Featured Review: Rapid, point-of-care antigen and molecular-based tests for diagnosis of SARS-CoV-2 infection
Why is this question important?
People with suspected COVID-19 need to know quickly whether they are infected, so that they can self-isolate, receive treatment, and inform close contacts. Currently, COVID-19 infection is confirmed by sending away samples, taken from the nose and throat, for laboratory testing. The laboratory test, called RT-PCR, requires specialist equipment, may require repeat healthcare visits, and typically takes at least 24 hours to produce a result.
Rapid point-of-care tests can provide a result ‘while you wait’, ideally within two hours of providing a sample. This could help people isolate early and reduce the spread of infection.
What did we want to find out?
We were interested in two types of rapid point-of-care tests, antigen and molecular tests. Antigen tests identify proteins on the virus, often using disposable devices. Molecular tests detect the virus’s genetic material, using small portable or table-top devices. Both test the same nose or throat samples as RT-PCR tests.
We wanted to know whether rapid point-of-care antigen and molecular tests are accurate enough to replace RT-PCR for diagnosing infection, or to select people for further testing if they have a negative result.
What did we do?
We looked for studies that measured the accuracy of rapid point-of-care tests compared with RT-PCR tests to detect current COVID-19 infection. Studies could assess any rapid antigen or molecular point-of-care test, compared with a reference standard test. The reference standard is the best available method for diagnosing the infection; we considered RT-PCR test results and clinically defined COVID-19 as reference tests. People could be tested in hospital or the community. Studies could test people with or without symptoms.
Tests had to use minimal equipment, be performed safely without risking infection from the sample, and have results available within two hours of the sample being collected. Tests could be used in small laboratories or wherever the patient is (in primary care, urgent care facilities, or in hospital).
How did studies assess diagnostic test accuracy?
Studies tested participants with the rapid point-of-care tests. Participants were classified as known to have – and not to have - COVID-19, by RT-PCR in all studies. Studies then identified false positive and false negative errors in the point-of-care test results, compared to RT-PCR. False positive tests incorrectly identified COVID-19 when it was not present, potentially leading to unnecessary self-isolation and further testing. False negatives missed COVID-19 when it was present, risking delayed self-isolation and treatment, and spread of infection.
What we found
We found 18 relevant studies. Ten studies took place in North America, four in Europe, two in South America, one in China and one in multiple countries.
Nine studies deliberately included a high percentage of people with confirmed COVID-19 or included only people with COVID-19. Fourteen studies did not provide any information about the people providing the samples for testing and 12 did not provide any information about where people were tested.
None of the studies reported included samples from people without symptoms.
Five studies reported eight evaluations of five different antigen tests. Overall, there was considerable variation between the results of the antigen tests in how well they detected COVID-19 infection. Tests gave false positive results in less than 1% of samples.
Thirteen evaluations of four different molecular tests correctly detected an average of 95% of samples with COVID-19 infection. Around 1% of samples gave false positive results.
If 1000 people had molecular tests, and 100 (10%) of them really had COVID-19:
- 105 people would test positive for COVID-19. Of these, 10 people (10%) would not have COVID-19 (false positive result).
- 895 people would test negative for COVID-19. Of these, 5 people (1%) would actually have COVID-19 (false negative result).
We noted a large difference in COVID-19 detection between the two most commonly evaluated molecular tests.
How reliable were the results of the studies?
Our confidence in the evidence is limited.
- Three-quarters of studies did not follow the test manufacturers’ instructions, so may have found different results if they had.
- Often, studies did not use the most reliable methods or did not report enough information for us to judge their methods. This may have affected estimates of test accuracy, but it is impossible to identify by how much.
- A quarter of studies were published early online as ‘preprints’ and are included in the review. Preprints do not undergo the normal rigorous checks of published studies, so we are uncertain how reliable they are.
What are the implications of this review?
Studies provided little information about their participants, so it is not possible to tell if the results can be applied to people with no symptoms, mild symptoms, or who were hospitalised with COVID-19. Accurate rapid tests would have the potential to select people for RT-PCR testing or to be used where RT-PCR is not available. However, the evidence currently is not strong enough and more studies are urgently needed to be able to say if these tests are good enough to be used in practice.
How up-to-date is this review?
This review includes evidence published up to 25 May 2020. Because new research is being published in this field, we will update this review soon.
Cochrane Sweden has been recognized for its outstanding achievements in promoting evidence-based decision-making in health care by moving from a Cochrane Associate Centre to being awarded full, independent Centre status
Being awarded full, independent Centre status acknowledges Cochrane Sweden’s dedication to producing and disseminating the best available information on health care for clinicians and patients in Sweden and beyond.
Cochrane is a global independent network of researchers, professionals, patients, carers and people interested in health. Cochrane works with collaborators from more than 130 countries to produce credible, accessible health information that is free from commercial sponsorship and other conflicts of interest, and our evidence is recognized as representing an international gold standard for high-quality, trusted information.
