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Lebu S, Kibone W, Muoghalu CC, Ochaya S, Salzberg A, Bongomin F, Manga M. Soil-transmitted helminths: A critical review of the impact of co-infections and implications for control and elimination. PLoS Negl Trop Dis 2023; 17:e0011496. [PMID: 37561673 PMCID: PMC10414660 DOI: 10.1371/journal.pntd.0011496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023] Open
Abstract
Researchers have raised the possibility that soil-transmitted helminth (STH) infections might modify the host's immune response against other systemic infections. STH infections can alter the immune response towards type 2 immunity that could then affect the likelihood and severity of other illnesses. However, the importance of co-infections is not completely understood, and the impact and direction of their effects vary considerably by infection. This review synthesizes evidence regarding the relevance of STH co-infections, the potential mechanisms that explain their effects, and how they might affect control and elimination efforts. According to the literature reviewed, there are both positive and negative effects associated with STH infections on other diseases such as malaria, human immunodeficiency virus (HIV), tuberculosis, gestational anemia, pediatric anemia, neglected tropical diseases (NTDs) like lymphatic filariasis, onchocerciasis, schistosomiasis, and trachoma, as well as Coronavirus Disease 2019 (COVID-19) and human papillomavirus (HPV). Studies typically describe how STHs can affect the immune system and promote increased susceptibility, survival, and persistence of the infection in the host by causing a TH2-dominated immune response. The co-infection of STH with other diseases has important implications for the development of treatment and control strategies. Eliminating parasites from a human host can be more challenging because the TH2-dominated immune response induced by STH infection can suppress the TH1 immune response required to control other infections, resulting in an increased pathogen load and more severe disease. Preventive chemotherapy and treatment are currently the most common approaches used for the control of STH infections, but these approaches alone may not be adequate to achieve elimination goals. Based on the conclusions drawn from this review, integrated approaches that combine drug administration with water, sanitation and hygiene (WASH) interventions, hygiene education, community engagement, and vaccines are most likely to succeed in interrupting the transmission of STH co-infections. Gaining a better understanding of the behavior and relevance of STH co-infections in the context of elimination efforts is an important intermediate step toward reducing the associated burden of disease.
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Affiliation(s)
- Sarah Lebu
- The Water Institute at UNC, Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Winnie Kibone
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Chimdi C. Muoghalu
- The Water Institute at UNC, Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Stephen Ochaya
- Department of Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
- Department of Biology, Faculty of Science, Gulu University, Gulu, Uganda
- Department of Clinical Pathology, Uppsala Academic Hospital, Uppsala, Sweden
| | - Aaron Salzberg
- The Water Institute at UNC, Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Felix Bongomin
- Department of Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Musa Manga
- The Water Institute at UNC, Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Calcagni N, Venier AG, Nasso R, Boudin G, Jarrige B, Parneix P, Quintard B. Respiratory infection prevention: perceptions, barriers and facilitators after SARS-CoV-2. Infect Dis Health 2023; 28:54-63. [PMID: 36123289 PMCID: PMC9420707 DOI: 10.1016/j.idh.2022.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Respiratory hygiene, especially in context of COVID-19, is of upmost importance. Healthcare professionals (HCPs) play an important role in the prevention of infections. Their perceptions of the subject are needed to tailor effective communication and training on prevention. METHODS 20 French HCPs were questioned about their perceptions on respiratory hygiene and infections, by the means of recorded semi-structured interviews and a focus group. The interviews and focus group were transcribed then analysed through lexicometric and thematic content analyses. RESULTS HCP discourse revolved around the use of face masks, the prevention and the characteristics of respiratory infections and the means to prevent them.COVID-19 excepted, HCPs considered respiratory infections as benign. They associated respiratory hygiene to the observance of cough etiquette, the preservation of lung health, the act of protecting oneself and others, and the adherence to safety protocols. Main barriers to good practices were organizational ones, such as the lack of consultation and mobilization of HCPs in the development of preventive measures, suboptimal information sharing and the physical and relational constraints of face masks. They advised means of improving communication and information promotion. CONCLUSION Since the pandemic crisis, HCPs have developed a better awareness about the prevention of respiratory infections. Except for COVID-19, respiratory infections are mostly considered as benign. Barriers and facilitators evoked by HCPs will help to build national communication and tools.
