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Jefferson T, Dooley L, Ferroni E, Al-Ansary LA, van Driel ML, Bawazeer GA, Jones MA, Hoffmann TC, Clark J, Beller EM, Glasziou PP, Conly JM. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev 2023; 1:CD006207. [PMID: 36715243 PMCID: PMC9885521 DOI: 10.1002/14651858.cd006207.pub6] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID-19 pandemic. OBJECTIVES To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. SEARCH METHODS We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cluster-RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. MAIN RESULTS We included 11 new RCTs and cluster-RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID-19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID-19 pandemic. Many studies were conducted during non-epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza-like illness (ILI)/COVID-19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate-certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory-confirmed influenza/SARS-CoV-2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate-certainty evidence). Harms were rarely measured and poorly reported (very low-certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low-certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low-certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate-certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low-certainty evidence). One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non-inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID-19 patients. Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta-analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate-certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low-certainty evidence), and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low-certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low-certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low-certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports. AUTHORS' CONCLUSIONS The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory-confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs.
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Affiliation(s)
- Tom Jefferson
- Department for Continuing Education, University of Oxford, Oxford OX1 2JA, UK
| | - Liz Dooley
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Eliana Ferroni
- Epidemiological System of the Veneto Region, Regional Center for Epidemiology, Veneto Region, Padova, Italy
| | - Lubna A Al-Ansary
- Department of Family and Community Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mieke L van Driel
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Ghada A Bawazeer
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mark A Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Tammy C Hoffmann
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Elaine M Beller
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Paul P Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - John M Conly
- Cumming School of Medicine, University of Calgary, Room AGW5, SSB, Foothills Medical Centre, Calgary, Canada
- O'Brien Institute for Public Health and Synder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Calgary Zone, Alberta Health Services, Calgary, Canada
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2
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BALCI A, ÇİLEKAR Ş, COŞĞUN İG. Knowledge and Attitude of New Coronavirus Epidemic (COVID-19) Among Health Care Workers. BEZMIALEM SCIENCE 2022. [DOI: 10.14235/bas.galenos.2021.4935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Change in Pediatric Health Care Spending and Drug Utilization during the COVID-19 Pandemic. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121183. [PMID: 34943379 PMCID: PMC8699860 DOI: 10.3390/children8121183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 11/26/2021] [Accepted: 12/09/2021] [Indexed: 12/23/2022]
Abstract
Objective: To evaluate how the restrictive measures implemented during the SARS-CoV-2 pandemic have influenced the incidence of the most common children’s diseases and the consumption of medications in 2020 compared to 2019. Methods: We involved all family pediatricians of the local health authority of Latina, from which we requested data of monthly visits in 2019 and 2020 for six common diseases disseminated through droplets and contact, and the territorial and integrative pharmaceutical unit of the area, from which we requested data of the net expenditure regarding the most commonly used drugs at pediatric age. Results: There was significant reduction in the incidence of the evaluated diseases and in the consumption of investigated drugs between 2019 and 2020 in the months when the restrictive measures were in place, with an attenuation of this effect during the months of the gradual loosening of those measures. Conclusion: Nonpharmaceutical intervention measures have caused changes in the diffusion of common pediatric diseases. We believe that the implementation of a reasonable containment strategy, even outside of the pandemic, could positively influence the epidemiology of infectious and allergic diseases in children, and healthcare system spending.
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Saadeh H, Saadeh M, Almobaideen W, Al Refaei A, Shewaikani N, Al Fayez RQ, Khawaldah H, Abu-Shanab S, Al-Hussaini M. Effect of COVID-19 Quarantine on the Sleep Quality and the Depressive Symptom Levels of University Students in Jordan During the Spring of 2020. Front Psychiatry 2021; 12:605676. [PMID: 33664681 PMCID: PMC7920987 DOI: 10.3389/fpsyt.2021.605676] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/25/2021] [Indexed: 01/08/2023] Open
Abstract
Objectives: This study was designed to assess the effect of COVID-19 home quarantine and its lifestyle challenges on the sleep quality and mental health of a large sample of undergraduate University students in Jordan. It is the first study applied to the Jordanian population. The aim was to investigate how quarantine for several weeks changed the students' habits and affected their mental health. Methods: A cross-sectional study was conducted using a random representative sample of 6,157 undergraduate students (mean age 19.79 ± 1.67 years, males 28.7%) from the University of Jordan through voluntarily filling an online questionnaire. The Pittsburgh Sleep Quality Index (PSQI) and the Center for Epidemiologic Studies-Depression Scale (CES-D) were used to assess sleep quality and depressive symptoms, respectively. Results: The PSQI mean score for the study participants was 8.1 ± 3.6. The sleep quality of three-quarters of the participants was negatively affected by the extended quarantine. Nearly half of the participants reported poor sleep quality. The prevalence of poor sleep quality among participants was 76% (males: 71.5% and females: 77.8%). Similarly, the prevalence of the depressive symptoms was 71% (34% for moderate and 37% for high depressive symptoms), with females showing higher prevalence than males. The overall mean CES-D score for the group with low depressive symptoms is 9.3, for the moderate group is 19.8, while it is 34.3 for the high depressive symptoms group. More than half of the students (62.5%) reported that the quarantine had a negative effect on their mental health. Finally, females, smokers, and students with decreased income levels during the extended quarantine were the common exposures that are significantly associated with a higher risk of developing sleep disturbances and depressive symptoms. Conclusions: Mass and extended quarantine succeeded in controlling the spread of the COVID-19 virus; however, it comes with a high cost of potential psychological impacts. Most of the students reported that they suffer from sleeping disorders and had a degree of depressive symptoms. Officials should provide psychological support and clear guidance to help the general public to reduce these potential effects and overcome the quarantine period with minimum negative impacts.
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Affiliation(s)
- Heba Saadeh
- Computer Science Department, King Abdullah II School of Information Technology Faculty, The University of Jordan, Amman, Jordan
| | - Maha Saadeh
- Computer Engineering and Informatics, Middlesex University Dubai, Dubai, United Arab Emirates
| | - Wesam Almobaideen
- Computer Science Department, King Abdullah II School of Information Technology Faculty, The University of Jordan, Amman, Jordan.,Electrical Engineering and Computing Sciences, Rochester Institute of Technology, Dubai, United Arab Emirates
| | | | | | - Reem Qadan Al Fayez
- Computer Information System Department, King Abdullah II School of Information Technology Faculty, The University of Jordan, Amman, Jordan
| | - Hamzah Khawaldah
- Geography Department, School of Arts, The University of Jordan, Amman, Jordan
| | | | - Maysa Al-Hussaini
- Department of Pathology and Laboratory Medicine, King Hussein Cancer Center, Amman, Jordan.,Human Research Protection Program Office, King Hussein Cancer Center, Amman, Jordan
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5
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Cowling BJ, Leung GM. Face masks and COVID-19: don't let perfect be the enemy of good. Euro Surveill 2020; 25:2001998. [PMID: 33303063 PMCID: PMC7730488 DOI: 10.2807/1560-7917.es.2020.25.49.2001998] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 12/09/2020] [Indexed: 01/31/2023] Open
Affiliation(s)
- Benjamin J Cowling
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health, Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China
| | - Gabriel M Leung
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health, Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China
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Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, van Driel ML, Jones MA, Thorning S, Beller EM, Clark J, Hoffmann TC, Glasziou PP, Conly JM. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev 2020; 11:CD006207. [PMID: 33215698 DOI: 10.1101/2020.03.30.20047217] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review published in 2007, 2009, 2010, and 2011. The evidence summarised in this review does not include results from studies from the current COVID-19 pandemic. OBJECTIVES To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. SEARCH METHODS We searched CENTRAL, PubMed, Embase, CINAHL on 1 April 2020. We searched ClinicalTrials.gov, and the WHO ICTRP on 16 March 2020. We conducted a backwards and forwards citation analysis on the newly included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cluster-RCTs of trials investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, and gargling) to prevent respiratory virus transmission. In previous versions of this review we also included observational studies. However, for this update, there were sufficient RCTs to address our study aims. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Three pairs of review authors independently extracted data using a standard template applied in previous versions of this review, but which was revised to reflect our focus on RCTs and cluster-RCTs for this update. We did not contact trialists for missing data due to the urgency in completing the review. We extracted data on adverse events (harms) associated with the interventions. MAIN RESULTS We included 44 new RCTs and cluster-RCTs in this update, bringing the total number of randomised trials to 67. There were no included studies conducted during the COVID-19 pandemic. Six ongoing studies were identified, of which three evaluating masks are being conducted concurrent with the COVID pandemic, and one is completed. Many studies were conducted during non-epidemic influenza periods, but several studies were conducted during the global H1N1 influenza pandemic in 2009, and others in epidemic influenza seasons up to 2016. Thus, studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Compliance with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included nine trials (of which eight were cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and seven in the community). There is low certainty evidence from nine trials (3507 participants) that wearing a mask may make little or no difference to the outcome of influenza-like illness (ILI) compared to not wearing a mask (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.82 to 1.18. There is moderate certainty evidence that wearing a mask probably makes little or no difference to the outcome of laboratory-confirmed influenza compared to not wearing a mask (RR 0.91, 95% CI 0.66 to 1.26; 6 trials; 3005 participants). Harms were rarely measured and poorly reported. Two studies during COVID-19 plan to recruit a total of 72,000 people. One evaluates medical/surgical masks (N = 6000) (published Annals of Internal Medicine, 18 Nov 2020), and one evaluates cloth masks (N = 66,000). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). There is uncertainty over the effects of N95/P2 respirators when compared with medical/surgical masks on the outcomes of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; very low-certainty evidence; 3 trials; 7779 participants) and ILI (RR 0.82, 95% CI 0.66 to 1.03; low-certainty evidence; 5 trials; 8407 participants). The evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirator compared to a medical/surgical mask probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; moderate-certainty evidence; 5 trials; 8407 participants). Restricting the pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies. One ongoing study recruiting 576 people compares N95/P2 respirators with medical surgical masks for healthcare workers during COVID-19. Hand hygiene compared to control Settings included schools, childcare centres, homes, and offices. In a comparison of hand hygiene interventions with control (no intervention), there was a 16% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.84, 95% CI 0.82 to 0.86; 7 trials; 44,129 participants; moderate-certainty evidence), suggesting a probable benefit. When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.98, 95% CI 0.85 to 1.13; 10 trials; 32,641 participants; low-certainty evidence) and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials; 8332 participants; low-certainty evidence) suggest the intervention made little or no difference. We pooled all 16 trials (61,372 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. The pooled data showed that hand hygiene may offer a benefit with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.84 to 0.95; low-certainty evidence), but with high heterogeneity. Few trials measured and reported harms. There are two ongoing studies of handwashing interventions in 395 children outside of COVID-19. We identified one RCT on quarantine/physical distancing. Company employees in Japan were asked to stay at home if household members had ILI symptoms. Overall fewer people in the intervention group contracted influenza compared with workers in the control group (2.75% versus 3.18%; hazard ratio 0.80, 95% CI 0.66 to 0.97). However, those who stayed at home with their infected family members were 2.17 times more likely to be infected. We found no RCTs on eye protection, gowns and gloves, or screening at entry ports. AUTHORS' CONCLUSIONS The high risk of bias in the trials, variation in outcome measurement, and relatively low compliance with the interventions during the studies hamper drawing firm conclusions and generalising the findings to the current COVID-19 pandemic. There is uncertainty about the effects of face masks. The low-moderate certainty of the evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of randomised trials did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks during seasonal influenza. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, especially in those most at risk of ARIs.