Cochrane Sweden, part of Cochrane since 2017, continues to promote evidence-based decision making in health care in Sweden by supporting and training new authors of Cochrane Reviews, as well as working with clinicians, researchers, professional associations, policy-makers, patients, and the media to encourage the dissemination and use of Cochrane evidence. Cochrane Sweden consists of longstanding, dedicated Cochrane enthusiasts and is located at the Skåne University Hospital, Lund, Sweden.
Being awarded full, independent Centre status acknowledges Cochrane Sweden’s dedication to producing and disseminating the best available information on health care for clinicians and patients in Sweden and beyond. Through their guidance Cochrane Interactive Learning has become a part of the curriculum at the Medical Faculty at Lund University and, more recently, at other Swedish faculties as well. Dina Muscat Meng, Communications Consultant at Cochrane Sweden, helped to launch of the Cochrane International Mobility Programme. Minna Johansson, Director of Cochrane Sustainable Health Care (which is based in Lund) and Karsten Juhl Jørgensen (Cochrane Nordic), toured the country giving talks at conferences and hosting workshops and seminars about Cochrane, which has resulted in an exciting increase in the publication of Cochrane reviews by Swedish authors.
Cochrane Sweden’s Director Matteo Bruschettini says: “We are grateful to Professor Ingemar Petersson, Head of Research at the University Hospital in Lund, for the wise and generous support since the very beginning. We’re also thankful to Professor Jan Kilhamn, Region Västra Götaland, for the support since 2020.
We aim to further expand the successful and strategic collaboration with the Cochrane Centres in Norway and Denmark and to facilitate networking and collaboration among the Scandinavian Cochrane Groups. Together with Martin Ringsten and all staff at Cochrane Sweden, we intend to collaborate in increasing the impact and use of Cochrane Reviews and to continue supporting Cochrane to reach its strategic objectives.”
Cochrane’s CEO Mark Wilson commented: “I am very pleased with the development of Cochrane Sweden into a full Cochrane Centre. Cochrane Sweden, despite being one of the newer Cochrane Groups, has already contributed substantially to Cochrane’s work in Sweden and beyond. Given the passion and generosity Matteo and team bring to everything they do, I am sure that he and the team will expand the reach and impact of Cochrane evidence in health decision making in Sweden in the coming years.”
Karsten Juhl Jørgensen, Acting Director of Cochrane Nordic, adds: “It has been a great pleasure to see the enthusiasm and growth of Cochrane Sweden over the past few years. We, at Cochrane Nordic, are extremely proud to have contributed our small bit to this development and we look forward to many years of continued collaboration, expanding our scope and support of Cochrane activities across Scandinavia, also including Cochrane Norway. Gaining full, independent Centre status for Cochrane Sweden is a considerable achievement and very well deserved.”
To mark the Centre status achievement, Cochrane Sweden will be holding an open online virtual seminar, ‘Cochrane – not just randomized trails of treatment effects’ on 1 September. In this webinar they will go over current activities and future initiatives of Cochrane in the Scandinavian countries. Each topic will be presented by experts in the respective field and followed by Q&A and a short discussion.
Answer this survey to help shape Cochrane’s future COVID-19 response.
Cochrane’s response to the COVID-19 pandemic so far has been a collaborative effort and drawn on the strengths of our global Community. We are proud of the COVID-19 evidence we have published, and we are grateful for the rapid innovation, flexibility, and responsiveness to changing priorities that our Community has shown. But as an organization that wants our choices to be evidence based – and with the global pandemic likely to continue for the foreseeable future – even at this early stage we want to gather data and a wide range of views on Cochrane’s COVID-19 response, reflect on the findings, and use them to guide our future activities and approaches.
For this reason, over the next month, we would like to hear from you, the users of our evidence.
- What types of COVID-19 evidence are influencing your decisions?
- Where do you get your COVID-19 information from?
- What are the types and formats of evidence you need most?
The answers to the survey will help influence what is produced in the future. We want to hear from everyone about using research evidence – health policy makers, healthcare providers, patients and carers, researchers, and the general public.
Please provide your input by taking 10-15 minutes to complete this survey by 21st September, 2020: https://www.surveymonkey.com/r/XSRW9W3. It’s open to everyone! You do not need to give your name and you can leave any questions blank if they are not relevant to you.
Thank you for helping to shape the future of Cochrane’s COVID-19 response.Monday, August 24, 2020
The Cochrane UK team are inviting applications from people who would like to be ‘Cochrane UK Consumer Champions’. Deadline: 30 August 2020
The role will largely involve:
- Raising awareness of Cochrane’s work within the community
- Advocating for wider use of Cochrane’s work within consumer groups/organizations
- Promoting consumer involvement within Cochrane and Cochrane Groups
- Providing a connection between Cochrane and consumers
Cochrane UK invite applications from people who:
- are based in the UK
- have experience as a patient, or as a family member/carer for a patient
- have a keen interest in being, or becoming, a consumer advocate in their own area (whether in their local area or for a particular health condition)
You should be able to commit at least 4 hours a month to the role (maximum of 16 hours per month) and have no conflicts of interest that would prevent participation in the role.
