Effectiveness of hand hygiene practices in preventing influenza virus infection in the community setting: A systematic review

Synthesising the evidence for effective hand hygiene in community settings: an integrated protocol for multiple related systematic reviews

INTRODUCTION

Despite evidence for the efficacy and effectiveness of hand hygiene in reducing the transmission of infectious diseases, there are gaps in global normative guidance around hand hygiene in community settings. The goal of this review is to systematically retrieve and synthesise available evidence on hand hygiene in community settings across four areas: (1) effective hand hygiene; (2) minimum requirements; (3) behaviour change and (4) government measures.

METHODS AND ANALYSIS

This protocol entails a two-phased approach to identify relevant studies for multiple related systematic reviews. Phase 1 involves a broad search to capture all studies on hand hygiene in community settings. Databases, trial registries, expert consultations and hand searches of reference lists will be used to ensure an exhaustive search. A comprehensive, electronic search strategy will be used to identify studies indexed in PubMed, Web of Science, EMBASE, CINAHL, Global Health, Cochrane Library, Global Index Medicus, Scopus, PAIS Index, WHO IRIS, UN Digital Library and World Bank eLibrary published in English from January 1980 to March 2023. The outcome of phase 1 will be a reduced sample of studies from which further screening, specific to research questions across the four key areas can be performed. Two reviewers will independently assess each study for inclusion and disagreements will be resolved by a third reviewer. Quantitative and qualitative data will be extracted following best practices. We will assess all studies using the Mixed Method Appraisal Tool. All effect measures pertaining to review outcomes will be reported and a narrative synthesis of all studies will be presented including 'data-driven' descriptive themes and 'theory-driven' analytical themes as applicable.

ETHICS AND DISSEMINATION

This systematic review is exempt from ethics approval because the work is carried out on published documents. The findings of the reviews will be disseminated in related peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42023429145.

Analysis of the effectiveness of non-pharmaceutical interventions on influenza during the Coronavirus disease 2019 pandemic by time-series forecasting

BACKGROUND

Coronavirus disease 2019 (COVID-19) was first identified in South Korea during the 2019-2020 seasonal influenza epidemic. The social distancing measures, as effective non-pharmaceutical interventions (NPIs), adopted to mitigate the spread of COVID-19 might have influenced influenza activity. We evaluated IFV(influenza virus) activity during the COVID-19 pandemic and the effect of NPI intensity on influenza transmission.

METHODS

IFV activity and epidemic duration during COVID-19 pandemic were predicted under a counterfactual scenario with no NPIs against COVID-19. The Seasonal Autoregressive Integrated Moving Average Model was used to quantify the effects of NPIs on the transmission of influenza virus. Influenza-like illness/1000 outpatients and IFV positivity rate from the 2011-2012 to 2021-2022 seasons were used in this study.

RESULTS

Comparison of the 2020-2021 and 2021-2022 seasonal influenza activities with those in 2013-2019 showed that COVID-19 outbreaks and associated NPIs such as face mask use, school closures, and travel restrictions reduced the influenza incidence by 91%. Without NPIs against COVID-19, the rates of influenza-like illness and IFV positivity would have been high during the influenza epidemic season, as in previous seasons. NPI intensity decreased the transmission of influenza; the magnitude of the reduction increased as the intensity of social-distancing measures increased (weak social distancing; step-by-step daily recovery: 58.10%, strong social distancing; special quarantine measures: 95.12%).

CONCLUSIONS

Our results suggest that NPIs and personal hygiene can be used to suppress influenza transmission. NPIs against COVID-19 may be useful strategies for the prevention and control of influenza epidemics.

Physical interventions to interrupt or reduce the spread of respiratory viruses

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.

Participatory action research to co-design a culturally appropriate COVID-19 risk communication and community engagement strategy in rural Pakistan

Background

Community engagement has shown to be fundamental component of the response to previous disease outbreaks. This study aimed co-design and implement a culturally appropriate COVID-19 risk communication and community engagement strategy with a resource-poor rural community in Northwest Pakistan.