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Affiliation(s)
- Tom Jefferson
- Centre for Evidence Based Medicine, University of Oxford, Oxford, UK
| | - Chris B Del Mar
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Liz Dooley
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Eliana Ferroni
- Epidemiological System of the Veneto Region, Regional Center for Epidemiology, Veneto Region, Padova, Italy
| | - Lubna A Al-Ansary
- Department of Family and Community Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ghada A Bawazeer
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mieke L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Mark A Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Sarah Thorning
- GCUH Library, Gold Coast Hospital and Health Service, Southport, Australia
| | - Elaine M Beller
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Tammy C Hoffmann
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Paul P Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - John M Conly
- Cumming School of Medicine, University of Calgary, Room AGW5, SSB, Foothills Medical Centre, Calgary, Canada
- O'Brien Institute for Public Health and Synder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Calgary Zone, Alberta Health Services, Calgary, Canada
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Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, van Driel ML, Jones MA, Thorning S, Beller EM, Clark J, Hoffmann TC, Glasziou PP, Conly JM. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev 2020; 11:CD006207. [PMID: 33215698 PMCID: PMC8094623 DOI: 10.1002/14651858.cd006207.pub5] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review published in 2007, 2009, 2010, and 2011. The evidence summarised in this review does not include results from studies from the current COVID-19 pandemic. OBJECTIVES To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. SEARCH METHODS We searched CENTRAL, PubMed, Embase, CINAHL on 1 April 2020. We searched ClinicalTrials.gov, and the WHO ICTRP on 16 March 2020. We conducted a backwards and forwards citation analysis on the newly included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cluster-RCTs of trials investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, and gargling) to prevent respiratory virus transmission. In previous versions of this review we also included observational studies. However, for this update, there were sufficient RCTs to address our study aims. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Three pairs of review authors independently extracted data using a standard template applied in previous versions of this review, but which was revised to reflect our focus on RCTs and cluster-RCTs for this update. We did not contact trialists for missing data due to the urgency in completing the review. We extracted data on adverse events (harms) associated with the interventions. MAIN RESULTS We included 44 new RCTs and cluster-RCTs in this update, bringing the total number of randomised trials to 67. There were no included studies conducted during the COVID-19 pandemic. Six ongoing studies were identified, of which three evaluating masks are being conducted concurrent with the COVID pandemic, and one is completed. Many studies were conducted during non-epidemic influenza periods, but several studies were conducted during the global H1N1 influenza pandemic in 2009, and others in epidemic influenza seasons up to 2016. Thus, studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Compliance with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included nine trials (of which eight were cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and seven in the community). There is low certainty evidence from nine trials (3507 participants) that wearing a mask may make little or no difference to the outcome of influenza-like illness (ILI) compared to not wearing a mask (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.82 to 1.18. There is moderate certainty evidence that wearing a mask probably makes little or no difference to the outcome of laboratory-confirmed influenza compared to not wearing a mask (RR 0.91, 95% CI 0.66 to 1.26; 6 trials; 3005 participants). Harms were rarely measured and poorly reported. Two studies during COVID-19 plan to recruit a total of 72,000 people. One evaluates medical/surgical masks (N = 6000) (published Annals of Internal Medicine, 18 Nov 2020), and one evaluates cloth masks (N = 66,000). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). There is uncertainty over the effects of N95/P2 respirators when compared with medical/surgical masks on the outcomes of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; very low-certainty evidence; 3 trials; 7779 participants) and ILI (RR 0.82, 95% CI 0.66 to 1.03; low-certainty evidence; 5 trials; 8407 participants). The evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirator compared to a medical/surgical mask probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; moderate-certainty evidence; 5 trials; 8407 participants). Restricting the pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies. One ongoing study recruiting 576 people compares N95/P2 respirators with medical surgical masks for healthcare workers during COVID-19. Hand hygiene compared to control Settings included schools, childcare centres, homes, and offices. In a comparison of hand hygiene interventions with control (no intervention), there was a 16% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.84, 95% CI 0.82 to 0.86; 7 trials; 44,129 participants; moderate-certainty evidence), suggesting a probable benefit. When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.98, 95% CI 0.85 to 1.13; 10 trials; 32,641 participants; low-certainty evidence) and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials; 8332 participants; low-certainty evidence) suggest the intervention made little or no difference. We pooled all 16 trials (61,372 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. The pooled data showed that hand hygiene may offer a benefit with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.84 to 0.95; low-certainty evidence), but with high heterogeneity. Few trials measured and reported harms. There are two ongoing studies of handwashing interventions in 395 children outside of COVID-19. We identified one RCT on quarantine/physical distancing. Company employees in Japan were asked to stay at home if household members had ILI symptoms. Overall fewer people in the intervention group contracted influenza compared with workers in the control group (2.75% versus 3.18%; hazard ratio 0.80, 95% CI 0.66 to 0.97). However, those who stayed at home with their infected family members were 2.17 times more likely to be infected. We found no RCTs on eye protection, gowns and gloves, or screening at entry ports. AUTHORS' CONCLUSIONS The high risk of bias in the trials, variation in outcome measurement, and relatively low compliance with the interventions during the studies hamper drawing firm conclusions and generalising the findings to the current COVID-19 pandemic. There is uncertainty about the effects of face masks. The low-moderate certainty of the evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of randomised trials did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks during seasonal influenza. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, especially in those most at risk of ARIs.
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Affiliation(s)
- Tom Jefferson
- Centre for Evidence Based Medicine, University of Oxford, Oxford, UK
| | - Chris B Del Mar
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Liz Dooley
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Eliana Ferroni
- Epidemiological System of the Veneto Region, Regional Center for Epidemiology, Veneto Region, Padova, Italy
| | - Lubna A Al-Ansary
- Department of Family and Community Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ghada A Bawazeer
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mieke L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Mark A Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Sarah Thorning
- GCUH Library, Gold Coast Hospital and Health Service, Southport, Australia
| | - Elaine M Beller
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Tammy C Hoffmann
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Paul P Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - John M Conly
- Cumming School of Medicine, University of Calgary, Room AGW5, SSB, Foothills Medical Centre, Calgary, Canada
- O'Brien Institute for Public Health and Synder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Calgary Zone, Alberta Health Services, Calgary, Canada
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8
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Violante T, Violante FS. Surgical masks vs respirators for the protection against coronavirus infection: state of the art. LA MEDICINA DEL LAVORO 2020; 111:365-371. [PMID: 33124607 PMCID: PMC7809975 DOI: 10.23749/mdl.v111i5.9692] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/23/2020] [Indexed: 12/15/2022]
Abstract
Background: During the Covid-19 outbreak, a recurrent subject in scientific literature has been brought back into discussion: whether surgical masks provide a sufficient protection against airborne SARS-CoV-2 infections. Objectives: The objective of this review is to summarize the available studies which have compared the respective effectiveness of surgical masks and filtering facepiece respirators for the prevention of infections caused by viruses that are transmitted by the respiratory tract. Methods: The relevant scientific literature was identified by querying the PubMed database with a combination of search strings. The narrower search string “(surgical mask *) AND (respirator OR respirators)” included all the relevant articles retrieved using broader search strategies. Of all the relevant articles found, seven systematic reviews were selected and examined. Results: The currently available scientific evidence seems to suggest that surgical masks and N95 respirators/FFP2 confer an equivalent degree of protection against airborne viral infections. Discussion: Since surgical masks are less expensive than N95 respirators but seem to be as effective in protecting against airborne infection and they are also more comfortable for the user, requiring less respiratory work, they should be the standard protective device for health care workers and especially for workers who carry out non-medical jobs. Filtering facepiece respirators, whose extended use is less comfortable for the wearer, may be preferred for procedures which require greater protection for a shorter time.
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Affiliation(s)
- Tommaso Violante
- School of General Surgery, Alma Mater Studiorum University of Bologna, Bologna, Italy.
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9
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Nasser Z, Fares Y, Daoud R, Abou-Abbas L. Assessment of knowledge and practice of dentists towards Coronavirus Disease (COVID-19): a cross-sectional survey from Lebanon. BMC Oral Health 2020; 20:281. [PMID: 33050914 PMCID: PMC7552581 DOI: 10.1186/s12903-020-01273-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/06/2020] [Indexed: 12/13/2022] Open
Abstract
Background Coronavirus Disease (COVID-19) epidemic is a public health emergency of international concern. Dentists are exposed to the enormous risk of COVID-19 infection during this epidemic. This study aims to assess the knowledge and practice of dentists toward the COVID-19 epidemic in Lebanon. Methods We conducted an online survey using the snowball-sampling technique. Information on socio-demographic data, knowledge, practice, and additional information required concerning COVID-19 were collected. Results Our results showed that the majority of the Lebanese dentists had good knowledge (91.3%), and nearly half of the respondents had a good practice (58.7%) regarding COVID-19. The most common information source was the World Health Organization (73.7%). Multiple linear regression showed that specialist dentists who completed training on COVID-19 with a high level of knowledge had better practice. Conclusions Lebanese dentists revealed good knowledge regarding COVID-19. However, dentists had limited comprehension of the extra precautionary measures that protect the dental staff and patients from this virus. Our findings have important implications for the development of strategies suitable for improving the level of practice among dentists and enhance prevention programs.
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Affiliation(s)
- Zeina Nasser
- Faculty of Medical Sciences, Neuroscience Research Center, Lebanese University, Hadath, Lebanon
| | - Youssef Fares
- Faculty of Medical Sciences, Neuroscience Research Center, Lebanese University, Hadath, Lebanon
| | - Rama Daoud
- Faculty of Sciences, Lebanese University, Hadath, Lebanon
| | - Linda Abou-Abbas
- Faculty of Medical Sciences, Neuroscience Research Center, Lebanese University, Hadath, Lebanon.