The Cochrane Central Register of Controlled Trials (CENTRAL) is compiled from a number of sources, including PubMed and Embase. Since 2017, Cochrane and our development partner Metaxis have increased the number of sources feeding into CENTRAL and improved the efficiency of our processes through the use of APIs, machine learning and crowdsourcing , via Cochrane Crowd.
Cochrane’s Centralised Search Service (CSS) is an initiative in Cochrane that aims to populate CENTRAL with reports of randomised and quasi-randomised trials. Currently six different sources are searched regularly for RCTs.
A recent study published in the Journal of Clinical Epidemiology found that Cochrane's centralised search and screening processes are proving highly sensitive. The CSS is helping to make CENTRAL a comprehensive repository of randomized control trials, supporting review teams globally to find the evidence they need quickly and easily.
Specifications: Permanant, full-time
Location: Copenhagen, Denmark
Application Closing Date: 4 September 2020
Are you passionate about quality software? Do you have a drive to make a difference for health care world-wide? We are a global, independent organization that strives to inform health-care decisions every day. We gather and summarize the best evidence from research to help doctors, nurses, patients, carers, researchers, funders, and policymakers. We do not accept commercial or conflicted funding, and work to minimize risk of bias, in order to generate authoritative and reliable information.
“Cochrane summarizes the findings so people making important decisions – you, your doctor, the people who write medical guidelines – can use unbiased information to make difficult choices without having to read every study out there…” Sifting the evidence, The Guardian, 14 September 2016
Our development team is located in Copenhagen and supports the process of creating systematic reviews through a web-based application. We are a group of motivated, mission-driven people who are energized by working together. We care about our users, taking pride in delivering features which both ensure the quality of Cochrane systematic reviews and make review production easier and more efficient.
As our new software test engineer, you'd be leading the testing of our software, as well as helping us upgrade and build automated tests for our product. Our goal is to maintain product development velocity while having confidence in the quality of our code.
Who we’re after
We are primarily looking for someone motivated by the mission of Cochrane and of our development team – that is, someone who cares about facilitating improved evidence-based healthcare decisions. We would consider it a bonus if you have specific knowledge of Cochrane, evidence-based health care, systematic reviews, and/or the global health sector.
On a technical level, we are looking for an analytical and efficient problem solver that can challenge our product and the processes around it, with experience in designing and implementing test strategies for web applications in an Agile setting. Further details are in the job description.
We work in English.
What you'd be doing
- Working with a talented, passionate and collaborative agile team;
- Advocating cross-team to ensure quality-minded practices;
- Designing, implementing, and maintaining automatic and manual test solutions.
How to apply
For further information on the role and how to apply, please click here. The deadline to receive your application is by 4th September 2020. The supporting statement should indicate why you are applying for the post, and how far you meet the requirements, using specific examples. Note that we will assess applications as they are received, and therefore may fill the post before the deadline.
Please note Interviews to be held on 11th and 14th September 2020.
Sprains, strains and bruises: Oral non-steroidal anti-inflammatory drugs compared with other oral pain killers
Sprains, strains, and bruises are common injuries, and people with these injuries often require pain relief, given as a tablet or capsule that is swallowed (oral). Many types of oral painkillers are available to treat such injuries. The authors wanted to know whether there were any differences in people’s pain, swelling, function, or unwanted side effects when sprains, strains, and bruises were treated with oral non-steroidal anti-inflammatory drugs (NSAIDs, e.g. ibuprofen) compared with paracetamol, opioids (e.g. codeine), complementary or alternative medicines, or combinations of these.
What did the authors do?
They searched medical databases up to January 2020 for studies that compared NSAIDs with other painkillers in people with sprains, strains, and bruises. Study participants could be any age. They assessed the included studies to judge the reliability (certainty) of the evidence. They categorised the evidence as being of high, moderate, low, or very low certainty. High certainty means they are confident in the evidence, moderate certainty means they are fairly confident, low or very low certainty means that they are unsure or very unsure of the reliability of the evidence.
Results of searches and description of studies
The review includes 20 studies, with 3305 participants. Seven studies included people with ankle sprain only. Three studies included children only. Most of the participants of the other studies were young adults, and there were slightly more men than women. Few participants were aged over 65 years. Eleven studies compared NSAIDs with paracetamol, six studies compared NSAIDs with opioids, and four studies compared NSAIDs with paracetamol combined with an opioid. Studies reported outcomes at times varying from one hour after taking the medication, up to 10 to 14 days.