Methods

Participatory Action Research (PAR) was conducted from January 2021 to March 2022. Five PAR meetings took place with community members (n = 30) to: (1) explore how the COVID-19 pandemic impacted on the community; (2) identify challenges to limit the spread of the virus; (3) identify and implement solutions to these challenges; and (4) highlight the enablers, challenges and knowledge of the cultural context needed to optimize safety during emergencies. Focus group discussions (N = 6) with community members not involved in the PAR meetings (N = 50) and children of the community (N = 26) were conducted following the PAR meetings. Thematic analysis of the PAR and focus group data was conducted.

Results

Delivery of messages on how to keep families safe, provision of personal protective equipment and improved water systems were part of the strategies taken by the community to create awareness and reduce the spread of COVID-19. Nine themes were identified: Attitudes to the pandemic: From skepticism to acceptance, Changing attitudes about vaccination: rumors and trust, COVID-19 and Faith, Social impact of the pandemic, Access to water, Resource mobilization: personal protective equipment, Spaces where collaborative effort can bring to solutions, Agents of change, and Empowerment of women.

Discussion

The participatory approach of this research allowed understanding of the challenges faced by the community to engage in behavior change strategies to reduce the spread of COVID-19 and enabled the community to find sustainable solutions. Engagement with the community empowered men and women to be agents of change and promoted necessary precautionary actions to reduce the risk of infection within their community.

Conclusion

Participatory approach highlighted the importance of engaging with and integrating to local culture and values to overcome challenges such as gender imbalance and distrust. Findings of this study are relevant to others working in diverse cultural settings in similar crises events regardless of particular cultural variations.

Limited handwashing facility and associated factors in sub-Saharan Africa: pooled prevalence and multilevel analysis of 29 sub-Saharan Africa countries from demographic health survey data

Introduction

Handwashing is fundamentally an inexpensive means of reducing the spread of communicable diseases. In developing countries, many people die due to infectious diseases that could be prevented by proper hand hygiene. The recent coronavirus (COVID-19) pandemic is a threat to people who are living in resource-limited countries including sub-Saharan Africa (SSA). Effective hand hygiene requires sufficient water from reliable sources, preferably accessible on premises, and access to handwashing facility (water and or soap) that enable hygiene behaviors. Therefore, this study aims to determine the prevalence of limited handwashing facility and its associated factors in sub-Saharan Africa.

Methods

Data from the Demographic and Health Surveys (DHS) were used, which have been conducted in 29 sub-Saharan African countries since January 1, 2010. A two-stage stratified random cluster sampling strategy was used to collect the data. This study comprised a total of 237,983 weighted samples. The mixed effect logistic regression model with a cluster-level random intercept was fitted. Meta-analysis and sub-group analysis were performed to establish the pooled prevalence.

Results

The pooled prevalence of limited handwashing facility was found to be 66.16% (95% CI; 59.67%—72.65%). Based on the final model, household head with age group between 35 and 60 [AOR = 0.89, 95% CI; 0.86—0.91], households with mobile type of hand washing facility [AOR = 1.73, 95% CI; 1.70—1.77], unimproved sanitation facility [AOR = 1.58, 95% CI; 1.55—1.62], water access more than 30 min round trip [AOR = 1.16, 95% CI; 1.13—1.19], urban residential area [AOR = 2.08, 95% CI; 2.04—2.13], low media exposure [AOR = 1.47, 95% CI; 1.31—1.66], low educational level [AOR = 1.30, 95% CI; 1.14—1.48], low income level [AOR = 2.41, 95% CI; 2.33—2.49] as well as lower middle-income level [AOR = 2.10, 95% CI; 2.14—2.17] and households who had more than three children [AOR = 1.25, 95% CI; 1.20—1.31] were associated with having limited handwashing facility.

Conclusion and recommendation

The pooled coverage of limited handwashing facility was high in sub-Saharan Africa. Raising awareness of the community and promoting access to handwashing materials particularly in poorer and rural areas will reduce its coverage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14390-4.

How are hygiene programmes designed in crises? Qualitative interviews with humanitarians in the Democratic Republic of the Congo and Iraq

BACKGROUND

Hygiene behaviour change programmes are complex to design. These challenges are heightened during crises when humanitarian responders are under pressure to implement programmes rapidly despite having limited information about the local situation, behaviours and opinions-all of which may also be rapidly evolving.

METHODS

We conducted in-depth interviews with 36 humanitarian staff involved in hygiene programme design in two crisis-affected settings-one a conflict affected setting (Iraq) and the other amid a cholera outbreak (Democratic Republic of the Congo). Interviews explored decision-making in each phase of the humanitarian project cycle and were thematically analysed.

