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Just over a year ago, the WHO announced that the spread of the coronavirus, sars-cov2, could be classified as a pandemic. Then there was no vaccine or specific drugs. The best way to reduce the spread of the infection were so-called non-pharmaceutical measures, such as closing schools, quarantining travelers, and closing restaurants, shops, and workplaces.
In the case of influenza, children are a driver in the spread of the infection, but during the first months of 2020 it was not clear if the same was happening with covid-19. Data from China did not show a large spread of the infection among children, but many were still concerned and demanded the closure of schools. Sweden kept primary schools open, but in most countries schools were closed or switched to distance education. In Norway, the students were sent home in mid-March 2020.
Schools are important for much more than just children’s learning, and therefore schools cannot be closed for long.
In 2020, schools around the world were closed due to uncertainty about the role of children in the pandemic.
Photo: Veronika Ljung-Nielsen
Atle Fretheim, Head of Research at The National Institute of Public Health, the Norwegian equivalent of the Swedish Public Health Agency, had the idea to obtain better data on the role of children in the pandemic. Imagine if you could randomly see which schools were opened and see how the spread of infection affects society. The country’s health minister and many municipal doctors thought it was a good idea. But there was no such study.
– The government did not believe they had public opinion with them. They thought that everyone wanted the children to go back to school and that is why they did not accept that half had to wait a while. Opinion fluctuates rapidly. In the spring, many people first wanted to close the schools, but a few weeks later they reopened. And when the second wave came in Europe, they wanted to close schools again, says Atle Fretheim.
He is a strong proponent of so-called randomized controlled trials, where two groups are randomly assigned to different types of measures. This type of study generally provides very good evidence as to whether it is the leading measure of outcome and is standard during clinical drug and vaccine trials. However, there have been hardly any randomized trials of non-pharmaceutical measures during the year.
– There are only a handful of randomized trials of non-pharmaceutical measures against COVID-19 around the world! Compare that to the maybe a thousand randomized studies done with different drugs. I am in favor of randomized drug trials. But there is nothing to explain why we have conducted so many randomized studies on drugs, but nothing about the main measures to reduce the spread of infection, and they are much more dramatic and affect people’s lives, says Atle Fretheim.
Atle Fretheim, head of research at the National Institute of Public Health
Photo: Private
Randomized trials for non-pharmaceutical measures it is more difficult to carry out than for drugs, but it is not impossible. On the one hand, researchers must have the support of the public and politicians. And furthermore, the studies must be very large to give clear results.
Atle Fretheim participated in a study in which people were randomly assigned to exercise in the gym or not. But because there was so little infection, the researchers did not get a clear result.
– It was a bit the same problem with the Danish oral protection study. There were very few cases of infection. The researchers had also calculated that mouth protection would reduce the risk of infection by 50 percent, it was unrealistically optimistic to think that the effect would be so high, he says.
We also do harm with non-pharmaceutical measures. Everyone agrees on that, but not much is said about it.
He believes that the Danish study needed to be much larger to have a chance of showing a statistically significant effect between the groups when the spread of infection was so low in Denmark at the time the study was conducted.
State of uncertain knowledge manager to different interpretations and strong opinions. Oral protection is one of those problems. A new collection of knowledge from the European Infection Control Agency estimates that the effect of oral protection in the general public is low to moderate, at the same time there are great scientific uncertainties and therefore it is not even possible to give a recommendation on whether people should wear cloth mouth guard or disposable mouth guard.
One discussion is whether equally strong evidence is needed to introduce different measures during a pandemic. Atle Fretheim points out that everyone agrees that the spread of infection is reduced by getting people to keep their distance. But how do we do it better?
You think it can be compared to vaccine studies. Although it was urgent to save lives, they did not want to skip the latest major studies on covid-19 vaccines because we needed to be sure that vaccines protected against disease and were safe.
– We also do harm with non-pharmaceutical measures. Everyone agrees on that, but not much is said about it. We need good documentation of the benefit to be able to compare it to the harm. This applies to non-pharmaceutical measures as well as drugs and vaccines, he says.
Photo: Henrik Isaksson / TT
But not everyone agrees with, especially during the emergency pandemic.
Another reason we don’t know much about infection control measures is that they are often introduced at the same time.
– If you close schools and shops, prohibit the sale of alcohol and recommend mouthwashes at the same time and you see that the infection goes down, you cannot know what has had the greatest effect or if something has really had the opposite effect. This is quite easily solved with a randomization, says Atle Fretheim.
It is not possible to carry out this type of study in Norway because all health research requires the consent of all affected people. Atle Fretheim and his colleagues were unaware of the legal limitation when they planned the school study. Now, instead, they are trying to collect data from different measures in different municipalities in Norway and compare it with municipalities that do not do the same, for example, the ban on serving alcohol.
– It is not an optimal data, because it is also more contagious what causes the closure of the alcohol service. But that’s the only thing we can do.
As the more are being vaccinated and the pandemic is expected to be ending, at least in our part of the world, reducing interest in conducting randomized trials on non-pharmaceutical measures. But it’s not just about learning about this pandemic, and therefore randomized studies are necessary even in an emergency, believes Atle Fretheim.
– We believe that there will be new pandemics, so it is important that we have thought about what we have learned. My agenda is to evaluate the measures that are being introduced now but also to generate knowledge for the next pandemic and how we can do real-time evaluations when the next wave arrives. The most important lesson is that we must be much more prepared to learn.
Read more: What does science know about helping against a pandemic?