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10
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Noone C, Warner N, Byrne M, Durand H, Lavoie KL, McGuire BE, Mc Sharry J, Meade O, Morrissey E, Molloy G, O'Connor L, Toomey E. Investigating and evaluating evidence of the behavioural determinants of adherence to social distancing measures - A protocol for a scoping review of COVID-19 research. HRB Open Res 2020; 3:46. [PMID: 32803123 PMCID: PMC7406949 DOI: 10.12688/hrbopenres.13099.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 12/21/2022] Open
Abstract
Background: The WHO has declared the outbreak of coronavirus disease 2019 (COVID-19) as a pandemic. With no vaccine currently available, using behavioural measures to reduce the spread of the virus within the population is an important tool in mitigating the effects of this pandemic. As such, social distancing measures are being implemented globally and have proven an effective tool in slowing the large-scale spread of the virus. Aim: This scoping review will focus on answering key questions about the state of the evidence on the behavioural determinants of adherence to social distancing measures in research on COVID-19. Methods: A scoping review will be conducted in accordance with guidelines for best practice. Literature searches will be conducted using online databases and grey literature sources. Databases will include Medline, Web of Science, Embase and PsycInfo, alongside relevant pre-print servers. Grey literature will be searched on Google Scholar. Screening, data extraction and quality appraisal will be conducted by members of the research team, with any discrepancies resolved by consensus discussion. Quality appraisal will be conducted using the Cochrane's ROBINS-I tool, the Cochrane Risk of Bias tool, and the JBI Critical Appraisal Checklist where appropriate. Results will be analysed by mapping findings onto the Theoretical Domains Framework and visualising characteristics of the included studies using EviAtlas. This scoping review is pre-registered with Open Science Framework. Conclusions The results of this study may facilitate the systematic development of behavioural interventions to increase adherence to social distancing measures.
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Affiliation(s)
- Chris Noone
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Nikolett Warner
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Molly Byrne
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Hannah Durand
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Kim L. Lavoie
- Department of Psychology, University of Quebec at Montreal, Montreal, Quebec, H2L 2C4, Canada
- Montreal Behavioral Medicine Centre, CIUSSS-NIM – Hôpital du Sacre-Coeur de Montreal, Montreal, Quebec, H4J 1C5, Canada
| | - Brian E. McGuire
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Jenny Mc Sharry
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Oonagh Meade
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Eimear Morrissey
- School of Medicine, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Gerry Molloy
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Laura O'Connor
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Elaine Toomey
- School of Allied Health, University of Limerick, Limerick, Limerick, V94 T9PX, Ireland
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11
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Mohsin SF, Agwan MA, Alsuwaydani ZA. Knowledge towards COVID-19 among healthcare students in the central region of Saudi Arabia: a cross-sectional observational study. Postgrad Med J 2020; 97:448-451. [PMID: 32759377 DOI: 10.1136/postgradmedj-2020-138274] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/18/2020] [Accepted: 06/20/2020] [Indexed: 02/03/2023]
Abstract
STUDY PURPOSE Coronavirus disease 2019 (COVID-19) is an infectious illness of high public concern. Healthcare students are directly or indirectly exposed to this disease. This study aimed to evaluate the knowledge of healthcare students in the central region of Saudi Arabia. STUDY DESIGN A cross-sectional survey was planned to collect information from healthcare students living in the central region of Saudi Arabia. A questionnaire was formulated to evaluate the healthcare student's knowledge towards COVID-19 pandemic. The collected data were analysed by using frequencies of correct knowledge answers. RESULTS A total of 612 students were analysed for the study. The overall knowledge score of healthcare students was 65.7%. The regression analysis showed a significant association between academic year and knowledge score p<0.001. CONCLUSIONS Our analysis demonstrates satisfactory student's knowledge but lacks awareness about background and mode of transmission of this disease; therefore, there is a strong need for further education and training programmes.
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Affiliation(s)
- Syed Fareed Mohsin
- Oral Maxillofacial Surgery and Diagnostic Sciences, Qassim University College of Dentistry, Ar Rass, Saudi Arabia
| | - Muhammad Atif Agwan
- Restorative Dentistry, Qassim University College of Dentistry, Ar Rass, Saudi Arabia
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12
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Noone C, Warner N, Byrne M, Durand H, Lavoie KL, McGuire BE, Mc Sharry J, Meade O, Morrissey E, Molloy G, O'Connor L, Toomey E. Investigating and evaluating evidence of the behavioural determinants of adherence to social distancing measures - A protocol for a scoping review of COVID-19 research. HRB Open Res 2020; 3:46. [PMID: 32803123 PMCID: PMC7406949 DOI: 10.12688/hrbopenres.13099.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2020] [Indexed: 12/28/2022] Open
Abstract
Background: The WHO has declared the outbreak of coronavirus disease 2019 (COVID-19) as a pandemic. With no vaccine currently available, using behavioural measures to reduce the spread of the virus within the population is an important tool in mitigating the effects of this pandemic. As such, social distancing measures are being implemented globally and have proven an effective tool in slowing the large-scale spread of the virus. Aim: This scoping review will focus on answering key questions about the state of the evidence on the behavioural determinants of adherence to social distancing measures in research on COVID-19. Methods: A scoping review will be conducted in accordance with guidelines for best practice. Literature searches will be conducted using online databases and grey literature sources. Databases will include Medline, Web of Science, Embase and PsycInfo, alongside relevant pre-print servers. Grey literature will be searched on Google Scholar. Screening, data extraction and quality appraisal will be conducted independently by two members of the research team, with any discrepancies resolved by consensus discussion and an additional team member if needed. Quality appraisal will be conducted using the Cochrane's ROBINS-I tool, the Cochrane Risk of Bias tool, and the JBI Critical Appraisal Checklist where appropriate. Results will be analysed by mapping findings onto the Theoretical Domains Framework and visualising characteristics of the included studies using EviAtlas. This scoping review is pre-registered with Open Science Framework. Conclusions The results of this study may facilitate the systematic development of behavioural interventions to increase adherence to social distancing measures.
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Affiliation(s)
- Chris Noone
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Nikolett Warner
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Molly Byrne
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Hannah Durand
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Kim L. Lavoie
- Department of Psychology, University of Quebec at Montreal, Montreal, Quebec, H2L 2C4, Canada
- Montreal Behavioral Medicine Centre, CIUSSS-NIM – Hôpital du Sacre-Coeur de Montreal, Montreal, Quebec, H4J 1C5, Canada
| | - Brian E. McGuire
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Jenny Mc Sharry
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Oonagh Meade
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Eimear Morrissey
- School of Medicine, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Gerry Molloy
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Laura O'Connor
- School of Psychology, National University of Ireland, Galway, Galway, Galway, H91 TK33, Ireland
| | - Elaine Toomey
- School of Allied Health, University of Limerick, Limerick, Limerick, V94 T9PX, Ireland
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Ahmed MA, Jouhar R, Ahmed N, Adnan S, Aftab M, Zafar MS, Khurshid Z. Fear and Practice Modifications among Dentists to Combat Novel Coronavirus Disease (COVID-19) Outbreak. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2821. [PMID: 32325888 PMCID: PMC7216192 DOI: 10.3390/ijerph17082821] [Citation(s) in RCA: 308] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/16/2020] [Accepted: 04/18/2020] [Indexed: 01/08/2023]
Abstract
An outbreak of novel coronavirus disease (COVID-19) in China has influenced every aspect of life. Healthcare professionals, especially dentists, are exposed to a higher risk of getting infected due to close contact with infected patients. The current study was conducted to assess anxiety and fear of getting infected among dentists while working during the current novel coronavirus diseases (COVID-19) outbreak. In addition, dentists' knowledge about various practice modifications to combat COVID-19 has been evaluated. A cross-sectional study was conducted using an online survey from 10th to 17th March 2020. The well-constructed questionnaire was designed and registered at online website (Kwiksurveys) and validated. A total of 669 participants from 30 different countries across the world responded. After scrutiny, completed questionnaires (n = 650) were included in the study. Statistical analysis was performed using SPSS version 25. Chi-Square and Spearman correlation tests were applied to control confounders and assess the relation of dentists' response with respect to gender and educational level. More than two-thirds of the general dental practitioners (78%) from 30 countries questioned were anxious and scared by the devastating effects of COVID-19. A large number of dentists (90%) were aware of recent changes in the treatment protocols. However, execution of amended treatment protocol was recorded as 61%. The majority of the dentists (76%) were working in the hospital setting out of which 74% were from private, and 20% were from government setups. Individually we received a large number of responses from Pakistan and Saudi Arabia, but collectively more than 50% of the responses were from other parts of the world. Despite having a high standard of knowledge and practice, dental practitioners around the globe are in a state of anxiety and fear while working in their respective fields due to the COVID-19 pandemic impact on humanity. A number of dental practices have either modified their services according to the recommended guidelines to emergency treatment only or closed down practices for an uncertain period.
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Affiliation(s)
- Muhammad Adeel Ahmed
- Department of Restorative Dentistry and Endodontics, College of Dentistry, King Faisal University, Al-Ahsa 31982, Saudi Arabia;
| | - Rizwan Jouhar
- Department of Restorative Dentistry and Endodontics, College of Dentistry, King Faisal University, Al-Ahsa 31982, Saudi Arabia;
| | - Naseer Ahmed
- Department of Prosthodontics, Altamash Institute of Dental Medicine, Karachi 75500, Pakistan;
| | - Samira Adnan
- Department of Operative Dentistry, Sindh Institute of Oral Health Sciences, Jinnah Sindh Medical University, Karachi 75510, Pakistan;
| | - Marziya Aftab
- Department of Operative Dentistry, Dr. Ishrat-ul-ebad khan Institute of Oral Health Science, Dow University of Health Sciences, Karachi 74200, Pakistan;
| | - Muhammad Sohail Zafar
- Department of Restorative Dentistry, College of Dentistry, Taibah University, Al-Madina Al-Munawwarah 41311, Saudi Arabia;
- Department of Dental Materials, Islamic International Dental College, Riphah International University, Islamabad 44000, Pakistan
| | - Zohaib Khurshid
- Department of Prosthodontics and Dental Implantology, College of Dentistry, King Faisal University, Al-Ahsa 31982, Saudi Arabia;
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Hovi T, Ollgren J, Savolainen-Kopra C. Intensified hand-hygiene campaign including soap-and-water wash may prevent acute infections in office workers, as shown by a recognized-exposure -adjusted analysis of a randomized trial. BMC Infect Dis 2017; 17:47. [PMID: 28068912 PMCID: PMC5223302 DOI: 10.1186/s12879-016-2157-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 12/22/2016] [Indexed: 11/15/2022] Open
Abstract
Background Variable exposure to causative agents of acute respiratory (RTI) or gastrointestinal tract infections (GTI) is a significant confounding factor in the analysis of the efficacy of interventions concerning these infections. We had an exceptional opportunity to reanalyze a previously published dataset from a trial assessing the effect of enhanced hand hygiene on the occurrence of RTI or GTI in adults, after adjustment for reported exposure and other covariates. Methods Twenty-one working units (designated clusters) each including at least 50 office employees, totaling 1,270 persons, were randomized into two intervention arms (either using water-and-soap or alcohol-rub in hand cleansing), or in the control arm. Self-reported data was collected through weekly emails and included own symptoms of RTI or GTI, and exposures to other persons with similar symptoms. Differences in the weekly occurrences of RTI and GTI symptoms between the arms were analyzed using multilevel binary regression model with log link with personal and cluster specific random effects, self-reported exposure to homologous disease, randomization triplet, and seasonality as covariates in the Bayesian framework. Results Over the 16 months duration of the trial, 297 persons in the soap and water arm, 238 persons in the alcohol-based hand rub arm, and 230 controls sent reports. The arms were similar in age distribution and gender ratios. A temporally-associated reported exposure strongly increased the risk of both types of infection in all trial arms. Persons in the soap-and-water arm reported a significantly – about 24% lower weekly prevalence of GTI than the controls whether they had observed an exposure or not during the preceding week, while for RTI, this intervention reduced the prevalence only during weeks without a reported exposure. Alcohol-rub did not affect the symptom prevalence. Conclusions We conclude that while frequent and careful hand washing with soap and water partially protected office-working adults from GTI, the effect on RTI was only marginal in this study. Potential reasons for this difference include partially different transmission routes and a difference in the virus load. In this trial, frequent standardized hand rubbing with ethanol-based disinfectant did not reduce the weekly prevalence of either type of infections. Trial registration ClinicalTrials.gov Identifier: NCT00821509, 12 March 2009. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-2157-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tapani Hovi
- Department of Infectious Diseases, Viral Infections Unit, National Institute for Health and Welfare (THL), P.O. Box 30, FIN-00271, Helsinki, Finland.