There is no difference between NSAIDs and paracetamol in pain after one to two hours, or after two to three days (high-certainty evidence), and there may be no difference after a week or more (low-certainty evidence). There is low-certainty evidence that NSAIDs may make little difference to swelling after a week or more. The authors are uncertain whether NSAIDs make a difference to return to function after a week or more (very low-certainty evidence). There is low-certainly evidence that NSAIDs may slightly increase unwanted side effects related to the gut.
There is probably no difference between NSAIDs and opioids in pain at one hour (moderate-certainly evidence), and there may be no difference four or seven days after taking medication (low-certainty evidence). They are uncertain whether NSAIDs make a difference to swelling after 10 days (very low-certainty evidence). There is low-certainty evidence that NSAIDs may increase return to function in 7 to 10 days. There is moderate-certainty evidence that NSAIDs probably result in fewer unwanted side effects, such as nausea and dizziness, compared with opioids.
The evidence suggests that there is little or no difference between NSAIDs and paracetamol combined with opioids in pain, swelling, return to function, or unwanted side effects. However, the evidence was very low certainty, so the authors are uncertain of these results.
No studies reported the risk of re-injury after treatment. The authors found no studies comparing NSAIDs with complementary or alternative medicines.
The body of evidence to date has found no difference between NSAIDs and other pain killers for pain relief for strains, sprains, and bruises in younger people. However, the authors need more, and better evidence on return to function and unwanted side effects in all age groups, particularly in older people.
Peter Jones Associate Professor of Emergency Medicine at the University of Auckland, Faculty of Medical and Health Sciences and Director of Emergency Medicine Research Adult Emergency Department, Auckland City Hospital summarized:
“Sprains, strains and bruises are common injuries. Often people are unsure which medication to take, anti-inflammatory drugs, paracetamol or an opioid such as codeine or to treat with a complimentary therapy or alternative medicine. We found evidence that there was no difference between the common pain medications in the amount of pain relief achieved. However, we need more, and better evidence on unwanted effects on the gut in all age groups but particularly in older people.”
This is an update of a Cochrane review published in 2015.
Thursday, August 13, 2020
For 12 hours the host Adam Smith (@BetterResearch) will be chatting with 55 researchers from all fields of dementia research, using video chat – live streamed using Zoom and YouTube. They will discus their research, the latest hot topics in their field, and how they are working to beat the disease and improve the lives of people affected. This event is open to everyone interested in finding out more about the latest research taking place on dementia and information will be accessible to researchers, healthcare professionals, and family and carers. It is a free event with donations being accepted to Alzheimer’s Research UK (@AlzResearchUK).
Dr Terry Quinn (@DrTerryQuinn), Coordinating Editor of Cochrane Dementia and Cogitative Improvement, will be sharing evidence from Cochrane systematic reviews and meta-analysis in dementia research and will be explaining how the Cochrane group is working to raise standards in research design and reporting. Dr Quinn will be speaking at the 19:30 - 20:00 GMT timeslot.
Cochrane is in the final year of its multi-year strategic plan, Strategy to 2020.
Strategy to 2020 has set in motion transformational change in the way Cochrane works at all levels of the organization with the aim of giving us the best chance to achieve our mission.
Watch the video below to see how Strategy to 2020 was developed and change it has ushered in for Cochrane:
We are now developing a new strategy for the period 2021 to 2025, and we want to hear from you! Let’s collaborate to define Cochrane’s strategy for the next five years.Wednesday, August 12, 2020
Cochrane is in the final year of its seven-year strategic plan, Strategy to 2020.
Strategy to 2020 set in motion transformational change in the way Cochrane works at all levels of the organization with the aim of giving us the best chance of achieving our mission. Watch the first in a new video series looking back over the last seven years and forward to the challenges and opportunities that remain for Cochrane on the Community website.
We intend that this new strategy, which will shape the organization’s priorities and investment approach for the next five years, will help us go further in realizing our vision of a world of better health for all people.
Many of the initiatives started during Strategy to 2020 are still being implemented and most of the strategic aims remain relevant. For this reason, the Governing Board and Senior Management Team are proposing the new strategic framework takes forward the structure of the Strategy to 2020, but with some important changes.
#Letscollaboratecochrane! The Governing Board and Senior Management Team want to hear from all Cochrane Groups, members and supporters about whether the proposed new vision, mission, goals and objectives represent your priorities for Cochrane over the coming years.
The aim is to launch the final version at the virtual Annual General Meeting in November 2020, with activities to deliver the outcomes set out in the framework beginning from 2021. Your input will be collated, reviewed and used to make changes to the version now open for consultation. As a collaborative membership organization, it is critical that the new strategic framework is sensitive to the experiences, insights and ambitions of Cochrane’s members and key stakeholders.
Our next strategy: Let’s collaborateWednesday, August 12, 2020
In a new systematic review, an author team from the Cochrane Infectious Diseases Group explored the evidence regarding managing histoplasmosis in people with HIV. Their review informed the PAHO/WHO guideline development process. The review authors worked with the guideline development group to formulate key questions, including which antifungal drug to start, how long to continue, and when to start antiretroviral medication. They also looked at tuberculosis therapy when people were infected with tuberculosis, HIV, and histoplasmosis.