RESULTS

Participants considered the design and implementation of hygiene programmes in crises to be sub-optimal. Humanitarians faced sector-specific challenges as well as more general constraints associated with operating within the humanitarian system. Programme-design decisions were made naturalistically and relied heavily on the intuitions and assumptions of senior staff. National organisations were often side-lined from programme design processes despite being in a better position to gather situational data. Consequently, programme design and decision-making processes adopted by humanitarians were similar across the two settings studied and led to similar types of hygiene promotion activities being delivered.

CONCLUSION

Hygiene programming in crises-affected settings could be strengthened by initiatives targeted at supporting humanitarian staff during the pre-implementation programme design phase. This may include rapid assessment tools to better understand behavioural determinants in crisis-affected contexts; the use of a theory of change to inform the selection of programme activities; and funding mechanisms which encourage equitable partnerships, phased programming, regular adaptation and have programmatic components targeted at sustainability and sector capacity building. Initiatives aimed at sector reform should be cognisant of inter and intra-organisational dynamics, the ways that expertise is created and valued by the sector, and humanitarian habits and norms that arise in response to system constraints and pressures. These micro-organisational processes affect macro-level outcomes related to programme quality and acceptability and determine or limit the roles of national actors in programme design processes.

Nonpharmaceutical interventions to prevent viral respiratory infection in community settings: an umbrella review

Background

Respiratory viruses pose an important public health threat to most communities. Nonpharmaceutical interventions (NPIs) such as masks, hand hygiene or physical distancing, among others, are believed to play an important role in reducing transmission of respiratory viruses. In this umbrella review, we summarise the evidence of the effectiveness of NPIs for the prevention of respiratory virus transmission in the community setting.

Observations

A systematic search of PubMed, Embase, Medline and Cochrane reviews resulted in a total of 24 studies consisting of 11 systematic reviews and meta-analyses, 12 systematic reviews without meta-analyses and one standalone meta-analysis. The current evidence from these data suggests that hand hygiene is protective against respiratory viral infection. The use of hand hygiene and facemasks, facemasks alone and physical distancing were interventions with inconsistent evidence. Interventions such as school closures, oral hygiene or nasal saline rinses were shown to be effective in reducing the risk of influenza; however, the evidence is sparse and mostly of low and critically low quality.

Conclusions

Studies on the effectiveness of NPIs for the prevention of respiratory viral transmission in the community vary in study design, quality and reported effectiveness. Evidence for the use of hand hygiene or facemasks is the strongest; therefore, the most reasonable suggestion is to use hand hygiene and facemasks in the community setting.

Public health implications of SARS-CoV-2 variants of concern: a rapid scoping review

OBJECTIVES

The four SARS-CoV-2 variants of concern (VOC; Alpha, Beta, Gamma and Delta) identified by May 2021 are highly transmissible, yet little is known about their impact on public health measures. We aimed to synthesise evidence related to public health measures and VOC.

DESIGN

A rapid scoping review.

DATA SOURCES

On 11 May 2021, seven databases (MEDLINE, Embase, the Cochrane Database of Systematic Reviews, Central Register of Controlled Trials, Epistemonikos' L-OVE on COVID-19, medRxiv, bioRxiv) were searched for terms related to VOC, public health measures, transmission and health systems. No limit was placed on date of publication.

ELIGIBILITY CRITERIA

Studies were included if they reported on any of the four VOCs and public health measures, and were available in English. Only studies reporting on data collected after October 2020, when the first VOC was reported, were included.

DATA EXTRACTION AND SYNTHESIS

Titles, abstracts and full-text articles were screened by two independent reviewers. Data extraction was completed by two independent reviewers using a standardised form. Data synthesis and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

RESULTS

Of the 37 included studies, the majority assessed the impact of Alpha (n=32) and were conducted in Europe (n=12) or the UK (n=9). Most were modelling studies (n=28) and preprints (n=28). The majority of studies reported on infection control measures (n=17), followed by modifying approaches to vaccines (n=13), physical distancing (n=6) and either mask wearing, testing or hand washing (n=2). Findings suggest an accelerated vaccine rollout is needed to mitigate the spread of VOC.

