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Lessons from Countries Implementing Find, Test, Trace, Isolation and Support Policies in the Rapid Response of the COVID-19 Pandemic: a Systematic Review

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Lessons from Countries Implementing Find, Test, Trace, Isolation and Support Policies in the Rapid Response of the COVID-19 Pandemic: a Systematic Review BMJ Open: first published as 10.1136/bmjopen-2020-047832 on 29 June 2021. Downloaded from Open access Original research Lessons from countries implementing find, test, trace, isolation and support policies in the rapid response of the COVID-19 pandemic: a systematic review Sheng- Chia Chung ,1 Sushila Marlow,2 Nicholas Tobias,3 Alessio Alogna,4 Ivano Alogna,5 San- Lin You,6,7 Kamlesh Khunti,8 Martin McKee ,9 Susan Michie,10 Deenan Pillay11 To cite: Chung S- C, Marlow S, ABSTRACT Strengths and limitations of this study Tobias N, et al. Lessons from Objective To systematically learn lessons from the countries implementing find, experiences of countries implementing find, test, trace, test, trace, isolation and support ► The study systematically reviews the core elements isolate, support (FTTIS) in the first wave of the COVID-19 policies in the rapid response of an effective find, test, trace, isolate, support of the COVID-19 pandemic: a pandemic. (FTTIS) system to interrupt the spread of COVID-19. systematic review. BMJ Open Design, data sources and eligibility criteria We Our findings can inform policy in future pandemics. 2021;11:e047832. doi:10.1136/ searched MEDLINE (PubMed), Cochrane Library, SCOPUS ► We reported optimal strategies reported in the lit- bmjopen-2020-047832 and JSTOR, initially between 31 May 2019 and 21 January erature to shorten case finding time, improve both 2021. Research articles and reviews on the use of contact ► Prepublication history and accuracy and efficiency of tests, coordinate stake- additional supplemental material tracing, testing, self- isolation and quarantine for COVID-19 holders and actors involved in an FTTIS system, sup- for this paper are available management were included in the review. port individuals as they progress from case finding online. To view these files, Data extraction and synthesis We extracted information to isolation and make appropriate use of digital tools please visit the journal online including study objective, design, methods, main findings to facilitate the programme. http://bmjopen.bmj.com/ (http:// dx. doi. org/ 10. 1136/ and implications. These were tabulated and a narrative ► The main limitation is the scarcity of quantitative bmjopen- 2020- 047832). synthesis was undertaken given the diverse research studies. Received 10 December 2020 designs, methods and implications. Revised 19 April 2021 Results We identified and included 118 eligible studies. Accepted 21 April 2021 We identified the core elements of an effective find, test, INTRODUCTION trace, isolate, support (FTTIS) system needed to interrupt Interrupting transmission of COVID-19 has the spread of a novel infectious disease, where treatment depended on rapid isolation of infected indi- or vaccination was not yet available, as pertained in viduals. For this to happen, a complex set of on July 5, 2021 at UCL Library Services. Protected by copyright. the initial stages of the COVID-19 pandemic. We report co- ordinated elements must be implemented methods used to shorten case finding time, improve accuracy and efficiency of tests, coordinate stakeholders to find potential cases, either by identifying and actors involved in an FTTIS system, support those who have symptoms or examination of individuals isolating and make appropriate use of digital individuals at risk, test to confirm the pres- tools. ence of infection, trace contacts, isolate those 1 2 Conclusions We identified in our systematic review infected and their contacts and support the key components of an FTTIS system. These include those in isolation to reduce the risk that they border controls, restricted entry, inbound traveller will breach any restrictions. quarantine and comprehensive case finding; repeated While various elements of a find, test, trace, © Author(s) (or their testing to minimise false diagnoses and pooled testing isolate, support (FTTIS) system have long employer(s)) 2021. Re- use in resource- limited circumstances; extended quarantine been core elements of the public health role, permitted under CC BY- NC. No period and the use of digital tools for contact tracing commercial re- use. See rights COVID-19 infection has some specific char- and permissions. Published by and self- isolation. Support for mental or physical health acteristics, such as transmission by presymp- BMJ. and livelihoods is needed for individuals undergoing tomatic and asymptomatic individuals3 and a For numbered affiliations see self- isolation/quarantine. An integrated system with strong age gradient in disease severity as well end of article. rolling- wave planning