【Cochrane快速评价】仅检疫隔离或检疫隔离结合其他公共卫生措施控制COVID-2019的效果如何？

为快速回应卫生决策者的即时需求，同时确保符合严格的方法学，需加快重要Cochrane系统综述的正常流程。快速评价（Rapid Review）是指“一种知识整合的形式，通过精简或省略特定方法以加速进行常规系统综述的过程，从而高效利用资源，并为利益相关者提供证据”[1]。

COVID-19正以惊人的速度蔓延全球，对证据的需求也在不断增加。Cochrane正在根据已有证据进行一系列快速评价，以帮助决策者应对新冠疫情。

在本综述中，来自奥地利多瑙河大学克雷姆斯分校（Danube University Krems）的Barbara Nussbaumer-Streit评价了检疫效力的研究，受世界卫生组织（WHO）委托并于2020年4月上旬发表[2]。

研究背景

2019年冠状病毒（COVID-19）是一种在全世界迅速传播的新型病毒。COVID-19很容易在人与人之间通过密切接触或咳嗽和打喷嚏传播。大多数感染者都表现出轻度流感样症状，但有的人病情进展严重，甚至死亡。

目前没有针对COVID-19的有效治疗方法或疫苗（阻止人们感染特定疾病的药物），因此需要其他减缓（控制）病毒传播的方法。世界卫生组织（World Health Organization，WHO）关于控制该病的推荐措施之一是检疫隔离。这意味着将健康的人彼此分隔开，以防止他们被病毒感染并传播病毒。其他类似的推荐措施包括隔离（类似于检疫隔离，但是是将有COVID-19症状的人隔离起来）和社交间隔（无症状的人与人之间保持一定身体距离）。

我们想知道什么？ 
我们想找出检疫隔离是否能有效地阻止COVID-19传播、它是如何做到的、以及它是否能防止死亡。我们想知道，如果检疫与其他措施（如关闭学校）相结合，是否会更有效。我们还想知道它的成本耗费。

研究特征

COVID-19正在迅速传播，所以我们需要尽快回答这个问题。这意味着我们缩短了正常 Cochrane 综述流程的一些步骤。但是，我们相信这些变化不会影响我们的总体结论。

我们检索了评估所有地区所有类型的检疫隔离对COVID-19传播与病情严重程度影响的研究。我们还查看了评估检疫隔离与其他措施一起（如隔离、社交间隔、学校关闭和手部卫生）的研究。COVID-19是一种新疾病，因此，为了找到尽可能多的证据，我们还检索了有关类似病毒的研究，如严重急性呼吸系统综合症（severe acute respiratory syndrome，SARS）和中东呼吸综合征（Middle East respiratory syndrome，MERS）。

研究测量了COVID-19、SARS或MERS的病例数量、感染人数、病毒传播速度、死亡人数以及检疫隔离费用。

（图片来源于网络）

主要结果

我们纳入了29项研究。10项研究聚焦于COVID-19，15项关于SARS，2项关于SARS加上其他病毒，2项聚焦于MERS。大多数研究结合现有数据，创建了一个模型（一种模拟），用于为处于不同情况的人预测事件如何随时间发生（称为建模研究）。COVID-19研究模拟了中国、英国、韩国和游轮“钻石公主号"（Diamond Princess）上的疫情。四项研究回顾了检疫隔离对178，122名有关SARS和MERS疫情的人的影响（称为"队列"研究）。其余的研究模拟了SARS和MERS的爆发。

模型研究发现，模拟检疫隔离措施使患病人数减少44%至81%，死亡人数减少31%至63%。将检疫隔离与其他措施相结合，如关闭学校或保持社交距离，在减少COVID-19传播方面比单独检疫隔离更有效。SARS和MERS研究与COVID-19的研究一致。

两项SARS模拟研究评估了成本。他们发现，检疫隔离措施开始的越早，成本越低。

由于几个原因，我们不能完全肯定我们找到的证据。COVID-19的研究基于有限的数据建立了模型，并对病毒做出了不同的假设（例如传播速度）。其他的研究调查了SARS和MERS，所以我们不能假设COVID-19的结果是相同的。

证据质量

研究人员不可能向ICU的工作人员隐藏进食方式，这可能会使调查结果产生偏倚，而研究者也并没有始终如一地报告好的研究方法。每项研究中的患者都患有不同类型的严重疾病（如外伤、基础病症或术后阶段），这可能影响了他们对喂养方式的应答，而且我们的许多测量数据都是有局限性的。我们认为证据的质量是低的或非常低的。

结论

尽管证据有限，但所有研究都发现，检疫隔离在减少感染人数和死亡人数方面具有重要意义。结果表明，实施检疫隔离越早效果越好，费用越低。将检疫隔离措施与其他防治措施相结合，比单纯的检疫隔离效果更好。

本快速评价纳入的证据截至2020年3月12日。

结论: 