| | - Jukka Ollgren
- Department of Infectious Diseases, Viral Infections Unit, National Institute for Health and Welfare (THL), P.O. Box 30, FIN-00271, Helsinki, Finland
| | - Carita Savolainen-Kopra
- Department of Infectious Diseases, Viral Infections Unit, National Institute for Health and Welfare (THL), P.O. Box 30, FIN-00271, Helsinki, Finland
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15
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Meilicke G, Riedmann K, Biederbick W, Müller U, Wierer T, Bartels C. Hygiene perception changes during the influenza A H1N1 pandemic in Germany: incorporating the results of two cross-sectional telephone surveys 2008-2009. BMC Public Health 2013; 13:959. [PMID: 24131544 PMCID: PMC3815629 DOI: 10.1186/1471-2458-13-959] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 10/07/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The federal campaign Wir gegen Viren [Us against viruses] promoted hygiene in Germany during the influenza A H1N1 pandemic in 2009. The intervention aimed to encourage people to protect themselves against respiratory infections by simple means of hygiene behaviour. Quantitative research was carried out to outline changes in hygiene perception of the population over time, and to find out whether the potential hygiene perception changes were consistent to the federal campaign about hygiene or not. METHODS To determine changes in the hygiene perception of the population, two cross-sectional telephone surveys were held, each one with n = 2006 participants. The initial survey was carried out before the influenza A H1N1 pandemic in calendar week 49-51 in 2008 and the second in week 48 in 2009 directly after the peak of the pandemic in Germany. The questionnaire contained indicators about perceived hand hygiene efficacy, preference for coughing into the sleeve, propensity for presenteeism while showing symptoms of a cold and acceptance of hygiene masks. RESULTS The proportion of people who perceive the efficacy of hand washing as "very good" increased significantly from 50.9% in 2008 to 61.1% in 2009. The proportion of people who perceive coughing into the sleeve as the best way to cough increased even more dramatically from 4.8% in 2008 to 38.3% in 2009. In contrast the propensity for presenteeism decreased significantly: The proportion of people who state that they always report to work while they show symptoms of a cold decreased from 50.8% in 2008 to 40.9% in 2009. Acceptance of hygiene masks has not changed significantly from 2008 to 2009. CONCLUSIONS The results revealed changes in hygiene perception during influenza A H1N1 pandemic in Germany. The changes we found are in accordance with the hygiene recommendations given by the federal campaign Wir gegen Viren [Us against viruses]. Results can constitute a practical benchmark for future research about hygiene perception and hygiene promotion for adults. A pivotal question is: does the increase in hygiene perception persist after the pandemic has ceased?
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16
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Rivers K, Bowen LE, Gao J, Yang K, Trombley JE, Bohannon JK, Eichelberger MC. Comparison of the effectiveness of antibody and cell-mediated immunity against inhaled and instilled influenza virus challenge. Virol J 2013; 10:198. [PMID: 23777453 PMCID: PMC3691648 DOI: 10.1186/1743-422x-10-198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 06/11/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND To evaluate immunity against influenza, mouse challenge studies are typically performed by intranasal instillation of a virus suspension to anesthetized animals. This results in an unnatural environment in the lower respiratory tract during infection, and therefore there is some concern that immune mechanisms identified in this model may not reflect those that protect against infectious virus particles delivered directly to the lower respiratory tract as an aerosol. METHOD To evaluate differences in protection against instilled and inhaled virus, mice were immunized with influenza antigens known to induce antibody or cell-mediated responses and then challenged with 100 LD50 A/PR/8/34 (PR8) in the form of aerosol (inhaled) or liquid suspension (instilled). RESULTS Mice immunized with recombinant adenovirus (Ad) expressing hemagglutinin were protected against weight loss and death in both challenge models, however immunization with Ad expressing nucleoprotein of influenza A (NPA) or M2 resulted in greater protection against inhaled aerosolized virus than virus instilled in liquid suspension. Ad-M2, but not Ad-NPA-immunized mice were protected against a lower instillation challenge dose. CONCLUSIONS These results demonstrate differences in protection that are dependent on challenge method, and suggest that cell-mediated immunity may be more accurately demonstrated in mouse inhalation studies. Furthermore, the data suggest immune mechanisms generally characterized as incomplete or weak in mouse models using liquid intranasal challenge may offer greater immunity against influenza infection than previously thought.
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Affiliation(s)
- Katie Rivers
- Division of Viral Products, OVRR, CBER, FDA, 8800 Rockville Pike, Building 29A 1D24, Bethesda, MD 20892, USA
| | - Larry E Bowen
- Southern Research Institute, Birmingham, AL 35205, USA
- Current address: Alion Science and Technology, NIEHS Inhalation Toxicology Facility, 5 Triangle Drive, P.O. Box 12313, Durham, NC 27709, USA
| | - Jin Gao
- Division of Viral Products, OVRR, CBER, FDA, 8800 Rockville Pike, Building 29A 1D24, Bethesda, MD 20892, USA
| | - Kevin Yang
- Division of Viral Products, OVRR, CBER, FDA, 8800 Rockville Pike, Building 29A 1D24, Bethesda, MD 20892, USA
| | | | | | - Maryna C Eichelberger
- Division of Viral Products, OVRR, CBER, FDA, 8800 Rockville Pike, Building 29A 1D24, Bethesda, MD 20892, USA
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Savolainen-Kopra C, Haapakoski J, Peltola PA, Ziegler T, Korpela T, Anttila P, Amiryousefi A, Huovinen P, Huvinen M, Noronen H, Riikkala P, Roivainen M, Ruutu P, Teirilä J, Vartiainen E, Hovi T. Hand washing with soap and water together with behavioural recommendations prevents infections in common work environment: an open cluster-randomized trial. Trials 2012; 13:10. [PMID: 22243622 PMCID: PMC3296604 DOI: 10.1186/1745-6215-13-10] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 01/16/2012] [Indexed: 12/05/2022] Open
Abstract
Background Hand hygiene is considered as an important means of infection control. We explored whether guided hand hygiene together with transmission-limiting behaviour reduces infection episodes and lost days of work in a common work environment in an open cluster-randomized 3-arm intervention trial. Methods A total of 21 clusters (683 persons) were randomized to implement hand hygiene with soap and water (257 persons), with alcohol-based hand rub (202 persons), or to serve as a control (224 persons). Participants in both intervention arms also received standardized instructions on how to limit the transmission of infections. The intervention period (16 months) included the emergence of the 2009 influenza pandemic and the subsequent national hand hygiene campaign influencing also the control arm. Results In the total follow-up period there was a 6.7% reduction of infection episodes in the soap-and water arm (p = 0.04). Before the onset of the anti-pandemic campaign, a statistically significant (p = 0.002) difference in the mean occurrence of infection episodes was observed between the control (6.0 per year) and the soap-and-water arm (5.0 per year) but not between the control and the alcohol-rub arm (5.6 per year). Neither intervention had a decreasing effect on absence from work. Conclusions We conclude that intensified hand hygiene using water and soap together with behavioural recommendations can reduce the occurrence of self-reported acute illnesses in common work environment. Surprisingly, the occurrence of reported sick leaves also increased in the soap-and water-arm. Trial Registration ClinicalTrials.gov: NCT00981877 Source of funding The Finnish Work Environment Fund and the National Institute for Health and Welfare.
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Affiliation(s)
- Carita Savolainen-Kopra
- National Institute for Health and Welfare (THL), Department of Infectious Disease Surveillance and Control, Intestinal Viruses Unit, PO Box 30, FIN-00271 Helsinki, Finland.
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Smith JH, Nagy T, Barber J, Brooks P, Tompkins SM, Tripp RA. Aerosol inoculation with a sub-lethal influenza virus leads to exacerbated morbidity and pulmonary disease pathogenesis. Viral Immunol 2011; 24:131-42. [PMID: 21449723 DOI: 10.1089/vim.2010.0085] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
A mouse model has been extensively used to investigate disease intervention approaches and correlates of immunity following influenza virus infection. The majority of studies examining cross-reactive and protective immune responses have used intranasal (IN) virus inoculation; however, infectious aerosols are a common means of transmitting influenza in the human population. In this study, IN and aerosol routes of inoculation were compared and end-points of immunity and disease pathogenesis were evaluated in mice using mouse-adapted H3N2 A/Aichi/2/68 (x31). Aerosol inoculation with sub-lethal x31 levels caused more robust infection, which was characterized by enhanced morbidity, mortality, pulmonary cell infiltration, and inflammation, compared to IN-inoculated mice, as well as higher levels of IL-6 expression in the lung. Treatment with IL-6-blocking antibodies reduced pulmonary infiltrates and lung pathology in aerosol-inoculated mice. This study shows that aerosol inoculation results in a distinctive host response and disease outcome compared to IN inoculation, and suggests a possible role for IL-6 in lung pathogenesis.