Histoplasmosis is an infection caused by inhaling a fungus called Histoplasma. The most severe form of histoplasmosis is called progressive disseminated histoplasmosis, in which the infection spreads from the lungs to other organs. It is life‐threatening for people with advanced HIV. Before this Cochrane Review and the updated PAHO/WHO guidelines, the guidelines for management of disseminated in histoplasmosis were designed for high-resource settings, and were out of date, given that antiretroviral therapy (ART) is widely available and treatment paradigms have changed.
LSTM’s Clinical Research Associate Dr Marylou Murray and Infectious Diseases Consultant and Research Fellow Dr Paul Hine assessed the available evidence and included 17 studies in the Cochrane Review. They found that liposomal amphotericin B may improve clinical success compared to deoxycholate amphotericin B when starting treatment, and that liposomal amphotericin B results in less kidney damage compared to deoxycholate amphotericin B when starting treatment.
Based on the review evidence, it is unclear how long people should stay on treatment after they have successfully completed the starting stage. It is also unclear at what time during treatment of the fungal infection it is best to start treatment to fight the HIV virus. However, recognising the uncertainty is a key step to help prioritise important research questions going forward.
Dr Hine said: “Cochrane Infectious Diseases Group have forged new partnerships in this neglected field, helping with a big step forward in agreeing international guidelines and policy into the future”.
The internationally available WHO/PAHO guidelines will help direct treatment and improve outcomes. In addition, the guidelines and the consensus reached may help improve access to antifungal drugs for people living in low- and middle-income countries who suffer from HIV and histoplasmosis.
- Murray M, Hine P. Treating progressive disseminated histoplasmosis in people living with HIV. Cochrane Database of Systematic Reviews 2020, Issue 4. Art. No.: CD013594. DOI: 10.1002/14651858.CD013594.
- PAHO/WHO. Guidelines for Diagnosing and Managing Disseminated Histoplasmosis among People Living with HIV. www.paho.org/en/node/71472
- Learn more about Cochrane Infectious Diseases Group
Tuesday, August 11, 2020
- Contract: Fixed-term, 12 months
- Hours: Full time, 37.5 per week (part time considered)
- Salary: £31,365 - £37,890 per annum pro rata (dependent on experience)
- Position Closing: 20 August 2020
Cochrane Acute and Emergency Care Network is seeking a Network Support Fellow. Cochrane is a global, independent network of health practitioners, researchers, patient advocates and others, responding to the challenge of making vast amounts of research evidence useful for informing decisions about health. We do this by synthesizing research findings to produce the best available evidence on what can work, what might harm and where more research is needed. Our work is recognised as the international gold standard for high quality, trusted information.
This job is hosted by the Cochrane Pain, Palliative and Supportive Care Review Group (PaPaS CRG) at the Churchill Hospital, part of the Oxford University Hospitals NHS Foundation Trust. Flexible (home) working will be considered, with the expectation that the post holder will attend meetings in person when required. The post is funded by the National Institute for Health Research (NIHR) to work with the Network of Cochrane Review Groups (CRGs).
The Network Support Fellow will work in support of the general aims and objectives of the CRG Transformation Plan, but with a particular focus on ensuring that the Network is positioned to provide maximum support for the NHS. The Network Support Fellow will have an individual work plan aligned to the Network’s Strategic Plan which has the following objectives:
- supporting review production and capacity;
- evaluating Network scope and prioritisation of topics;
- fostering collaboration within the Network and with the wider Cochrane community;
- supporting knowledge translation to increase the impact of Cochrane Systematic Reviews;
- ensuring accountability and sustainability of the Network.
Please refer to the full job description and person specification for more details of the role.
Interventions for acute severe asthma attacks in children: an overview of Cochrane Reviews
Asthma is a common childhood illness that is caused by narrowing of the small air passages in the lungs. This narrowing is due to swelling and inflammation and to muscles around the air passages becoming tighter. An acute asthma attack results in shortness of breath, cough, wheeze, and chest tightness.
When children have an asthma attack, the standard treatment is to give steroids to reduce inflammation and swelling (usually given by mouth) and inhaled medications to relax the muscles in the air passages (called "bronchodilators"). In this review, that standard treatment is called "first-line" treatment. These medications are well understood to be the best treatments for use in the first instance.
Some children's asthma attacks do not improve with first-line treatment, and more treatment is necessary - usually at the emergency department or hospital; in this review, we call this 'second-line' treatment. However, the best second-line treatment for children who do not respond to first-line treatment is poorly understood. Many treatment options are available, and what is done for children varies from hospital to hospital.