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Affiliation(s)
- Nicolas Calcagni
- CHU de Bordeaux, Université de Bordeaux, F-33000, Bordeaux, France.
| | - Anne-Gaëlle Venier
- Centre d'appui pour la prévention des infections associées aux soins, CPias Nouvelle-Aquitaine, CHU de Bordeaux, F-33000, Bordeaux, France
| | - Raymond Nasso
- Centre d'appui pour la prévention des infections associées aux soins, CPias Iles de Guadeloupe, F-97100 Pointe à Pitre, France
| | - Georges Boudin
- Centre d'appui pour la prévention des infections associées aux soins, CPias Nouvelle-Aquitaine, CHU de Bordeaux, F-33000, Bordeaux, France
| | - Bruno Jarrige
- Centre d'appui pour la prévention des infections associées aux soins, CPias Iles de Guadeloupe, F-97100 Pointe à Pitre, France
| | - Pierre Parneix
- Centre d'appui pour la prévention des infections associées aux soins, CPias Nouvelle-Aquitaine, CHU de Bordeaux, F-33000, Bordeaux, France
| | - Bruno Quintard
- Laboratoire de Psychologie EA 4139, Université de Bordeaux, F-33000, Bordeaux, France
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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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Nasiri MJ, Danaei B, Deravi N, Chirani AS, Bonjar AHS, Khoshgoftar Z, Karimi F. Impact of educational interventions on the prevention of influenza: A systematic review. Front Public Health 2022; 10:978456. [PMID: 36203669 PMCID: PMC9530567 DOI: 10.3389/fpubh.2022.978456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/30/2022] [Indexed: 01/25/2023] Open
Abstract
Introduction Seasonal influenza, a contagious viral disease affecting the upper respiratory tract, circulates annually, causing considerable morbidity and mortality. The present study investigates the effectiveness of educational interventions to prevent influenza. Methods We searched PubMed/Medline, Embase, and Cochrane Controlled Register of Trials (CENTRAL) for relevant clinical studies up to March 1 2022. The following terms were used: "influenza," "flu," "respiratory infection," "prevent," "intervention," and "education." Results Out of 255 studies, 21 articles satisfied the inclusion criteria and were included in our study: 13 parallel randomized controlled trials (RCT) studies, two cross-over RCT studies, two cohort studies, and four quasi-experimental studies. A total of approximately 12,500 adults (18 years old or above) and 11,000 children were evaluated. Educational sessions and reminders were the most common interventions. The measured outcomes were vaccination rates, the incidence of respiratory tract infection (RTI), and preventive behaviors among participants. Eighteen out of 21 articles showed a significant association between educational interventions and the outcomes. Conclusions The included studies in the current systematic review reported the efficacy of health promotion educational interventions in improving knowledge about influenza, influenza prevention behaviors, vaccination rates, and decreased RTI incidence regardless of the type of intervention and the age of cases.
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Affiliation(s)
- Mohammad Javad Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Mohammad Javad Nasiri
| | - Bardia Danaei
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Niloofar Deravi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Amir Hashem Shahidi Bonjar
- Clinician Scientist of Dental Materials and Restorative Dentistry, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zohreh Khoshgoftar
- Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Zohreh Khoshgoftar
| | - Forouzan Karimi
- Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran,*Correspondence: Forouzan Karimi
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Gozdzielewska L, Kilpatrick C, Reilly J, Stewart S, Butcher J, Kalule A, Cumming O, Watson J, Price L. The effectiveness of hand hygiene interventions for preventing community transmission or acquisition of novel coronavirus or influenza infections: a systematic review. BMC Public Health 2022; 22:1283. [PMID: 35780111 PMCID: PMC9250256 DOI: 10.1186/s12889-022-13667-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 06/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Novel coronaviruses and influenza can cause infection, epidemics, and pandemics. Improving hand hygiene (HH) of the general public is recommended for preventing these infections. This systematic review examined the effectiveness of HH interventions for preventing transmission or acquisition of such infections in the community. METHODS PubMed, MEDLINE, CINAHL and Web of Science databases were searched (January 2002-February 2022) for empirical studies related to HH in the general public and to the acquisition or transmission of novel coronavirus infections or influenza. Studies on healthcare staff, and with outcomes of compliance or absenteeism were excluded. Study selection, data extraction and quality assessment, using the Cochrane Effective Practice and Organization of Care risk of bias criteria or Joanna Briggs Institute Critical Appraisal checklists, were conducted by one reviewer, and double-checked by another. For intervention studies, effect estimates were calculated while the remaining studies were synthesised narratively. The protocol was pre-registered (PROSPERO 2020: CRD42020196525). RESULTS Twenty-two studies were included. Six were intervention studies evaluating the effectiveness of HH education and provision of products, or hand washing against influenza. Only two school-based interventions showed a significant protective effect (OR: 0.64; 95% CI 0.51, 0.80 and OR: 0.40; 95% CI 0.22, 0.71), with risk of bias being high (n = 1) and unclear (n = 1). Of the 16 non-intervention studies, 13 reported the protective effect of HH against influenza, SARS or COVID-19 (P < 0.05), but risk of bias was high (n = 7), unclear (n = 5) or low (n = 1). However, evidence in relation to when, and how frequently HH should be performed was inconsistent. CONCLUSIONS To our knowledge, this is the first systematic review of effectiveness of HH for prevention of community transmission or acquisition of respiratory viruses that have caused epidemics or pandemics, including SARS-CoV-1, SARS-CoV-2 and influenza viruses. The evidence supporting the protective effect of HH was heterogeneous and limited by methodological quality; thus, insufficient to recommend changes to current HH guidelines. Future work is required to identify in what circumstances, how frequently and what product should be used when performing HH in the community and to develop effective interventions for promoting these specific behaviours in communities during epidemics.