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Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al‐Ansary LA, Bawazeer GA, van Driel ML, Nair NS, Jones MA, Thorning S, Conly JM. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev 2011; 2011:CD006207. [PMID: 21735402 PMCID: PMC6993921 DOI: 10.1002/14651858.cd006207.pub4] [Citation(s) in RCA: 242] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a global threat. Antiviral drugs and vaccinations may be insufficient to prevent their spread. OBJECTIVES To review the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses. SEARCH STRATEGY We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2010, Issue 3), which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to October 2010), OLDMEDLINE (1950 to 1965), EMBASE (1990 to October 2010), CINAHL (1982 to October 2010), LILACS (2008 to October 2010), Indian MEDLARS (2008 to October 2010) and IMSEAR (2008 to October 2010). SELECTION CRITERIA In this update, two review authors independently applied the inclusion criteria to all identified and retrieved articles and extracted data. We scanned 3775 titles, excluded 3560 and retrieved full papers of 215 studies, to include 66 papers of 67 studies. We included physical interventions (screening at entry ports, isolation, quarantine, social distancing, barriers, personal protection, hand hygiene) to prevent respiratory virus transmission. We included randomised controlled trials (RCTs), cohorts, case-controls, before-after and time series studies. DATA COLLECTION AND ANALYSIS We used a standardised form to assess trial eligibility. We assessed RCTs by randomisation method, allocation generation, concealment, blinding and follow up. We assessed non-RCTs for potential confounders and classified them as low, medium and high risk of bias. MAIN RESULTS We included 67 studies including randomised controlled trials and observational studies with a mixed risk of bias. A total number of participants is not included as the total would be made up of a heterogenous set of observations (participant people, observations on participants and countries (object of some studies)). The risk of bias for five RCTs and most cluster-RCTs was high. Observational studies were of mixed quality. Only case-control data were sufficiently homogeneous to allow meta-analysis. The highest quality cluster-RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children. Benefit from reduced transmission from children to household members is broadly supported also in other study designs where the potential for confounding is greater. Nine case-control studies suggested implementing transmission barriers, isolation and hygienic measures are effective at containing respiratory virus epidemics. Surgical masks or N95 respirators were the most consistent and comprehensive supportive measures. N95 respirators were non-inferior to simple surgical masks but more expensive, uncomfortable and irritating to skin. Adding virucidals or antiseptics to normal handwashing to decrease respiratory disease transmission remains uncertain. Global measures, such as screening at entry ports, led to a non-significant marginal delay in spread. There was limited evidence that social distancing was effective, especially if related to the risk of exposure. AUTHORS' CONCLUSIONS Simple and low-cost interventions would be useful for reducing transmission of epidemic respiratory viruses. Routine long-term implementation of some measures assessed might be difficult without the threat of an epidemic.
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Affiliation(s)
- Tom Jefferson
- University of OxfordCentre for Evidence Based MedicineOxfordUKOX2 6GG
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)University DriveGold CoastQueenslandAustralia4229
| | - Liz Dooley
- Bond UniversityFaculty of Health Sciences and MedicineGold CoastQueenslandAustralia4229
| | - Eliana Ferroni
- Regional Center for Epidemiology, Veneto RegionEpidemiological System of the Veneto RegionPassaggio Gaudenzio 1PadovaItaly35131
| | - Lubna A Al‐Ansary
- World Health OrganizationDepartment of Health Metrics and MeasurementGenevaSwitzerland
| | - Ghada A Bawazeer
- King Saud UniversityDepartment of Clinical Pharmacy, College of PharmacyP.O. Box 22452RiyadhSaudi Arabia11495
| | - Mieke L van Driel
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineBrisbaneQueenslandAustralia4029
- Ghent UniversityDepartment of Public Health and Primary CareCampus UZ 6K3, Corneel Heymanslaan 10GhentBelgium9000
| | - N Sreekumaran Nair
- Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) (Institution of National Importance Under Ministry of Health and Family Welfare, Government of India)Department of Medical Biometrics & Informatics (Biostatistics)4th Floor, Administrative BlockDhanvantri NagarPuducherryIndia605006
| | - Mark A Jones
- Bond UniversityInstitute for Evidence‐Based Healthcare11 University DriveRobinaGold CoastQueenslandAustralia4226
| | - Sarah Thorning
- Gold Coast Hospital and Health ServiceGCUH LibraryLevel 1, Block E, GCUHSouthportQueenslandAustralia4215
| | - John M Conly
- Foothills Medical Centre, Room 930, North Tower1403‐29th St NWCalgaryABCanadaT2N 2T9
- WHO. Infection Prevention and Control in Health CareDepartment of Global Alert and Response ‐ Health Security and EnvironmentOffice L420, 20, Avenue AppiaGenevaSwitzerlandCH‐1211
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Seale H, Dwyer DE, Cowling BJ, Wang Q, Yang P, MacIntyre CR. A review of medical masks and respirators for use during an influenza pandemic. Influenza Other Respir Viruses 2011; 3:205-6. [PMID: 19702582 PMCID: PMC4941551 DOI: 10.1111/j.1750-2659.2009.00101.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Holly Seale
- School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Australia
| | - Dominic E. Dwyer
- Institute for Clinical Pathology and Medical Research, Westmead Hospital, Sydney, Australia
| | - Benjamin J. Cowling
- Department of Community Medicine and School of Public Health, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Quanyi Wang
- Institute for Infectious Diseases, Beijing Center for Disease Prevention and Control, Beijing, China
| | - Peng Yang
- Institute for Infectious Diseases, Beijing Center for Disease Prevention and Control, Beijing, China
| | - C. Raina MacIntyre
- School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Australia
- National Centre for Immunization Research and Surveillance of Vaccine Preventable Diseases (NCIRS), The Children’s Hospital at Westmead, Australia
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21
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Simmerman JM, Suntarattiwong P, Levy J, Jarman RG, Kaewchana S, Gibbons RV, Cowling BJ, Sanasuttipun W, Maloney SA, Uyeki TM, Kamimoto L, Chotipitayasunondh T. Findings from a household randomized controlled trial of hand washing and face masks to reduce influenza transmission in Bangkok, Thailand. Influenza Other Respir Viruses 2011; 5:256-67. [PMID: 21651736 PMCID: PMC4634545 DOI: 10.1111/j.1750-2659.2011.00205.x] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Evidence is needed on the effectiveness of non-pharmaceutical interventions (NPIs) to reduce influenza transmission. METHODOLOGY We studied NPIs in households with a febrile, influenza-positive child. Households were randomized to control, hand washing (HW), or hand washing plus paper surgical face masks (HW + FM) arms. Study nurses conducted home visits within 24 hours of enrollment and on days 3, 7, and 21. Respiratory swabs and serum were collected from all household members and tested for influenza by RT-PCR or serology. PRINCIPAL FINDINGS Between April 2008 and August 2009, 991 (16·5%) of 5995 pediatric influenza-like illness patients tested influenza positive. Four hundred and forty-two index children with 1147 household members were enrolled, and 221 (50·0%) were aged <6 years. Three hundred and ninety-seven (89·8%) households reported that the index patient slept in the parents' bedroom. The secondary attack rate was 21·5%, and 56/345 (16·3%; 95% CI 12·4-20·2%) secondary cases were asymptomatic. Hand-washing subjects reported 4·7 washing episodes/day, compared to 4·9 times/day in the HW + FM arm and 3·9 times/day in controls (P = 0·001). The odds ratios (ORs) for secondary influenza infection were not significantly different in the HW arm (OR = 1·20; 95% CI 0·76-1·88; P-0.442), or the HW + FM arm (OR = 1·16; 95% CI .0·74-1·82; P = 0.525). CONCLUSIONS Influenza transmission was not reduced by interventions to promote hand washing and face mask use. This may be attributable to transmission that occurred before the intervention, poor facemask compliance, little difference in hand-washing frequency between study groups, and shared sleeping arrangements. A prospective study design and a careful analysis of sociocultural factors could improve future NPI studies.
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Affiliation(s)
- James M Simmerman
- International Emerging Infections Program, Thailand MOPH-US CDC Collaboration, Nonthaburi, Thailand.
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Curran MP, Leroux-Roels I. Inactivated split-virion seasonal influenza vaccine (Fluarix): a review of its use in the prevention of seasonal influenza in adults and the elderly. Drugs 2010; 70:1519-43. [PMID: 20687619 DOI: 10.2165/11205020-000000000-00000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Fluarix is a trivalent, inactivated, split-virion influenza vaccine containing 15 microg haemagglutinin from each of the three influenza virus strains (including an H1N1 influenza A virus subtype, an H3N2 influenza A virus subtype and an influenza B virus) that are expected to be circulating in the up-coming influenza season. Fluarix is highly immunogenic in healthy adults and elderly, and exceeds the criteria that make it acceptable for licensure in various regions (including the US and Europe). In a large, phase III, placebo-controlled, double-blind trial conducted in the US (2004/2005) in subjects aged 18-64 years, postvaccination seroconversion rates against the H1N1, H3N2 and B antigens were 60-78% and respective postvaccination seroprotection rates were 97-99% in Fluarix recipients. Another phase III trial conducted in the US (2005/2006) established the noninferiority of Fluarix versus another trivalent inactivated influenza virus vaccine in subjects aged >or=18 years, including a subgroup of elderly subjects. In annual European registration trials, Fluarix has consistently exceeded the immunogenicity criteria set by the EU Committee for Medicinal Products for Human Use for adults and the elderly. Fluarix demonstrated immunogenicity in small, open-label studies in at-risk subjects. During a year when the vaccine was well matched to the circulating strain, Fluarix demonstrated efficacy against culture-confirmed influenza A and/or B in a placebo-controlled trial in adults aged 18-64 years. In addition, Fluarix vaccination of pregnant women demonstrated efficacy in reducing the rate of laboratory-confirmed influenza in the infants and reducing febrile respiratory illnesses in the mothers and their new-born infants in a randomized trial. Fluarix was generally well tolerated in adults and the elderly in well designed clinical trials and in the annual European registration trials, with most local and general adverse events being transient and mild to moderate in intensity. The most common adverse reactions in recipients of Fluarix were pain, redness or swelling at the injection site, muscle aches, fatigue, headache and arthralgia. In conclusion, Fluarix is an important means of decreasing the impact of seasonal influenza viruses on adults and the elderly.
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Affiliation(s)
- Monique P Curran
- Adis, a Wolters Kluwer Business, Mairangi Bay, North Shore, Auckland, New Zealand.