The author team wanted to look at existing Cochrane Reviews of second-line treatments for children having asthma attacks. They aimed to be able to bring this information together in a useful way and to present the evidence that would help the practitioner make the best treatment decision for each child having an asthma attack when inhaled bronchodilators and oral steroids have not helped with symptoms.
The overview includes 13 Cochrane Systematic Reviews on various treatment options, including inhaled medication, intravenous medications, and other therapies. This overview provides the most up-to-date evidence from systematic reviews with meta-analyses of randomised controlled trials on acute severe asthma in children. This overview is current to December 2019.
For children with acute severe asthma requiring additional treatment, the authors found that:
- intravenous magnesium sulfate (a bronchodilator given through a vein) appears to reduce the length of time spent in hospital;
- no evidence suggests that any treatment reduced the risk of being admitted to intensive care;
- some treatments appeared to reduce the risk of hospital admission. These included adding a second type of inhaled bronchodilator treatment (anticholinergic medication such as ipratropium bromide) to standard inhaled treatment (beta-agonist such as salbutamol), giving intravenous magnesium sulfate, and breathing a mixture of helium and oxygen;
- serious adverse events may be reduced by inhaled magnesium sulfate;
- nausea and/or vomiting is more common with aminophylline (another bronchodilator medication given through a vein); and
- adding a second type of inhaled bronchodilator treatment (anticholinergic medication such as Ipratropium bromide) reduces the risk of nausea and tremor but not vomiting.
Why is this question important?
The global COVID-19 pandemic highlights the importance of accurate and timely contact tracing. Contact tracing tells people that they may have been near someone with - or showing symptoms of - an infectious disease, allowing them to self-isolate and helping to stop the spread of infection. Traditionally, contact tracing begins with notification that someone has an infectious disease. They are asked to recall their contacts, going back two to three days before symptom onset. This is time-consuming and may not always give a complete picture, so digital aids could help contact tracers.
Digital contact tracing uses technology to track and trace contacts. Individuals download an app onto their smartphones and record location and symptom information, or their devices might use location-finding technology, like Bluetooth or GPS (global positioning system). If the user is infected, the technology identifies close contacts and/or secondary infections (people to whom they passed the disease), and informs people whom they have been near. The technology identifies where the infection was passed on and its duration (the context).
However, problems may occur where access to technology is limited, in low-income settings or for elderly people, for example. Also, some people see it as an invasion of privacy and are suspicious of how their data will be used.
The authors wanted to know whether digital contact tracing, compared to manual contact tracing, is effective in reducing the spread of infection, as measured by secondary infections, identifying close contacts, tracing a complete set of contacts, and identifying the context of infection.
The authors found 12 relevant studies. Six assessed the effectiveness of digital contact tracing on specific groups (cohorts) of people: three during an outbreak (Ebola in Sierra Leone; tuberculosis in Botswana; and whooping cough (pertussis) in USA); and three replicated an outbreak in schools to assess systems for identifying close contacts of participants. The remaining six were modelling studies, which simulated digital contact tracing.
Digital contact tracing with self-isolation probably reduces the number of secondary infections, but not as much as manual contact tracing with self-isolation (2 modelling studies).
Digital contact tracing found more close contacts in two outbreaks than manual (2 studies in USA and Sierra Leone). Devices in non-outbreak settings can identify more close contacts than self-reported diaries or surveys.
An app may reduce the time to complete a set of close contacts (1 study). Digital systems were faster to use than paper systems for recording new contacts and monitoring known contacts, and possibly less prone to data loss.
Problems with system access (2 studies) included patchy network coverage, lack of data, technical problems and higher staff training needs. Contact tracers' personal expenses increased (1 study) due to travel and recharging phone batteries. Devices all appeared to protect diagnosed users from contacts, snoopers and authorities but one app's users were members of public health agencies. Studies recorded stolen hardware (second-hand mobile phones); reported that paper forms were "often lost", and that digital data were password protected (2 studies) and encrypted (1 study).
We found no evidence on contextual information and acceptability.
What this means
It is unlikely that digital technologies would be the sole method of contact tracing during an outbreak; they would probably be used alongside manual methods. Unfortunately, the technology is largely unproven in real-world outbreak settings and none of our included studies assessed digital plus manual contact tracing with digital contact tracing alone. Our included studies assessed different technologies and used different methods from each other, so we are uncertain about their evidence.
Governments that implement digital contact tracing should ensure that at-risk populations are not disadvantaged and take privacy concerns into account.
This review is up to date to May 2020.
Featured Review: Interventions available during pandemics for heavy menstrual bleeding: an overview of Cochrane reviews
Cochrane authors summarised the available evidence on the effectiveness and safety of treatments for heavy menstrual bleeding which can continue during pandemics.
Pandemics impact upon the ability to deliver specialist assessment and treatments. Examples of treatments that commonly continue during pandemics include non-steroidal anti-inflammatory drugs (NSAIDs), antifibrinolytics, combined hormonal contraceptives, and progestogen.