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Affiliation(s)
- Lucyna Gozdzielewska
- Department of Nursing and Community Health, Research Centre for Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, Scotland, UK.
| | | | - Jacqui Reilly
- Department of Nursing and Community Health, Research Centre for Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, Scotland, UK
| | - Sally Stewart
- Department of Nursing and Community Health, Research Centre for Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, Scotland, UK
| | - John Butcher
- Department of Nursing and Community Health, Research Centre for Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, Scotland, UK
| | - Andrew Kalule
- Department of Nursing and Community Health, Research Centre for Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, Scotland, UK
| | - Oliver Cumming
- Department of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Julie Watson
- Department of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Lesley Price
- Department of Nursing and Community Health, Research Centre for Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, Scotland, UK
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Coker RK, Armstrong A, Church AC, Holmes S, Naylor J, Pike K, Saunders P, Spurling KJ, Vaughn P. BTS Clinical Statement on air travel for passengers with respiratory disease. Thorax 2022; 77:329-350. [PMID: 35228307 PMCID: PMC8938676 DOI: 10.1136/thoraxjnl-2021-218110] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Robina Kate Coker
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Alison Armstrong
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | | | - Katharine Pike
- Department of Paediatric Respiratory Medicine, Bristol Royal Hospital for Children, Bristol, UK
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Abaluck J, Kwong LH, Styczynski A, Haque A, Kabir MA, Bates-Jefferys E, Crawford E, Benjamin-Chung J, Raihan S, Rahman S, Benhachmi S, Bintee NZ, Winch PJ, Hossain M, Reza HM, Jaber AA, Momen SG, Rahman A, Banti FL, Huq TS, Luby SP, Mobarak AM. Impact of community masking on COVID-19: A cluster-randomized trial in Bangladesh. Science 2022; 375:eabi9069. [PMID: 34855513 PMCID: PMC9036942 DOI: 10.1126/science.abi9069] [Citation(s) in RCA: 137] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
We conducted a cluster-randomized trial to measure the effect of community-level mask distribution and promotion on symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in rural Bangladesh from November 2020 to April 2021 (N = 600 villages, N = 342,183 adults). We cross-randomized mask type (cloth versus surgical) and promotion strategies at the village and household level. Proper mask-wearing increased from 13.3% in the control group to 42.3% in the intervention arm (adjusted percentage point difference = 0.29; 95% confidence interval = [0.26, 0.31]). The intervention reduced symptomatic seroprevalence (adjusted prevalence ratio = 0.91 [0.82, 1.00]), especially among adults ≥60 years old in villages where surgical masks were distributed (adjusted prevalence ratio = 0.65 [0.45, 0.85]). Mask distribution with promotion was a scalable and effective method to reduce symptomatic SARS-CoV-2 infections.