can best use effective FTTIS tools as other features that remain poorly under- to respond to the fast- changing COVID-19 pandemic. stood. Despite this uncertainty, some coun- Correspondence to Results of the review may inform countries considering tries have implemented successful COVID-19 Dr Sheng- Chia Chung; implementing these measures. s. chung@ ucl. ac. uk FTTIS programmes, which have achieved Chung S- C, et al. BMJ Open 2021;11:e047832. doi:10.1136/bmjopen-2020-047832 1 BMJ Open: first published as 10.1136/bmjopen-2020-047832 on 29 June 2021. Downloaded from Open access coordination among relevant actors, including central strategy is included in the online supplemental appendix and local government authorities, laboratories and the 1 section 1, and we apply the same search criteria for all medical care system.1 These actors are interconnected by the literature databases. The initial search included mate- integrated real- time information flow. However, the ways rial published up to 28 May 2020. Studies were limited to that they have created these systems have varied, largely those in which the subjects were human. Relevant reports determined by existing structures. and literature cited in the papers identified as well as mate- There are no simple solutions. Thus, digital tools were rial from other sources such as the COVID-19 Response initially seen as making a major contribution to FTTIS Monitor developed by the European Observatory on programmes.1 3 Yet while the English National Health Health Systems and Policies were also considered.10 Service (NHS) contact tracing app showed positive results The initial search was subsequently updated to include in a pilot study, decreasing rates of transmission,4 it strug- material published between June 2020 and January 2021 gled to achieve a sufficient level of uptake to be effective.5 (online supplemental appendix 1 section 2). Individuals, organisations or occupational groups with high COVID-19 risk need additional support to use such Study selection apps2 while it can be challenging to reduce the burden of In the MEDLINE search, clinical studies, clinical trials, unnecessary or repeated episodes of quarantine. evaluation studies, government documents, journal arti- The main challenges in implementing an FTTIS cles, multicentre studies, observational studies, practice programme include developing a strategy that can reduce guidelines, pragmatic clinical trials and technical reports delays in finding cases and contacts,1 ensuring the accu- were included, as were reviewed. Studies whose subject racy of tests,1 establishing integrated systems,6 7 reducing areas were in medicine or social sciences in SCOPUS, and barriers to adhering to regulations, especially isolating8 9 research reports in JSTOR (excluding book chapters) and mitigating adverse economic impacts on the liveli- were selected. We screened title, abstract and content hood of individuals affected.9 To inform and support the to remove studies unrelated to elements of FTTIS or design, implementation and continuous improvement of COVID-19. an FTTIS system, we conducted a systematic review, struc- Data collection process and data items tured to answer a series of key questions that arose during the initial response to the COVID-19 pandemic. These For each publication, we extracted (where appropriate) information on study design, method, results, main find- policy questions addressed the following issues: (1) infra- 11 structure and processes needed to achieve a sampling- ings and limitations using the PICOS tool. to- results process taking 24 hours or less, (2) adherence Summary measures and synthesis of results to isolation and local support needs, (3) real- time data http://bmjopen.bmj.com/ Following discussion with researchers involved in the management, linkage of datasets and dashboards and COVID-19 response in the UK (https://www. indepen- ownership of the data generated, (4) achieving a ‘rapid dentsage. org/), a list of key questions to answer was response’, (5) assimilation of an application (app) in developed and answered using the literature collected. light of the above, (6) overcoming the barriers to and Sheng- Chia Chung, Sushila Marlow and Nicholas Tobias enablers of being tested, reporting contacts and isolating screened studies and extracted the data and disagree- as a result of being contacted. ments were resolved through discussions. Risk of bias in individual studies on July 5, 2021 at UCL Library Services. Protected by copyright. METHODS As studies eligible for policy review were mostly qualita- The systematic review follows the Preferred Reporting tive, we managed by using the Critical Appraisal Skills Items for Systematic Reviews and Meta-Analyses guide- Programme (CASP) tool to assess the methodological line. The review protocol is described as the following. rigour of included studies12 (CASP Qualitative Studies Checklist).13 Eligible studies Eligible studies
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