There is low-certainty evidence that NSAIDs (mefenamic acid) reduce heavy menstrual bleeding when compared with placebo.
There is moderate-certainty evidence that antifibrinolytics (tranexamic acid) and combined hormonal contraceptives reduce heavy menstrual bleeding when compared with placebo.
There is low-certainty evidence that antifibrinolytics (tranexamic acid) are more effective in reducing heavy menstrual bleeding when compared with NSAIDs and short-cycle progesterone
We were unable to draw conclusions about the effects of antifibrinolytics (tranexamic acid) when compared to long-cycle progesterone.
No conclusions can be made with regards to quality of life, women's satisfaction with treatment, or serious adverse events.
Dr James Duffy, Clinical Fellow, King’s Fertility, underscores the importance of the overview review, “During the COVID-19 pandemic it has become clear that the impact upon specialist assessment and treatment will continue. It is important health care professionals and women experiencing heavy menstrual bleeding have access to a Cochrane review which evaluates and summarises the evidence base for the treatments which can often continue during the pandemic.”
A decision aid has been developed to support shared decision making during virtual consultations. Women with heavy menstrual bleeding helped to develop the decision aid, which draws upon the evidence summarised within the Cochrane review.
Dr Duffy adds: "Developing a decision aid alongside the Cochrane overview presents a unique opportunity to bring together the best research evidence alongside a women’s preferences, circumstances, and values. We anticipate the decision aid will support shared decision making. It is important women experiencing heavy menstrual bleeding are able to understand the range of possible treatments available, their risks and benefits, and be afforded the opportunity to consider these decisions within their own context and circumstances."
Many healthcare workers are at the front line of the COVID-19 pandemic, delivering emergency and critical care, while others continue to deliver the broader services of the health system in hospitals, clinics, offices, communities, and homes. Working under difficult and stressful circumstances that are likely to continue for some time, exacerbates existing risk factors such as occupational stress and shift work. Supporting the wellbeing of healthcare workers will be crucial to sustaining our health systems during and beyond the current crisis.
This Special Collection brings together Cochrane evidence on interventions that may help support the wellbeing of the healthcare workforce and reducing occupational stress.
These reviews have been produced Cochrane Review Groups in three Networks: Cochrane Mental Health and Neuroscience; Cochrane Musculoskeletal, Oral, Skin and Sensory; and Cochrane Public Health and Health Systems. Some reviews in this collection have associated Cochrane Clinical Answers.
The Usher Institute at the University of Edinburgh is seeking a highly skilled and motivated epidemiologist/research fellow to work in the field of vascular disease, including both the diagnosis and treatment of peripheral vascular diseases and the development of vascular complications of type 2 diabetes. The primary role will be to undertake a series of high quality systematic reviews on the prevention, diagnosis and treatment of vascular diseases, including abdominal aortic aneurysm, venous thromboembolism and peripheral arterial disease, within the core programme of work which constitutes the CSO funded research project, Cochrane Vascular, one of 25 Cochrane review groups based in the UK. The main purpose of this work is to identify key areas of clinical importance to the management of peripheral vascular disease globally, and to produce and disseminate high quality evidence to guide clinical management, using state-of-the art systematic review methodology. They will also have a data management, quality control and supervisory role for a well-established epidemiological study (the Edinburgh Type 2 Diabetes Study), which aims to identify biomarkers and potential aetiological risk factors for vascular complications affecting people with type 2 diabetes.
Applicants must have (or expect to achieve) a PhD in epidemiology or related subject, with experience of the design, conduct and reporting of large-scale randomised controlled trials, prospective cohort studies and other epidemiological study types; execution of statistical analysis; adherence to data/research governance and best practice guidelines for use of health-related data; experience of handling large data-sets in a variety of databases. Applicants will also have excellent scientific writing skills, with a good publication track record (minimum three publications in peer-reviewed journals, with at least one paper reporting analysis of an epidemiological study and/or systematic review).
The post is available from 1 August 2020 or as soon as possible thereafter, part-time (20 hours per week) and available until 31 December 2022.
In medicine, rehabilitation is a multiprofessional process aimed at enhancing and restoring functional ability and quality of life to people with impairments or disabilities. In the context of the COVID-19 pandemic, rehabilitation focuses on the sequelae of the disease as well as on the impairment due to treatments applied. COVID-19 patients may develop a myriad of acute medical problems and their treatment often requires invasive procedures: all of which can cause mid- and long-term consequences requiring rehabilitation. Rehabilitation is applied throughout the continuum of care, starting in the acute, mostly in the post-acute and continuing in the chronic phase of a disease. As well, there has been a disruption of regular rehabilitation of people with disabilities and chronic diseases due to quarantine, social isolation, movement restriction, and other healthcare systems’ disruptions. Given the current COVID-19 situation, having the best available rehabilitation evidence is even more important to help reduce clinical uncertainty.