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Affiliation(s)
- Jason Abaluck
- Yale School of Management, Yale University, New Haven, CT, USA.,Corresponding author. (J.A.); (A.M.M.)
| | - Laura H. Kwong
- Woods Institute for the Environment, Stanford University, Stanford, CA, USA.,Division of Environmental Health Sciences, University of California, Berkeley, Berkeley, CA, USA
| | - Ashley Styczynski
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Ashraful Haque
- Innovations for Poverty Action Bangladesh, Dhaka, Bangladesh
| | | | | | - Emily Crawford
- Yale School of Management, Yale University, New Haven, CT, USA
| | - Jade Benjamin-Chung
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, CA, USA
| | - Shabib Raihan
- Innovations for Poverty Action Bangladesh, Dhaka, Bangladesh
| | - Shadman Rahman
- Innovations for Poverty Action Bangladesh, Dhaka, Bangladesh
| | - Salim Benhachmi
- Yale Research Initiative on Innovation and Scale, Yale University, New Haven, CT, USA
| | | | - Peter J. Winch
- Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Hasan Mahmud Reza
- Department of Pharmaceutical Sciences, North South University, Dhaka, Bangladesh
| | | | | | - Aura Rahman
- NGRI, North South University, Dhaka, Bangladesh
| | | | | | - Stephen P. Luby
- Woods Institute for the Environment, Stanford University, Stanford, CA, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Ahmed Mushfiq Mobarak
- Yale School of Management, Yale University, New Haven, CT, USA.,Department of Economics, Deakin University, Melbourne, Australia.,Corresponding author. (J.A.); (A.M.M.)
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Veys K, Dockx K, Van Remoortel H, Vandekerckhove P, De Buck E. The effect of hand hygiene promotion programs during epidemics and pandemics of respiratory droplet-transmissible infections on health outcomes: a rapid systematic review. BMC Public Health 2021; 21:1745. [PMID: 34563144 PMCID: PMC8467175 DOI: 10.1186/s12889-021-11815-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 09/14/2021] [Indexed: 01/03/2023] Open
Abstract
Background Public health strategies in the context of respiratory droplet-transmissible diseases (such as influenza or COVID-19) include intensified hand hygiene promotion, but a review on the effectiveness of different ways of promoting hand hygiene in the community, specifically for this type of infections, has not been performed. This rapid systematic review aims to summarize the effectiveness of community-based hand hygiene promotion programs on infection transmission, health outcomes and behavioral outcomes during epidemic periods in the context of respiratory droplet-transmissible diseases. We also included laboratory-confirmed health outcomes for epidemic-prone disease during interepidemic periods. Methods We searched for controlled experimental studies. A rapid systematic review was performed in three databases and a COVID-19 resource. Following study selection (in which studies performed in the (pre-)hospital/health care setting were excluded), study characteristics and effect measures were synthesized, using meta-analyses of cluster-RCTs where possible. Risk of bias of each study was assessed and the certainty of evidence was appraised according to the GRADE methodology. Results Out of 2050 unique references, 12 cluster-RCTs, all in the context of influenza, were selected. There were no controlled experimental studies evaluating the effectiveness of hand hygiene promotion programs in the context of COVID-19 that met the in−/exclusion criteria. There was evidence that preventive hand hygiene promotion interventions in interepidemic periods significantly decreased influenza positive cases in the school setting. However, no improvement could be demonstrated for programs implemented in households to prevent secondary influenza transmission from previously identified cases (epidemic and interepidemic periods). Conclusions The data suggest that proactive hand hygiene promotion interventions, i.e. regardless of the identification of infected cases, can improve health outcomes upon implementation of such a program, in contrast to reactive interventions in which the program is implemented after (household) index cases are identified. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11815-4.
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Affiliation(s)
- Koen Veys
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, Mechelen, Belgium
| | - Kim Dockx
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, Mechelen, Belgium
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, Mechelen, Belgium
| | - Philippe Vandekerckhove
- Belgian Red Cross, Mechelen, Belgium.,Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Emmy De Buck
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, Mechelen, Belgium. .,Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.