CONCLUSIONS

The increased severity of VOC requires proactive public health measures to control their spread. Further research is needed to strengthen the evidence for continued implementation of public health measures in conjunction with vaccine rollout. With no studies reporting on Delta, there is a need for further research on this and other emerging VOC on public health measures.

Handwashing Practice and Its Predictors Among Mothers of Children Aged 0 to 23 Months in South Ethiopia: Community Based Cross-Sectional Study

BACKGROUND

Maternal handwashing practice is an important measure to prevent the spreading of childhood disease. Handwashing is still being practiced to a very low extent especially at critical times since the global prevalence of handwashing with soap was estimated at 19% by a systematic review after compiling 42 studies all over the world.

OBJECTIVE

To assess the handwashing practice and its predictors among mothers of children aged 0 to 23 months in Mareka District, south Ethiopia, 2020.

METHOD

A community-based cross-sectional study was conducted with a multistage sampling technique on 520 women having children aged 0 to 23 months in Mareka District. Data were collected by using interviewer-administered pre-tested structured questionnaires. Data were checked for completeness and entered into Epi data entry 4.6.2. The data were exported into SPSS version 22 for analysis with multivariate logistic regression analysis at P < .05.

RESULT

Mothers wash their hands with soap and water after visiting the latrine (27.1%), after cleaning the child's bottom (28.5%), before cooking (6.2%), before eating (6.9%), and before feeding the child (21.2%). The most important predictors were water availability near the handwashing location with an adjusted odds ratio (AOR) 5.26 (95% CI 1.99-13.69) and soap availability near the handwashing location with AOR 0.40 (95% CI 0.18-0.89) for good handwashing practice.

CONCLUSION

The handwashing practice at critical times was low. The presences of water and soap near the handwashing location were the most important predictors. It is necessary to increase the provision of both water and soap near the handwashing location for improving handwashing with soap and water at key times.

Preventive effects of tea and tea catechins against influenza and acute upper respiratory tract infections: a systematic review and meta-analysis

Purpose

Gargling with tea has protective effects against influenza infection and upper respiratory tract infection (URTI). To evaluate if tea and tea catechin consumption has the same protective effects as gargling with tea, we performed a systematic review and meta-analysis.

Methods

We performed a comprehensive literature search using the PubMed, Cochrane Library, Web of Science, and Ichu-shi Web databases. The search provided six randomized controlled trials (RCTs) and four prospective cohort studies (n = 3748). The quality of each trial or study was evaluated according to the Cochrane risk-of-bias tool or Newcastle–Ottawa Scale. We collected data from publications meeting the search criteria and conducted a meta-analysis of the effect of tea gargling and tea catechin consumption for preventing URTI using a random effects model.

Results

Tea gargling and tea catechin consumption had significant preventive effects against URTI (risk ratio [RR] = 0.74, 95% confidence interval [CI] 0.64–0.87). In sub-analyses, a significant preventive effect was observed by study type (prospective cohort study: RR = 0.67, 95% CI 0.50–0.91; RCT: RR = 0.79, 95% CI 0.66–0.94) and disease type (influenza: RR = 0.69, 95% CI 0.58–0.84; acute URTI: RR = 0.78, 95% CI 0.62–0.98). Both gargling with tea and consuming tea catechins effectively protected against URTI (tea and tea catechins consumption: RR = 0.68, 95% CI 0.52–0.87; tea gargling: RR = 0.83, 95% CI 0.72–0.96).

Conclusion

Our findings suggest that tea gargling and tea catechin consumption may have preventive effects against influenza infection and URTI. The potential effectiveness of these actions as non-pharmaceutical interventions, however, requires further investigation.

Identifying drivers for user preference and acceptability of different hydro-alcoholic hand rub formulations

BACKGROUND

In the current era, the importance of proper hand hygiene to reduce the transmission of infectious diseases has become difficult to debate. Yet, compliance rates remain low and are affected by many factors, amongst which is user acceptability of hand hygiene products.

AIM

The present study aimed at investigating drivers of preference towards different hand hygiene formulations.

METHODS

Three different formulations (liquid, foam and gel) of the same brand were randomly and blindly evaluated by 54 participants based on the WHO Protocol for Evaluation of Tolerability and Acceptability of Alcohol-based Handrubs.