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Ward K, Seale H, Zwar N, Leask J, Macintyre CR. Annual influenza vaccination: coverage and attitudes of primary care staff in Australia. Influenza Other Respir Viruses 2010; 5:135-41. [PMID: 21306577 PMCID: PMC4942009 DOI: 10.1111/j.1750-2659.2010.00158.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Please cite this paper as: Ward et al. (2011) Annual influenza vaccination: coverage and attitudes of primary care staff in Australia. Influenza and Other Respiratory Viruses 5(2), 135–141. Background Annual influenza vaccination is recommended for all Australian health care workers (HCWs) including those working in primary health care. There is limited published data on coverage, workplace provision, attitudes and personal barriers to influenza vaccination amongst primary health care staff. The aim of this study was to contribute to the limited literature base in this important area by investigating these issues in the primary health care setting in New South Wales (NSW), Australia. Methods A postal survey was sent to general practitioners (GPs) and practice nurses (PNs) from inner city, semi‐urban and rural areas of NSW, Australia. There were 139 responses in total (response rate 36%) from 79 GPs (response rate 30%) and 60 PNs (response rate 46%). Results Reported influenza vaccination coverage in both 2007 and 2008 was greater than 70%, with GPs reporting higher coverage than PNs in both years. The main barriers identified were lack of awareness of vaccination recommendations for general practice staff and concern about adverse effects from the vaccine. Conclusions Rates of influenza vaccination coverage reported in this study were higher than in previous studies of hospital and institutional HCWs, though it is possible that the study design may have contributed to these higher results. Nevertheless, these findings highlight that more needs to be done to understand barriers to vaccination in this group, to inform the development of appropriate strategies to increase vaccination coverage in primary health care staff, with a special focus on PNs.
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Borkow G, Zhou SS, Page T, Gabbay J. A novel anti-influenza copper oxide containing respiratory face mask. PLoS One 2010; 5:e11295. [PMID: 20592763 PMCID: PMC2892464 DOI: 10.1371/journal.pone.0011295] [Citation(s) in RCA: 240] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 06/01/2010] [Indexed: 12/22/2022] Open
Abstract
Background Protective respiratory face masks protect the nose and mouth of the wearer from vapor drops carrying viruses or other infectious pathogens. However, incorrect use and disposal may actually increase the risk of pathogen transmission, rather than reduce it, especially when masks are used by non-professionals such as the lay public. Copper oxide displays potent antiviral properties. A platform technology has been developed that permanently introduces copper oxide into polymeric materials, conferring them with potent biocidal properties. Methodology/Principal Findings We demonstrate that impregnation of copper oxide into respiratory protective face masks endows them with potent biocidal properties in addition to their inherent filtration properties. Both control and copper oxide impregnated masks filtered above 99.85% of aerosolized viruses when challenged with 5.66±0.51 and 6.17±0.37 log10TCID50 of human influenza A virus (H1N1) and avian influenza virus (H9N2), respectively, under simulated breathing conditions (28.3 L/min). Importantly, no infectious human influenza A viral titers were recovered from the copper oxide containing masks within 30 minutes (≤0.88 log10TCID50), while 4.67±1.35 log10TCID50 were recovered from the control masks. Similarly, the infectious avian influenza titers recovered from the copper oxide containing masks were ≤0.97±0.01 log10TCID50 and from the control masks 5.03±0.54 log10TCID50. The copper oxide containing masks successfully passed Bacterial Filtration Efficacy, Differential Pressure, Latex Particle Challenge, and Resistance to Penetration by Synthetic Blood tests designed to test the filtration properties of face masks in accordance with the European EN 14683:2005 and NIOSH N95 standards. Conclusions/Significance Impregnation of copper oxide into respiratory protective face masks endows them with potent anti-influenza biocidal properties without altering their physical barrier properties. The use of biocidal masks may significantly reduce the risk of hand or environmental contamination, and thereby subsequent infection, due to improper handling and disposal of the masks.
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Savolainen-Kopra C, Haapakoski J, Peltola PA, Ziegler T, Korpela T, Anttila P, Amiryousefi A, Huovinen P, Huvinen M, Noronen H, Riikkala P, Roivainen M, Ruutu P, Teirilä J, Vartiainen E, Hovi T. STOPFLU: is it possible to reduce the number of days off in office work by improved hand-hygiene? Trials 2010; 11:69. [PMID: 20525328 PMCID: PMC2889989 DOI: 10.1186/1745-6215-11-69] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Accepted: 06/04/2010] [Indexed: 11/28/2022] Open
Abstract
Background Acute infectious diseases are major causes of short periods of days off from work, day care and school. These diseases are mainly caused by viruses and hands have a key role in their transmission. Thus, hypothetically, they can be controlled with means of intensified hand hygiene. In this study we aim to elucidate the effect of acute infectious diseases on the work contribution in common office work and study the influence of improved hand hygiene on possible reduction of infectious disease episodes and days off from work due to acute infectious diseases. Design The voluntary participants have been recruited from six companies in the Helsinki region. The designated 21 study clusters were identified as operationally distinct working units each containing at least 50 people. The clusters were matched and randomized based on results of a pre-trial contagion risk survey. Improved hand hygiene is being executed with guided hand-washing with soap and water in one intervention arm and with alcohol based hand rubbing disinfectant in the other. Participants in both arms have received guidance on how to avoid infections and how to implement contagion stopping habits. A control arm is acting as before regarding hand hygiene. Data collection for evaluation of the efficacy of the interventions is based on self-reporting through weekly electronic reports. The questionnaire is enquiring about possible respiratory or gastrointestinal symptoms during the preceding week, and requests a daily report of presence of symptoms and working capacity. Etiology of the symptoms is not searched for individually, but contribution of different viruses is evaluated by sentinel surveillance, where occupational health clinics located in the premises of the participating companies collect specimens from employees visiting the clinic. Common causative agents of the diseases are being searched for using real-time PCR techniques. The duration of the intervention will be 16 months. Primary endpoints of the study are the number of reported infection episodes in a cluster within a time frame of 100 reporting weeks and the number of reported sick leave episodes in a cluster within a time frame of 100 reporting weeks. Trial Registration ClinicalTrials.gov Identifier: NCT00821509
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Affiliation(s)
- Carita Savolainen-Kopra
- National Institute for Health and Welfare (THL), Department of Infectious Disease Surveillance and Control, Gastrointestinal Infections Unit, Helsinki, Finland.
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Deaths preventable in the U.S. by improvements in use of clinical preventive services. Am J Prev Med 2010; 38:600-9. [PMID: 20494236 DOI: 10.1016/j.amepre.2010.02.016] [Citation(s) in RCA: 181] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2009] [Revised: 02/21/2010] [Accepted: 02/24/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Healthcare reform plans refer to improved quality, but there is little quantification of potential health benefits of quality care. PURPOSE This paper aims to estimate the health benefits by greater use of clinical preventive services. METHODS Two mathematical models were developed to estimate the number of deaths potentially prevented per year by increasing use of nine clinical preventive services. One model estimated preventable deaths from all causes, and the other estimated preventable deaths from specific categories of causes. Models were based on estimates of the prevalence of risk factors for which interventions are recommended, the effect of those risk factors on mortality, the effect of the interventions on mortality in those at risk, and current and achievable rates of utilization of the interventions. RESULTS Both models predicted substantial numbers of deaths prevented by greater use of the preventive services, with the greatest increases from services that prevent cardiovascular disease. For example, the all-cause model predicted that every 10% increase in hypertension treatment would lead to an additional 14,000 deaths prevented and every 10% increase in treatment of elevated low-density lipoprotein cholesterol or aspirin prophylaxis would lead to 8000 deaths prevented in those aged <80 years, per year. Overall, the models suggest that optimal use of all of these interventions could prevent 50,000-100,000 deaths per year in those aged <80 years and 25,000-40,000 deaths per year in those aged <65 years. CONCLUSIONS Substantial improvements in population health are achievable through greater use of a small number of preventive services. Healthcare systems should maximize use of these services.
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An intervention to improve compliance with transmission precautions for influenza in the emergency department: successes and challenges. J Emerg Med 2010; 42:79-85. [PMID: 20452164 PMCID: PMC7125696 DOI: 10.1016/j.jemermed.2010.02.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 11/20/2009] [Accepted: 02/18/2010] [Indexed: 11/23/2022]
Abstract
Background: Concern with the potential for hospital-based transmission of influenza has come to the forefront due to emergency department (ED) crowding and the novel H1N1 pandemic. Compliance with infection control guidelines for influenza in the ED is generally unknown, and effective yet low-resource training is needed to educate staff on the importance of decreasing the potential for ED transmission of the virus. Objectives: This study evaluates compliance with patient assignment and transport precautions for influenza in an urban ED before and after implementation of electronic reminders. Methods: We included patients with a diagnosis of influenza for two consecutive influenza seasons, and retrospectively collected limited patient encounter data on patient location, transport, and compliance with assignment and transport precautions for both years. For the second influenza season we sent monthly reminders to all ED providers via the electronic medical record (EMR), explaining the importance and proper use of infection control precautions in patients with suspected influenza. Compliance between the two seasons was compared using descriptive statistics and chi-squared analysis. Results: Overall compliance with infection control precautions was poor, but increased with the use of electronic reminders from 29% to 45% (p = 0.015). Compliance with precautions for patients moved to the hallway or Radiology increased from 7% to 24% (p = 0.001). Conclusions: The EMR may be a useful tool for improving compliance with transmission-based precautions by implementing reminders on order sets and informational mailings, and by tracking compliance. Future study should be undertaken to determine the most effective interventions to prevent ED transmission of influenza.
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Aiello AE, Coulborn RM, Aragon TJ, Baker MG, Burrus BB, Cowling BJ, Duncan A, Enanoria W, Fabian MP, Ferng YH, Larson EL, Leung GM, Markel H, Milton DK, Monto AS, Morse SS, Navarro JA, Park SY, Priest P, Stebbins S, Stern AM, Uddin M, Wetterhall SF, Vukotich CJ. Research findings from nonpharmaceutical intervention studies for pandemic influenza and current gaps in the research. Am J Infect Control 2010; 38:251-8. [PMID: 20226569 DOI: 10.1016/j.ajic.2009.12.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 12/17/2009] [Accepted: 12/20/2009] [Indexed: 11/18/2022]
Abstract
In June 2006, the Centers for Disease Control and Prevention released a request for applications to identify, improve, and evaluate the effectiveness of nonpharmaceutical interventions (NPIs)-strategies other than vaccines and antiviral medications-to mitigate the spread of pandemic influenza within communities and across international borders (RFA-CI06-010). These studies have provided major contributions to seasonal and pandemic influenza knowledge. Nonetheless, key concerns were identified related to the acceptability and protective efficacy of NPIs. Large-scale intervention studies conducted over multiple influenza epidemics, as well as smaller studies in controlled laboratory settings, are needed to address the gaps in the research on transmission and mitigation of influenza in the community setting. The current novel influenza A (H1N1) pandemic underscores the importance of influenza research.
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Affiliation(s)
- Allison E Aiello
- Center for Social Epidemiology and Population Health, Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, USA.