目前关于COVID-19的证据仅为基于当前零散知识进行的参数假设建模研究。研究结果一致表明，检疫隔离对于降低COVID-19大流行期间的发病率和死亡率十分重要。尽早实施检疫隔离，并与其他公共卫生措施相结合，对确保检疫隔离的有效性具有重要意义。为了保持措施的最佳平衡，决策者必须不断监测疫情情况和实施措施的影响。在不同环境下对代表性样本进行测试可以帮助评估病毒感染的真实患病率，并减少建模假设的不确定性。

本综述由WHO委托进行，并得到多瑙河大学克雷姆斯分校（Danube-University-Krems）的支持。

译者：江月；审校：乔舒昱、鲁春丽；编辑排版：张晓雯、刘美迪，北京中医药大学循证医学中心

针对疫情，Cochrane目前已推出4个特辑：重症医护证据、防控措施证据、大流行期间戒烟措施证据、局部麻醉以减少麻醉中的药物使用并避免气雾生成，以上特辑涉及的系统综述已汉化。更多资源可进入官网查阅Cochrane新冠疫情资源合集[3]。

[1]https://www.cochrane.org/cochranes-work-rapid-reviews-response-covid-19

[2]https://www.cochrane.org/CD013574/INFECTN_how-effective-quarantine-alone-or-combined-other-public-health-measures-control-coronavirus-covid

[3]https://www.cochrane.org/coronavirus-covid-19-cochrane-resources-and-news

【Cochrane Plain Language Summary】How effective is quarantine alone or combined with other public health measures to control coronavirus (COVID-2019)?

Background

Coronavirus (COVID-19) is a new virus that has spread quickly throughout the world. COVID-19 spreads easily between people who are in close contact, or through coughs and sneezes. Most infected people suffer mild, flu-like symptoms but some become seriously ill and even die.

There is no effective treatment or vaccine (a medicine that stops people catching a specific disease) for COVID-19, so other ways of slowing (controlling) its spread are needed. One of the World Health Organization’s (WHO) recommendations for controlling the disease is quarantine. This means separating healthy people from other healthy people, in case they have the virus and could spread it. Other similar recommendations include isolation (like quarantine, but for people with COVID-19 symptoms) and social distancing (where people without symptoms keep a distance from each other physically).

What did we want to find out?

We wanted to find out whether and how effectively quarantine stops COVID-19 spreading and if it prevents death. We wanted to know if it was more effective when combined with other measures, such as closing schools. We also wanted to know what it costs.

Study characteristics

COVID-19 is spreading rapidly, so we needed to answer this question as quickly as possible. This meant we shortened some steps of the normal Cochrane Review process. Nevertheless, we are confident that these changes do not affect our overall conclusions.

We looked for studies that assessed the effect of any type of quarantine, anywhere, on the spread and severity of COVID-19. We also looked for studies that assessed quarantine alongside other measures, such as isolation, social distancing, school closures and hand hygiene. COVID-19 is a new disease, so, to find as much evidence as possible, we also looked for studies on similar viruses, such as SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome).

Studies measured the number of COVID-19, SARS or MERS cases, how many people were infected, how quickly the virus spread, how many people died, and the costs of quarantine.

Key results

We included 29 studies. Ten studies focused on COVID-19, 15 on SARS, two on SARS plus other viruses, and two on MERS. Most of the studies combined existing data to create a model (a simulation) for predicting how events might occur over time, for people in different situations (called modelling studies). The COVID-19 studies simulated outbreaks in China, UK, South Korea, and on the cruise ship Diamond Princess. Four studies looked back on the effect of quarantine on 178,122 people involved in SARS and MERS outbreaks (called ‘cohort’ studies). The remaining studies modelled SARS and MERS outbreaks.

The modelling studies all found that simulated quarantine measures reduce the number of people with the disease by 44% to 81%, and the number of deaths by 31% to 63%. Combining quarantine with other measures, such as closing schools or social distancing, is more effective at reducing the spread of COVID-19 than quarantine alone. The SARS and MERS studies agreed with the studies on COVID-19.

Two SARS modelling studies assessed costs. They found that the costs were lower when quarantine measures started earlier.

We cannot be completely certain about the evidence we found for several reasons. The COVID-19 studies based their models on limited data and made different assumptions about the virus (e.g. how quickly it would spread). The other studies investigated SARS and MERS so we could not assume the results would be the same for COVID-19.

Conclusion

Despite limited evidence, all the studies found quarantine to be important in reducing the number of people infected and the number of deaths. Results showed that quarantine was most effective, and cost less, when it was started earlier. Combining quarantine with other prevention and control measures had a greater effect than quarantine alone.

This review includes evidence published up to 12 March 2020.

Authors' conclusions:

Current evidence for COVID-19 is limited to modelling studies that make parameter assumptions based on the current, fragmented knowledge. Findings consistently indicate that quarantine is important in reducing incidence and mortality during the COVID-19 pandemic. Early implementation of quarantine and combining quarantine with other public health measures is important to ensure effectiveness. In order to maintain the best possible balance of measures, decision makers must constantly monitor the outbreak situation and the impact of the measures implemented. Testing in representative samples in different settings could help assess the true prevalence of infection, and would reduce uncertainty of modelling assumptions.

This review was commissioned by WHO and supported by Danube-University-Krems.

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