RESULTS

The majority (76%) of respondents indicated that the product formulation impacted their level of compliance with hand hygiene protocols. The preferred formulation was liquid, with 50% of participants ranking it as first choice. General product satisfaction, the product texture, the drying speed and the ease of application, were the statistically significant drivers for participants to rank a formulation as their first choice vs not ranking it as their first choice.

CONCLUSIONS

When designing alcohol formulations and implementing hand hygiene protocols, understanding drivers of preference for formulations may enhance product user acceptability and therefore compliance with hand hygiene.

Sexual Debut Among Heterosexual Men of African and Caribbean Descent: Are the Youth Initiating Sex Earlier than the Older Generation?

Although age at first sex is considered a measure of sexual risk and vulnerability for HIV infection, there is a dearth of literature on age at sexual debut in the Canadian context. This study examined time variations to first sex among heterosexual African, Caribbean, and Black (ACB) men in four Ontarian cities. A population-based retrospective survey (n = 879) on timing to first sexual intercourse was conducted between 2018 and 2019 among self-identified heterosexual ACB men 16 years or older and residing in London, Ottawa, Toronto or Windsor. We used the lognormal survival analysis technique to examine variations in time to first sexual intercourse among age cohorts and between cities. The findings showed a generational shift in the pattern of sexual initiation, with younger heterosexual ACB men initiating sexual intercourse earlier compared with those currently older than 50 years. We observed those between 16 and 19 years, 20 and 29 years, and 30 and 39 years of age to have significantly higher risk ratios of TR = 0.852, TR = 0.869, and TR = 0.855, respectively. At city level, the results show marked spatial variations, with youth in cities of Toronto, Ottawa, and London at the highest risk of early sexual debut relative to those in Windsor. Early initiation of first sexual intercourse among heterosexual ACB youth was observed with those in the larger cities being at a relatively higher risk. There is the need for programs aimed at delaying sexual debut among youth in general. It is, however, important to recognize the relative risk of those in the larger cities.

Association between well-being and compliance with COVID-19 preventive measures by healthcare professionals: A cross-sectional study

IMPORTANCE

Knowledge and attitude influence compliance and individuals' practices. The risk and protective factors associated with high compliance to these preventive measures are critical to enhancing pandemic preparedness.

OBJECTIVE

This survey aims to assess differences in mental health, knowledge, attitudes, and practices (KAP) of preventive measures for COVID-19 amongst healthcare professionals (HCP) and non-healthcare professionals.

DESIGN

Multi-national cross-sectional study was carried out using electronic surveys between May-June 2020.

SETTING

Multi-national survey was distributed across 36 countries through social media, word-of-mouth, and electronic mail.

PARTICIPANTS

Participants ≥21 years working in healthcare and non-healthcare related professions.

MAIN OUTCOME

Risk factors determining the difference in KAP towards personal hygiene and social distancing measures during COVID-19 amongst HCP and non-HCP.

RESULTS

HCP were significantly more knowledgeable on personal hygiene (AdjOR 1.45, 95% CI -1.14 to 1.83) and social distancing (AdjOR 1.31, 95% CI -1.06 to 1.61) compared to non-HCP. They were more likely to have a positive attitude towards personal hygiene and 1.5 times more willing to participate in the contact tracing app. There was high compliance towards personal hygiene and social distancing measures amongst HCP. HCP with high compliance were 1.8 times more likely to flourish and more likely to have a high sense of emotional (AdjOR 1.94, 95% CI (1.44 to 2.61), social (AdjOR 2.07, 95% CI -1.55 to 2.78), and psychological (AdjOR 2.13, 95% CI (1.59-2.85) well-being.

CONCLUSION AND RELEVANCE

While healthcare professionals were more knowledgeable, had more positive attitudes, their higher sense of total well-being was seen to be more critical to enhance compliance. Therefore, focusing on the well-being of the general population would help to enhance their compliance towards the preventive measures for COVID-19.

Nonpharmacological interventions to reduce respiratory viral transmission: an evidence-based review with recommendations

BACKGROUND

Viral respiratory infections are a leading cause of worldwide mortality and exert the potential to cause global socioeconomic crises. However, inexpensive, efficacious, and rapidly deployable strategies to reduce viral transmission are increasingly important in the setting of an ongoing pandemic, though not entirely understood. This article provides a comprehensive review of commonly employed nonpharmacological interventions to interrupt viral spread and provides evidence-based recommendations for their use.