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Larson EL, Ferng YH, Wong-McLoughlin J, Wang S, Haber M, Morse SS. Impact of non-pharmaceutical interventions on URIs and influenza in crowded, urban households. Public Health Rep 2010; 125:178-91. [PMID: 20297744 DOI: 10.1177/003335491012500206] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES We compared the impact of three household interventions-education, education with alcohol-based hand sanitizer, and education with hand sanitizer and face masks-on incidence and secondary transmission of upper respiratory infections (URIs) and influenza, knowledge of transmission of URIs, and vaccination rates. METHODS A total of 509 primarily Hispanic households participated. Participants reported symptoms twice weekly, and nasal swabs were collected from those with an influenza-like illness (ILI). Households were followed for up to 19 months and home visits were made at least every two months. RESULTS We recorded 5034 URIs, of which 669 cases reported ILIs and 78 were laboratory-confirmed cases of influenza. Demographic factors significantly associated with infection rates included age, gender, birth location, education, and employment. The Hand Sanitizer group was significantly more likely to report that no household member had symptoms (p < 0.01), but there were no significant differences in rates of infection by intervention group in multivariate analyses. Knowledge improved significantly more in the Hand Sanitizer group (p < 0.0001). The proportion of households that reported > or = 50% of members receiving influenza vaccine increased during the study (p < 0.001). Despite the fact that compliance with mask wearing was poor, mask wearing as well as increased crowding, lower education levels of caretakers, and index cases 0-5 years of age (compared with adults) were associated with significantly lower secondary transmission rates (all p < 0.02). CONCLUSIONS In this population, there was no detectable additional benefit of hand sanitizer or face masks over targeted education on overall rates of URIs, but mask wearing was associated with reduced secondary transmission and should be encouraged during outbreak situations. During the study period, community concern about methicillin-resistant Staphylococcus aureus was occurring, perhaps contributing to the use of hand sanitizer in the Education control group, and diluting the intervention's measurable impact.
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Affiliation(s)
- Elaine L Larson
- School of Nursing, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.
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Turner TJ, Barnes H, Reid J, Garrubba M. Evidence for perinatal and child health care guidelines in crisis settings: can Cochrane help? BMC Public Health 2010; 10:170. [PMID: 20350326 PMCID: PMC3091544 DOI: 10.1186/1471-2458-10-170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 03/29/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is important that healthcare provided in crisis settings is based on the best available research evidence. We reviewed guidelines for child and perinatal health care in crisis situations to determine whether they were based on research evidence, whether Cochrane systematic reviews were available in the clinical areas addressed by these guidelines and whether summaries of these reviews were provided in Evidence Aid. METHODS Broad internet searches were undertaken to identify relevant guidelines. Guidelines were appraised using AGREE and the clinical areas that were relevant to perinatal or child health were extracted. We searched The Cochrane Database of Systematic Reviews to identify potentially relevant reviews. For each review we determined how many trials were included, and how many were conducted in resource-limited settings. RESULTS Six guidelines met selection criteria. None of the included guidelines were clearly based on research evidence. 198 Cochrane reviews were potentially relevant to the guidelines. These reviews predominantly addressed nutrient supplementation, breastfeeding, malaria, maternal hypertension, premature labour and prevention of HIV transmission. Most reviews included studies from developing settings. However for large portions of the guidelines, particularly health services delivery, there were no relevant reviews. Only 18 (9.1%) reviews have summaries in Evidence Aid. CONCLUSIONS We did not identify any evidence-based guidelines for perinatal and child health care in disaster settings. We found many Cochrane reviews that could contribute to the evidence-base supporting future guidelines. However there are important issues to be addressed in terms of the relevance of the available reviews and increasing the number of reviews addressing health care delivery.
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Affiliation(s)
- Tari J Turner
- Monash Institute of Health Services Research, Monash University, Locked Bag 29, Clayton 3168 Australia
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Hayley Barnes
- previously of the Australasian Cochrane Centre, Monash University, Locked Bag 29, Clayton 3168 Australia
| | - Jane Reid
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Marie Garrubba
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
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Nichol KL, Tummers K, Hoyer-Leitzel A, Marsh J, Moynihan M, McKelvey S. Modeling seasonal influenza outbreak in a closed college campus: impact of pre-season vaccination, in-season vaccination and holidays/breaks. PLoS One 2010; 5:e9548. [PMID: 20209058 PMCID: PMC2832017 DOI: 10.1371/journal.pone.0009548] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 02/09/2010] [Indexed: 11/29/2022] Open
Abstract
Background College and university students experience substantial morbidity from influenza and influenza-like illness, and they can benefit substantially from vaccination. Public health authorities encourage vaccination not only before the influenza season but also into and even throughout the influenza season. We conducted the present study to assess the impact of various vaccination strategies including delayed (i.e., in-season) vaccination on influenza outbreaks on a college campus. Methods/Findings We used a Susceptible → Infected → Recovered (SIR) framework for our mathematical models to simulate influenza epidemics in a closed, college campus. We included both students and faculty/staff in the model and derived values for the model parameters from the published literature. The values for key model parameters were varied to assess the impact on the outbreak of various pre-season and delayed vaccination rates; one-way sensitivity analyses were conducted to test the sensitivity of the model outputs to changes in selected parameter values. In the base case, with a pre-season vaccination rate of 20%, no delayed vaccination, and 1 student index case, the total attack rate (total percent infected, TAR) was 45%. With higher pre-season vaccination rates TARs were lower. Even if vaccinations were given 30 days after outbreak onset, TARs were still lower than the TAR of 69% in the absence of vaccination. Varying the proportions of vaccinations given pre-season versus delayed until after the onset of the outbreak gave intermediate TAR values. Base case outputs were sensitive to changes in infectious contact rates and infectious periods and a holiday/break schedule. Conclusion Delayed vaccination and holidays/breaks can be important adjunctive measures to complement traditional pre-season influenza vaccination for controlling and preventing influenza in a closed college campus.
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Affiliation(s)
- Kristin L Nichol
- Research Service, Veterans Affairs Medical Center, Minneapolis, Minnesota, United States of America.
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Aiello AE, Murray GF, Perez V, Coulborn RM, Davis BM, Uddin M, Shay DK, Waterman SH, Monto AS. Mask use, hand hygiene, and seasonal influenza-like illness among young adults: A randomized intervention trial. J Infect Dis 2010; 201:491-8. [DOI: 10.1086/650396] [Citation(s) in RCA: 217] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Abstract
Background . During the influenza A(H1N1) pandemic, antiviral prescribing was limited, vaccines were not available early, and the effectiveness of nonpharmaceutical interventions (NPIs) was uncertain. Our study examined whether use of face masks and hand hygiene reduced the incidence of influenza-like illness (ILI).
Methods . A randomized intervention trial involving 1437 young adults living in university residence halls during the 2006–2007 influenza season was designed. Residence halls were randomly assigned to 1 of 3 groups—face mask use, face masks with hand hygiene, or control— for 6 weeks. Generalized models estimated rate ratios for clinically diagnosed or survey-reported ILI weekly and cumulatively.
Results . We observed significant reductions in ILI during weeks 4–6 in the mask and hand hygiene group, compared with the control group, ranging from 35% (confidence interval [CI], 9%–53%) to 51% (CI, 13%–73%), after adjusting for vaccination and other covariates. Face mask use alone showed a similar reduction in ILI compared with the control group, but adjusted estimates were not statistically significant. Neither face mask use and hand hygiene nor face mask use alone was associated with a significant reduction in the rate of ILI cumulatively.
Conclusions . These findings suggest that face masks and hand hygiene may reduce respiratory illnesses in shared living settings and mitigate the impact of the influenza A(H1N1) pandemic.
Trial Registration . ClinicalTrials.gov identifier: NCT00490633.
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Affiliation(s)
- Allison E. Aiello
- Department of Epidemiology, School of Public Health, University of Michigan Ann Arbor, Michigan
- Center for Social Epidemiology and Population Health, School of Public Health, University of Michigan Ann Arbor, Michigan
| | - Genevra F. Murray
- Department of Sociology, Anthropology, and Social Work, University of South Alabama Atlanta, Georgia
| | - Vanessa Perez
- Department of Epidemiology, School of Public Health, University of Michigan Ann Arbor, Michigan
- Center for Social Epidemiology and Population Health, School of Public Health, University of Michigan Ann Arbor, Michigan
| | - Rebecca M. Coulborn
- Department of Epidemiology, School of Public Health, University of Michigan Ann Arbor, Michigan
- Center for Social Epidemiology and Population Health, School of Public Health, University of Michigan Ann Arbor, Michigan
| | - Brian M. Davis
- Department of Epidemiology, School of Public Health, University of Michigan Ann Arbor, Michigan
- Center for Social Epidemiology and Population Health, School of Public Health, University of Michigan Ann Arbor, Michigan
| | - Monica Uddin
- Department of Epidemiology, School of Public Health, University of Michigan Ann Arbor, Michigan
- Center for Social Epidemiology and Population Health, School of Public Health, University of Michigan Ann Arbor, Michigan
| | - David K. Shay
- Centers for Disease Control and Prevention Atlanta, Georgia
| | | | - Arnold S. Monto
- Department of Epidemiology, School of Public Health, University of Michigan Ann Arbor, Michigan
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Jefferson T, Del Mar C, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, van Driel ML, Nair S, Foxlee R, Rivetti A. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev 2010:CD006207. [PMID: 20091588 DOI: 10.1002/14651858.cd006207.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a world-wide threat. Antiviral drugs and vaccinations may be insufficient to prevent catastrophe. OBJECTIVES To systematically review the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 2); MEDLINE (1966 to May 2009); OLDMEDLINE (1950 to 1965); EMBASE (1990 to May 2009); and CINAHL (1982 to May 2009). SELECTION CRITERIA We scanned 2958 titles, excluded 2790 and retrieved the full papers of 168 trials, to include 59 papers of 60 studies. We included any physical interventions (isolation, quarantine, social distancing, barriers, personal protection and hygiene) to prevent transmission of respiratory viruses. We included the following study designs: randomised controlled trials (RCTs), cohorts, case controls, cross-over, before-after, and time series studies. DATA COLLECTION AND ANALYSIS We used a standardised form to assess trial eligibility. RCTs were assessed by: randomisation method; allocation generation; concealment; blinding; and follow up. Non-RCTs were assessed for the presence of potential confounders, and classified into low, medium, and high risks of bias. MAIN RESULTS The risk of bias for the four RCTs, and most cluster RCTs, was high. The observational studies were of mixed quality. Only case-control data were sufficiently homogeneous to allow meta-analysis.The highest quality cluster RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children. Additional benefit from reduced transmission from children to other household members is broadly supported in results of other study designs, where the potential for confounding is greater. Six case-control studies suggested that implementing barriers to transmission, isolation, and hygienic measures are effective at containing respiratory virus epidemics. We found limited evidence that N95 respirators were superior to simple surgical masks, but were more expensive, uncomfortable, and caused skin irritation. The incremental effect of adding virucidals or antiseptics to normal handwashing to decrease respiratory disease remains uncertain. Global measures, such as screening at entry ports, were not properly evaluated. There was limited evidence that social distancing was effective especially if related to the risk of exposure. AUTHORS' CONCLUSIONS Many simple and probably low-cost interventions would be useful for reducing the transmission of epidemic respiratory viruses. Routine long-term implementation of some of the measures assessed might be difficult without the threat of a looming epidemic.
