outcomes. Broadly, travel restrictions may limit the spread of disease across national borders. Entry and exit symptom screening measures on their own are not likely to be effective in detecting a meaningful proportion of cases to prevent seeding new cases within the protected region; combined with subsequent quarantine, observation and PCR testing, the effectiveness is likely to improve. There was insufficient evidence to draw firm conclusions about the effectiveness of travel-related quarantine on its own. Some of the included studies suggest that effects are likely to depend on factors such as the stage of the epidemic, the interconnectedness of countries, local measures undertaken to contain community transmission, and the extent of implementation and adherence.
背景:2019 年末,新型冠状病毒 SARS-CoV-2 引发的 2019 冠状病毒病(COVID-19)首例病例在中国武汉报告。随后,COVID-19 在全球迅速蔓延。为了控制随之而来的大流行,许多国家实施了与国际旅行相关的控制措施,包括关闭边境、部分旅行限制、入境或出境筛查以及对旅行者的隔离。
目的:评估 COVID-19 大流行期间与旅行相关的控制措施对传染病和筛查相关结果的有效性。
检索策略:我们于 2020 年 6 月 26 日在 MEDLINE、Embase 和 COVID-19 特定数据库(包括世界卫生组织全球 COVID-19 研究数据库、考科蓝 COVID-19 研究注册库和美国疾病控制与预防中心 COVID-19 研究数据库)上进行了检索。我们还对现有综述进行了回溯性引文检索。
选择标准:我们考虑了评估影响 COVID-19 大流行期间人类跨国旅行的旅行相关控制措施的效果的实验、准实验、观察性和建模研究。我们还将严重急性呼吸综合征(SARS)和中东呼吸综合征(MERS)的研究纳入间接证据。主要结局为避免的病例数、检测到的病例数以及由于这些措施而改变的疾病发展趋势。次要结局为其他传染病传播结局、医疗保健利用、资源需求以及在评估至少一个主要结局的研究中确定的不良影响。
数据收集和分析:一名综述作者筛选标题和摘要;所有排除的摘要均由两名综述作者独立筛选。两名综述作者独立筛选全文。一名综述作者提取数据、评估偏倚风险并评估研究质量。至少有一名额外的综述作者检查了报告在“偏倚风险”评估、质量评估和数据综合中的所有数据的正确性。对于评估纳入研究的偏倚风险和质量,我们使用针对筛查的观察性研究的《诊断准确性研究的质量评估工具》(QUADAS-2)工具、针对观察性生态学研究的 ROBINS-I 工具以及针对建模研究的专用工具。我们以叙述性方式综合发现。一名综述作者使用 GRADE 评估证据的确定性,并由综述作者团队讨论评级。
主要结果:我们纳入了 40 份记录,其中报道了 36 项独特的研究。我们发现了 17 项建模研究、7 项观察性筛查研究和一项关于 COVID-19 的观察性生态学研究、4 项建模研究和 6 项关于 SARS 的观察性研究,以及一项关于 SARS 和 MERS 的建模研究,涵盖了各种设置和疾病流行阶段。大多数研究将旅行相关控制措施与干预措施未实施的情况下的对照情况进行了比较。然而,一些建模研究描述了其他比较情景,例如不同级别的旅行限制或措施的组合。许多建模研究的质量以及观察性筛查研究的偏倚风险令人担忧。许多建模研究对模型的结构和输入参数做出了潜在不合适的假设,并且未能充分评估不确定性。观察性筛查研究的常见问题通常与参考测试和筛查过程的流程有关。
研究 COVID-19 旅行限制减少跨境旅行 11 项研究使用模型模拟旅行量减少;一项观察性生态学研究评估了 COVID-19 大流行期间的旅行限制。来自建模研究的非常低确定性证据表明,在疫情爆发初期实施跨境旅行限制可能会导致新发病例减少 26%至 90%(4 项研究)、死亡人数减少(1 项研究)、爆发时间提前 2 至 26 天(2 项研究)、爆发风险降低 1%至 37%(2 项研究)和有效繁殖数减少(1 项建模研究和 1 项观察性生态学研究)。来自建模研究的低确定性证据表明,进出口病例数减少 70%至 81%(5 项研究),以及疫情进展加速的情况减少(1 项研究)。边境筛查(有或没有检疫) 来自 3 项针对入境和出境症状筛查且无检疫的建模研究的证据表明,发病时间延迟 1 至 183 天(非常低确定性证据)和受感染者旅行者的检出率为 10%至 53%(低确定性证据)。在特定情况下(如疏散航班和游轮疫情)进行了 6 项入境和出境筛查的观察性研究。筛查方法各不相同,但都遵循类似的结构,包括所有离境或抵达时的症状筛查,随后是检疫,并在至少 14 天的时间内进行不同的观察和 PCR 检测程序。检测到的病例比例范围为 0%至 91%(取决于筛查方法),阳性预测值范围为 0%至 100%(非常低确定性证据)。然而,应根据所使用的筛查方法和受筛查旅行者的感染率来解释这些结果;例如,仅基于症状的筛查通常比单独使用症状筛查和随后在检疫期间进行的 PCR 筛查和观察的组合效果差。旅行者检疫 来自一项模拟 14 天检疫的建模研究的证据表明,入境病例引发的病例数量减少;随着模拟的检疫合规率从 70%至 100%变化(非常低确定性证据),合规率从 277 例减少到 19 例。
作者结论:由于大多数证据来自建模研究,特别是关于旅行限制减少跨境旅行和旅行者检疫的研究,因此许多此类措施缺乏“现实生活”证据。大多数与旅行相关的控制措施的证据确定性非常低,实际效果可能与这里报告的有很大不同。尽管如此,COVID-19 大流行期间的一些旅行相关控制措施可能对传染病结果产生积极影响。一般来说,旅行限制可能会限制疾病在国家边界之间的传播。单独的入境和出境症状筛查措施不太可能有效地检测到有意义比例的病例,以防止在受保护区域内引发新病例;与随后的检疫、观察和 PCR 检测相结合,效果可能会提高。关于旅行相关检疫本身的有效性,证据不足,无法得出明确结论。一些纳入的研究表明,效果可能取决于疾病流行阶段、国家之间的相互联系、当地遏制社区传播的措施以及实施和遵守的程度等因素。
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