METHODOLOGY

A systematic review of three databases was performed. Studies with defined endpoints of subjects receiving one of five interventions (nasal washing, gargling, personal protective equipment (PPE), social distancing, and hand hygiene) were included. An evidence-based review of the highest level of evidence, with recommendations, was created in accordance with a previously described, rigorous, iterative process.

RESULTS

Fifty-four primary studies were included. The most commonly studied intervention was hand hygiene, followed by PPE, gargling, saline nasal washing, and social distancing.

CONCLUSIONS

Mask use and hand hygiene are strong recommendations for prevention of viral transmission. Donning gloves, gowns, and eye protection are a recommendation in healthcare settings. Saline nasal washing and gargling are options in selected populations. Although an aggregate level of evidence is not provided, the authors recommend social distancing.

Cost-effectiveness of surgical mask, N-95 respirator, hand-hygiene and surgical mask with hand hygiene in the prevention of COVID-19: Cost effectiveness analysis from Indian context

INTRODUCTION

In the absence of specific treatment, preventive strategies are of paramount importance in management of coronavirus disease 2019(COVID-19) pandemic. We estimated cost-effectiveness of non-pharmacological interventions such as hand-hygiene, surgical-mask N-95 respirators and surgical mask in general population.

METHODS

We performed a decision tree and markov-model based economic evaluation. We estimated total costs and outcomes from public payer's perspective, based on information available through systematic literature search on relative intervention effect during early pandemic phase. We estimated outcomes as number COVID-19 prevented and Quality Adjusted life year (QALY) over one-year time-horizon with one-day cycle-length. Incremental cost effectiveness ratios (ICER) was calculated multiple sensitivity analyses were applied to assess parameter uncertainty.

RESULTS

Use of surgical mask with hand hygiene, fit tested N-95 respirator, surgical-mask, non-fit tested N-95 and hand-hygiene interventions prevented additional 1139, 1124, 1121, 1043 and 975 COVID-19 cases per-million as compared to using none. Additional costs incurred (in billion) were ₹29.78 ($0.40), ₹148.09 ($1.99), ₹72.51 ($0.98), ₹26.84 ($0.36) and ₹2.48 ($0.03) as well as additional QALYs gained were 357.4, 353.01, 327.95, 351.52 and 307.04 for surgical mask with hand hygiene, fit-tested N-95, non-fit-tested N-95, surgical mask and hand-hygiene respectively. ICERs with surgical with hand hygiene, hand-hygiene alone, surgical-mask alone, N-95 respirator fit and non-fit test were 83.32($1.12), 8.07($0.11), 76.36($1.03), 419.51($5.65) and 221.10 ($2.98) million ₹ ($)/QALY respectively. Results were robust on uncertainty analysis.

DISCUSSION

Among the non-pharmacological interventions to be considered for preventing spread of COVID-19, hand hygiene was cost-effective and avoidance of use of surgical masks and respirators by the general public could save resources.

Availability and factors influencing community level handwashing facility in Ethiopia: Implication for prevention of infectious diseases

Background

Handwashing is one of the most effective ways to prevent transmission of infectious diseases. A substantial body of research has examined the status and determinants of handwashing facilities in healthcare settings and schools. However, its status at home in the community, especially in developing countries, remains unclear. This study aimed to examine the availability and factors influencing basic handwashing facilities at households in Ethiopia.

Method

We analysed the 2016 Ethiopian Demographic and Health Survey (EDHS) data. EDHS employed a two-stage stratified cluster sampling technique. Data were collected from the lowest administrative unit (kebele). A multivariable logistic regression model that allowed cluster-level random effects was employed to examine factors that affect the availability of basic handwashing facilities (water plus soap) at households. Estimates from the regression model are reported as odds ratios (ORs) with standard errors clustered at the DHS cluster level to account for a sampling methodology.