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Affiliation(s)
- Tom Jefferson
- Vaccines Field, The Cochrane Collaboration, Via Adige 28a, Anguillara Sabazia, Roma, Italy, 00061
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Santibañez S, Fiore AE, Merlin TL, Redd S. A primer on strategies for prevention and control of seasonal and pandemic influenza. Am J Public Health 2009; 99 Suppl 2:S216-24. [PMID: 19797735 PMCID: PMC4504386 DOI: 10.2105/ajph.2009.164848] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2009] [Indexed: 11/04/2022]
Abstract
The United States has made considerable progress in pandemic preparedness. Limited attention, however, has been given to the challenges faced by populations that will be at increased risk of the consequences of the pandemic, including challenges caused by societal, economic, and health-related factors. This supplement to the American Journal of Public Health focuses on the challenges faced by at-risk and vulnerable populations in preparing for and responding to an influenza pandemic. Here, we provide background information for subsequent articles throughout the supplement. We summarize (1) seasonal influenza epidemiology, transmission, clinical illness, diagnosis, vaccines, and antiviral medications; (2) H5N1 avian influenza; and (3) pandemic influenza vaccines, antiviral medications, and nonpharmaceutical interventions.
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Affiliation(s)
- Scott Santibañez
- Centers for Disease Control and Prevention, 1600 Clifton Rd, MS A-20, Atlanta GA 30333, USA.
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35
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Affiliation(s)
- John M Embil
- Infection Prevention and Control Program, Winnipeg Regional Health Authority.
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36
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Grammatikos AP, Mantadakis E, Falagas ME. Meta-analyses on Pediatric Infections and Vaccines. Infect Dis Clin North Am 2009; 23:431-57. [DOI: 10.1016/j.idc.2009.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Head-to-head comparison of four nonadjuvanted inactivated cell culture-derived influenza vaccines: effect of composition, spatial organization and immunization route on the immunogenicity in a murine challenge model. Vaccine 2009; 26:6555-63. [PMID: 18848856 DOI: 10.1016/j.vaccine.2008.09.057] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Revised: 08/13/2008] [Accepted: 09/17/2008] [Indexed: 01/22/2023]
Abstract
In order to study the influence of antigen composition, spatial organization of antigen and the route of administration, four cell culture-derived, inactivated, nonadjuvanted influenza vaccine formulations, i.e. whole inactivated virus (WIV), split, subunit and virosome vaccines were prepared from a single antigen batch. We directly compared the immunogenicity and efficacy of these vaccine formulations after intramuscular (i.m.) or intranasal (i.n.) administration in mice. Prime and boost vaccination were followed by a potentially lethal homologous aerosol challenge. For all vaccines, the i.m. route induced higher serum humoral immune responses as compared to the i.n. route and protected all mice against challenge at a dose of 5 microg. Upon i.n. immunization only WIV and split vaccines induced detectable IgG titers and partial protection against challenge but only very low HI titers were induced in almost all mice. WIV induced mainly IgG2a/c titers via both routes, whereas split vaccine induced exclusively IgG1 titers via both routes. Subunit and virosome vaccines induced exclusively IgG1 via the i.m. route. Mucosal sIgA levels were only detected after i.n. vaccination with WIV. Furthermore, vaccines containing all viral components (WIV and split vaccine) induced higher serum HI titers and serum antibody titers than subunit and virosome vaccines. The differences in magnitude and quality of immune responses of split and WIV, having the same composition, are likely related to their distinct spatial organization. In conclusion, the direct comparison between WIV, split, subunit and virosomes, shows that the differences in immune responses between these well known influenza vaccines can be explained by both the composition and particulate structure of these vaccine formulations.
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Jefferson T, Di Pietrantonj C, Debalini MG, Rivetti A, Demicheli V. Inactivated influenza vaccines: methods, policies, and politics. J Clin Epidemiol 2009; 62:677-86. [PMID: 19124222 DOI: 10.1016/j.jclinepi.2008.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Accepted: 07/01/2008] [Indexed: 11/24/2022]
Affiliation(s)
- T Jefferson
- Cochrane Vaccines Field, ASL AL, Alessandria, Italy.
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39
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Driel M, Mar C. Interventions to prevent transmission of the common cold. COMMOND COLD 2009. [PMCID: PMC7123870 DOI: 10.1007/978-3-7643-9912-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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40
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Meilicke G, Weissenborn A, Biederbick W, Bartels C. [Fighting the flu with soap and water. Hand washing as an infection control recommendation to the population--7 hypotheses from a qualitative study about hygiene, flu and pandemic]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2008; 51:1273-9. [PMID: 19043755 DOI: 10.1007/s00103-008-0701-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Medical interventions like vaccination and antiviral prophylaxis are only two ways of protecting the population from infectious diseases. A third and decisive method is to apply non-pharmaceutical interventions like hand hygiene. A qualitative study identified the role hand washing actually plays in the daily life of the population. Based on the results, seven hypotheses are proposed which point to the need for further research about promotion of hand hygiene, e.g. the conception and evaluation of hand washing advertising campaigns. HYPOTHESIS 1: Health tips are more likely to be followed if they communicate clearly and understandably the personal relevance of the information to the recipients. HYPOTHESIS 2: For many, hygiene serves above all to make them feel good and more comfortable around others. HYPOTHESIS 3: The feeling of disgust is an emotional connection between health and hygiene. HYPOTHESIS 4: People mainly wash their hands ritually and when they actually feel the need to clean their hands. HYPOTHESIS 5: As far as most people are aware, the means of transmission of influenza and other respiratory diseases are only the ones they can observe, namely coughing, sneezing, and the resulting visible droplets. HYPOTHESIS 6: People are more motivated to wash their hands after learning that infections can be spread via the hands. HYPOTHESIS 7: A pandemic situation increases the population's demand for information and people's willingness to protect themselves from infection.
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High quality evidence from vaccine field studies is needed to recommend influenza vaccination of hospital staff in the acute care setting. Vaccine 2008; 26:6741-2. [DOI: 10.1016/j.vaccine.2008.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Accepted: 10/06/2008] [Indexed: 11/23/2022]
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Brockmann SO, Schwehm M, Duerr HP, Witschi M, Koch D, Vidondo B, Eichner M. Modeling the effects of drug resistant influenza virus in a pandemic. Virol J 2008; 5:133. [PMID: 18973656 PMCID: PMC2590604 DOI: 10.1186/1743-422x-5-133] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 10/30/2008] [Indexed: 11/13/2022] Open
Abstract
Neuraminidase inhibitors (NI) play a major role in plans to mitigate future influenza pandemics. Modeling studies suggested that a pandemic may be contained at the source by early treatment and prophylaxis with antiviral drugs. Here, we examine the influence of NI resistant influenza strains on an influenza pandemic. We extend the freely available deterministic simulation program InfluSim to incorporate importations of resistant infections and the emergence of de novo resistance. The epidemic with the fully drug sensitive strain leads to a cumulative number of 19,500 outpatients and 258 hospitalizations, respectively, per 100,000 inhabitants. Development of de novo resistance alone increases the total number of outpatients by about 6% and hospitalizations by about 21%. If a resistant infection is introduced into the population after three weeks, the outcome dramatically deteriorates. Wide-spread use of NI treatment makes it highly likely that the resistant strain will spread if its fitness is high. This situation is further aggravated if a resistant virus is imported into a country in the early phase of an outbreak. As NI-resistant influenza infections with high fitness and pathogenicity have just been observed, the emergence of drug resistance in treated populations and the transmission of drug resistant strains is an important public health concern for seasonal and pandemic influenza.
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Affiliation(s)
- Stefan O Brockmann
- Department of Epidemiology and Health Reporting, Baden-Württemberg State Health Office, District Government Stuttgart, Germany.
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Tobin GJ, Trujillo JD, Bushnell RV, Lin G, Chaudhuri AR, Long J, Barrera J, Pena L, Grubman MJ, Nara PL. Deceptive imprinting and immune refocusing in vaccine design. Vaccine 2008; 26:6189-99. [PMID: 18852005 DOI: 10.1016/j.vaccine.2008.09.080] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 09/18/2008] [Indexed: 10/21/2022]
Abstract
A large number of the world's most widespread and problematic pathogens evade host immune responses by inducing strain-specific immunity to immunodominant epitopes with high mutation rates capable of altering antigenic profiles. The immune system appears to be decoyed into reacting to these immunodominant epitopes that offer little cross protection between serotypes or subtypes. For example, during HIV-1 infection, the immune system reacts strongly to the V1, V2, and/or V3 loops of the surface envelope glycoprotein but not to epitopes that afford broad protection against strain variants. Similarly, the host mounts strain-specific immunity to immunodominant epitopes of the influenza hemagglutinin (HA) protein. A large number of pathogens appear to exploit this weakness in the host immune system by focusing antigenic attention upon highly variable epitopes while avoiding surveillance toward more highly conserved receptor binding sites or other essential functional domains. Because the propensity of the immune system to react against immunodominant strain-specific epitopes appears to be genetically hard-wired, the phenomenon has been termed "deceptive imprinting." In this review, the authors describe observations related to deceptive imprinting in multiple systems and propose strategies for overcoming this phenomenon in the design of vaccines capable of inducing protection against highly variable pathogens.
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Affiliation(s)
- Gregory J Tobin
- Biological Mimetics, Inc., 124 Byte Drive Frederick, MD 21702, USA.
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Schanzer DL, Langley JM, Tam TWS. Co-morbidities associated with influenza-attributed mortality, 1994-2000, Canada. Vaccine 2008; 26:4697-703. [PMID: 18620016 DOI: 10.1016/j.vaccine.2008.06.087] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 06/10/2008] [Accepted: 06/13/2008] [Indexed: 11/15/2022]
Abstract
The elderly and persons with specific chronic conditions are known to face elevated morbidity and mortality risks resulting from an influenza infection, and hence are routinely recommended for annual influenza vaccination. However, risk-specific mortality rates have not been established. We estimated age-specific influenza-attributable mortality rates stratified by the presence of chronic conditions and type of residence based on deaths of persons who were admitted to hospital with a respiratory complication captured in our national database. The majority of patients had chronic heart or respiratory conditions (80%) and were admitted from the community (80%). Influenza-attributable mortality rates clearly increase with age for all risk groups. Our influenza-specific estimates identified higher risk ratios for chronic lung or heart disease than have been suggested by other methods. These estimates identify groups most in need of improved vaccines and for whom the use of additional strategies, such as immunization of household contacts or caregivers should be considered.
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Affiliation(s)
- Dena L Schanzer
- Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, Ontario, Canada.
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