To update the rehabilitation community on the growing evidence for the role of rehabilitation in management of COVID-19 patients, Cochrane Rehabilitation launched the REH-COVER (Rehabilitation – Covid-19 Evidence-based Response) action.
The aim of this action is to focus on the timely collection, review, and dissemination of summarized and synthesized evidence relating to COVID-19 and rehabilitation. This will create an evidence-based answer repository to the newly-risen clinical questions and problems. The action was developed by an international multi-professional Steering Committee, whose role will continue to advise on all initiatives included in this action.
Cochrane Rehabilitation REH-COVER action currently includes four main initiatives:
- Rapid living Systematic Reviews on Rehabilitation and COVID-19 updates published monthly
- Interactive living evidence map on Rehabilitation and COVID-19
- Definition of the research topics on “Rehabilitation and COVID-19” in collaboration with the WHO rehabilitation programme
- Forthcoming Cochrane Library Special Collection: Coronavirus (COVID-19): rehabilitation of patients with functional consequences of acute illness and its treatments, will be published soon
Other initiatives under development include:
- Living Systematic Review on “current evidence on rehabilitation of patients with functional consequences of COVID-19 and its treatments”: results expected in July 2020
- Collaboration with COVID-END for the topics “rehabilitation” and “disability”: discussion started in June 2020
The number of people who do not have enough to eat in the world has been increasing since 2015. Most of these people live in low- and middle-income countries (LMICs), especially in Asia and Africa. Food insecurity is when people do not have physical, social and economic access to sufficient, safe, nutritious foods to be healthy. That is, they do not have enough money to buy food, or do not have anywhere to shop or cannot find food near to where they live. Food insecurity affects the health, social and economic situation of individuals and communities.
COVID-19 and food insecurity Food insecurity has increased as a result of measures implemented throughout the world to prevent the spread of COVID-19. ‘Lockdowns’ restrict people’s movement and their ability to work, leading to loss of income and livelihoods, particularly for people in the informal economy. This, in turn, limits people’s physical and economic access to food. Disruptions to food supply, from harvesting to transport to labour supply, negatively affect food prices and availability. School closures affect millions of children who access food through school meal schemes. The effects of lockdown are felt everywhere, but disproportionally affect poor and vulnerable people.
This Cochrane Review looked at the effect of community-level interventions on individuals, households and communities in LMICs to improve access to nutritious food. The main outcome was food security, measured by prevalence of undernourishment, proportion of household expenditure on food, and proportion of people and households who ate a diverse diet, that is, a variety of foods from different food groups. Other outcomes reflected nutritional status, such as how well children grew (stunting), low body weight (wasting) and cognitive function (thoughts and understanding).
The review authors found 59 studies that assessed different interventions, mainly in Africa and Latin America. Many studies assessed cash transfers, which are welfare programmes where money is provided to households. Of these, 21 studies evaluated unconditional cash transfers, where there are no conditions for receiving the money, and 14 studies assessed conditional cash transfers, where people had to meet specific conditions in order to receive the money. Seventeen studies looked at income generation interventions (for example, livestock management or self-help groups), four studies at food vouchers, four studies at providing food and nutrition subsidies, and two studies looked at social support interventions such as village savings and loans and community grant programmes.
Unconditional cash transfers improve food security but make little or no difference to cognitive function or development. They may increase dietary diversity and may reduce stunting. It is very uncertain whether unconditional cash transfers reduce the proportion of household expenditure on food or reduce wasting. Evidence from one study indicates that unconditional cash transfers reduce the proportion of infants who are overweight.
Conditional cash transfers make little to no difference in the proportion of household expenditure on food and slightly improve cognitive function in children, probably slightly improve dietary diversity, and may make little to no difference to stunting or wasting. Evidence from two studies shows that conditional cash transfers make no difference to the proportion of overweight children.
Income generation strategies make little or no difference to stunting or wasting, may result in little to no difference to food security and may improve dietary diversity in children but not for households.
Food vouchers probably reduce stunting, may slightly improve dietary diversity and may result in little to no difference in wasting.
Food and nutrition subsidies may improve dietary diversity among school children. We are very uncertain about the effects on household expenditure on healthy foods as a proportion of total expenditure on food.
Social support interventions such as community grants probably make little to no difference to wasting and may make little or no difference to stunting. We are very uncertain about the effects of village savings and loans on food security or dietary diversity.
None of the included studies reported on one of the primary outcomes: prevalence of undernourishment.
This review provides policy makers with a comprehensive evidence base to evaluate the effects of a wide range of community-level interventions to address access to food in low- and middle-income countries (LMICs). The body of evidence indicates that UCTs can improve food security but the review authors are less sure about the effects of other interventions. Some limitations of the review include not having all necessary information about what outcomes the studies measured, having to make judgements regarding which outcome measures to report and inability to pool the results of all studies reporting on the same outcome. Another limitation was that the review authors were unable to find out what specific intervention features enable or impede the effective implementation of the intervention.