Results

In our sample, only 1292 (8% [95% CI, 7.6%–8.4%]) of the households had basic handwashing facilities. Compared with head of household who had no formal education, the odds of having basic handwashing facilities was higher among head of household who completed secondary level of education (adjusted odds ratio [AOR] = 1.83; 95% CI: 1.35–2.49) and higher level of education (AOR = 2.35; 95% CI: 1.63–3.39). Odds of having basic handwashing facilities was increased with having radio (AOR = 1.32; 95% CI: 1.10–1.63) and television (AOR = 1.49; 95% CI: 1.10–2.02) at home. Households that had improved latrine were two times more likely to have basic handwashing facilities (AOR = 2.09; 95% CI: 1.56–2.80). Being at higher household wealth quintiles was associated with increased odds of having basic handwashing facilities.

Conclusion

Very low basic handwashing facilities was demonstrated by this study, whereas, awareness and socio-economic related factors were identified as a determinants for its availability in the household. Greater efforts are needed to increase the coverage of community-level handwashing facilities.

COVID-19 Pandemic and Water, Sanitation, and Hygiene: Impacts, Challenges, and Mitigation Strategies

BACKGROUND

In order to protect public health during the outbreaks of infectious diseases including the pandemic COVID-19, provision of Water, Sanitation, and Hygiene (WASH) services is important. The challenges of inaccessible WASH services along with the pandemic COVID-19 in low-income countries can lead to a devastating problem.

METHOD

A systematic search of published articles was identified using PubMed, Web of Science, and Google Scholar, on relevant studies of COVID-19 and WASH services. Published articles were identified using abstracts and titles of the articles, followed by assessed for eligibility, and screening of the full text reports of relevant studies.

RESULTS

Electronic database search identified 798 articles from which 28 full text articles were included in the systematic review. A lack of access to WASH services in households, schools, health care facilities, and other public spaces were the main identified COVID-19 related public health risks. A lack of adequate data and financial shortages were the challenges for mitigating the problems of COVI-19 and WASH services.

CONCLUSION

This systematical review identified the impacts and challenges of COVID-19 in the provision of WASH services. The results implied that COVID-19 has significant impacts on WASH services that can affect the health of the public. Therefore, strengthening and ensuring access to WASH services are important for preventing COVID-19 and realizing human rights. Community engagement also can be used to support for prevention and control of COVID-19. Countries need to be expand their investment in WASH services as an important mechanism for mitigating COVID-19.

Association between socioeconomic status and influenza-like illness: A study from Western part of India

Objectives:

Health status is associated with socioeconomic status (SES) of the individuals. The aim of this study was to identify any link between the SES and influenza-like illness (ILI).

Materials and Methods:

This observational case-control study was done on 18–70 years old patients presented with ILI (cases) at tertiary care hospital of western India. Controls were selected from demographically matched elective surgery patients except the SES. SES was evaluated as per the Modified B G Prasad 2017 scale and participants were further classified in lower SES (per capita income <2000 INR) and non-lower SES groups.

Results:

810 cases and 830 controls were compared. Many cases were from lower SES, had poor hand hygiene, and were using soil, mud, ash (SMA) for hand cleaning as compared to the control. Among the cases significant numbers were from lower SES (543/810[67%], P < 0.02), many were alcoholics, smokers, had poor hand hygiene, were using SMA for hand cleaning, and had preexisting chronic obstructive pulmonary disease (COPD), while few were having diabetes in the lower SES group as compared to the non-lower SES group. ILI was more common among lower SES class in unadjusted analysis (odds ratio [OR] 1.58, 95% CI 0.89–2.76) and the results were significant even after the adjustment of covariates (OR 1.62, 95% CI, 0.94–2.85).

Conclusion:

Lower SES people were 2.8 times more prone to ILI as compared to the age- and sex-matched control in western part of India.

Physical interventions to interrupt or reduce the spread of respiratory viruses

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.

Mask use during COVID-19: A risk adjusted strategy

In the context of Coronavirus Disease (2019) (COVID-19) cases globally, there is a lack of consensus across cultures on whether wearing face masks is an effective physical intervention against disease transmission. This study 1) illustrates transmission routes of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2); 2) addresses controversies surrounding the mask from perspectives of attitude, effectiveness, and necessity of wearing the mask with evidence that the use of mask would effectively interrupt the transmission of infectious diseases in both hospital settings and community settings; and 3) provides suggestion that the public should wear the mask during COVID-19 pandemic according to local context. To achieve this goal, government should establish a risk adjusted strategy of mask use to scientifically publicize the use of masks, guarantee sufficient supply of masks, and cooperate for reducing health resources inequities.

Effectiveness of Surgical Face Masks in Reducing Acute Respiratory Infections in Non-Healthcare Settings: A Systematic Review and Meta-Analysis

Background: Acute respiratory illnesses (ARIs) are the most common respiratory infectious diseases among humans globally. Surgical mask (SM) wearing has been shown to be effective in reducing ARI among healthcare workers. However, the effectiveness of SM in reducing ARI in the non-healthcare settings remains unclear. This review aims to summarize and assess the association between SM wearing and ARI incidence, from existing interventional and observational studies conducted in non-healthcare settings.

Methods: Systematic literature searches conducted in PubMed, Cochrane Library, and Embase databases identified 503 unique studies. After screening, 15 studies (5 randomized controlled trials and 10 observational studies) were assessed for reporting and methodological qualities. Proportions of ARI episodes in each group and adjusted summary statistics with their relevant 95% CIs were extracted. Data from 10 observational studies were pooled using the generic inverse variance method.

Results: A total of 23,892 participants between 7 and 89 years old involved across 15 studies from 11 countries were involved. Key settings identified were Hajj, schools, and in-flight settings. A modest but non-significant protective effect of SM on ARI incidence was observed (pooled OR 0.96, 95% CI 0.8–1.15). Subgroup analysis according to age group, outcome ascertainment and different non-healthcare settings also revealed no significant associations between SM use and ARI incidence.

Conclusion: Surgical mask wearing among individuals in non-healthcare settings is not significantly associated with reduction in ARI incidence in this meta-review.

Handwashing in averting infectious diseases: Relevance to COVID-19

After officially declared as a pandemic by the World Health Organization (WHO), drastic measures to restrict human movements to contain the COVID-19 infection are employed by most of the countries. Maintaining high personal hygiene by frequent handwashing and be vigilant of clinical signs are widely recommended to reduce the disease burden. The national and international health agencies, including the Centers for Disease Control and Prevention (CDC) and the WHO, have provided guidelines for prevention and treatment suggestions. Here, in this brief article, based on available clinical information, the author discusses why handwashing could be protective of COVID-19 infections. Although a detailed and in-depth discussion of various preventive and protective measures is beyond the scope of this article, this review will focus on the utility of frequent handwashing in minimizing the risk of spreading COVID-19 infection.

Lower respiratory tract infection in the community: associations between viral aetiology and illness course

OBJECTIVES

This study determined associations between respiratory viruses and subsequent illness course in primary care adult patients presenting with acute cough and/or suspected lower respiratory tract infection.

METHODS

A prospective European primary care study recruited adults with symptoms of lower respiratory tract infection between November 2007 and April 2010. Real-time in-house polymerase chain reaction (PCR) was performed to test for six common respiratory viruses. In this secondary analysis, symptom severity (scored 1 = no problem, 2 = mild, 3 = moderate, 4 = severe) and symptom duration were compared between groups with different viral aetiologies using regression and Cox proportional hazard models, respectively. Additionally, associations between baseline viral load (cycle threshold (Ct) value) and illness course were assessed.

RESULTS

The PCR tested positive for a common respiratory virus in 1354 of the 2957 (45.8%) included patients. The overall mean symptom score at presentation was 2.09 (95% confidence interval (CI) 2.07-2.11) and the median duration until resolution of moderately bad or severe symptoms was 8.70 days (interquartile range 4.50-11.00). Patients with influenza virus, human metapneumovirus (hMPV), respiratory syncytial virus (RSV), coronavirus (CoV) or rhinovirus had a significantly higher symptom score than patients with no virus isolated (0.07-0.25 points or 2.3-8.3% higher symptom score). Time to symptom resolution was longer in RSV infections (adjusted hazard ratio (AHR) 0.80, 95% CI 0.65-0.96) and hMPV infections (AHR 0.77, 95% CI 0.62-0.94) than in infections with no virus isolated. Overall, baseline viral load was associated with symptom severity (difference 0.11, 95% CI 0.06-0.16 per 10 cycles decrease in Ct value), but not with symptom duration.

CONCLUSIONS

In healthy, working adults from the general community presenting at the general practitioner with acute cough and/or suspected lower respiratory tract infection other than influenza impose an illness burden comparable to influenza. Hence, the public health focus for viral respiratory tract infections should be broadened.