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Hoffmann T, Bakhit M, Krzyzaniak N, Del Mar C, Scott AM, Glasziou P. Soap versus sanitiser for preventing the transmission of acute respiratory infections in the community: a systematic review with meta-analysis and dose-response analysis. BMJ Open 2021; 11:e046175. [PMID: 34408031 PMCID: PMC8375726 DOI: 10.1136/bmjopen-2020-046175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To compare the effectiveness of hand hygiene using alcohol-based hand sanitiser to soap and water for preventing the transmission of acute respiratory infections (ARIs) and to assess the relationship between the dose of hand hygiene and the number of ARI, influenza-like illness (ILI) or influenza events. DESIGN Systematic review and meta-analysis. DATA SOURCES Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and trial registries were searched in April 2020. INCLUSION CRITERIA We included randomised controlled trials that compared a community-based hand hygiene intervention (soap and water, or sanitiser) with a control, or trials that compared sanitiser with soap and water, and measured outcomes of ARI, ILI or laboratory-confirmed influenza or related consequences. DATA EXTRACTION AND ANALYSIS Two review authors independently screened the titles and abstracts for inclusion and extracted data. RESULTS Eighteen trials were included. When meta-analysed, three trials of soap and water versus control found a non-significant increase in ARI events (risk ratio (RR) 1.23, 95% CI 0.78 to 1.93); six trials of sanitiser versus control found a significant reduction in ARI events (RR 0.80, 95% CI 0.71 to 0.89). When hand hygiene dose was plotted against ARI relative risk, no clear dose-response relationship was observable. Four trials were head-to-head comparisons of sanitiser and soap and water but too heterogeneous to pool: two found a significantly greater reduction in the sanitiser group compared with the soap group and two found no significant difference between the intervention arms. CONCLUSIONS Adequately performed hand hygiene, with either soap or sanitiser, reduces the risk of ARI virus transmission; however, direct and indirect evidence suggest sanitiser might be more effective in practice.
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Affiliation(s)
- Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Natalia Krzyzaniak
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Chris Del Mar
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Anna Mae Scott
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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Leslie RA, Zhou SS, Macinga DR. Inactivation of SARS-CoV-2 by commercially available alcohol-based hand sanitizers. Am J Infect Control 2021; 49:401-402. [PMID: 32818578 PMCID: PMC7431409 DOI: 10.1016/j.ajic.2020.08.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 01/14/2023]
Abstract
Alcohol-based hand sanitizers are being recommended as an infection prevention measure for COVID-19. Recently published data indicates that ethanol effectively inactivates the SARS-CoV-2 virus, but there is a lack of data for formulated hand sanitizer products currently used in U.S. healthcare and general settings. This study demonstrates a commercially available foam and gel alcohol-based hand sanitizer are effective in inactivating SARS-CoV-2 in suspension.
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Yeasmin D, Dutta NC, Nizame FA, Rahman MJ, Ashraf S, Ram PK, Leontsini E, Rahman M, Winch PJ, Luby SP, Unicomb L. Could Alcohol-Based Hand Sanitizer Be an Option for Hand Hygiene for Households in Rural Bangladesh? Am J Trop Med Hyg 2021; 104:874-883. [PMID: 33534756 PMCID: PMC7941831 DOI: 10.4269/ajtmh.20-0755] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 11/10/2020] [Indexed: 11/20/2022] Open
Abstract
In low- and middle-income countries (LMICs), hand sanitizer may be a convenient alternative to soap and water to increase hand hygiene practices. We explored perceptions, acceptability, and use of hand sanitizer in rural Bangladesh. We enrolled 120 households from three rural villages. Promoters distributed free alcohol-based hand sanitizer, installed handwashing stations (bucket with tap, stand, basin, and bottle for soapy water), and conducted household visits and community meetings. During Phase 1, promoters recommended handwashing with soap or soapy water, or hand sanitizer after defecation, after cleaning a child's anus/feces, and before food preparation. In Phase 2, they recommended separate key times for hand sanitizer: before touching a child ≤ 6 months and after returning home. Three to 4 months after each intervention phase, we conducted a survey, in-depth interviews, and group discussions with child caregivers and male household members. After Phase 1, 82/89 (92%) households reported handwashing with soap after defecation versus 38 (43%) reported hand sanitizer use. Participants thought soap and water removed dirt from their hands, whereas hand sanitizer killed germs. In Phase 2, 76/87 (87%) reported using hand sanitizer after returning home and 71/87 (82%) before touching a child ≤ 6 months. Qualitative study participants reported that Phase 2-recommended times for hand sanitizer use were acceptable, but handwashing with soap was preferred over hand sanitizer when there was uncertainty over choosing between the two. Hand sanitizer use was liked by household members and has potential for use in LMICs, including during the coronavirus pandemic.
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Affiliation(s)
- Dalia Yeasmin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Notan C. Dutta
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Fosiul A. Nizame
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Musarrat J. Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Sania Ashraf
- The Center for Social Norms and Behavioral Dynamics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavani K. Ram
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York
| | - Elli Leontsini
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mahbubur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Peter J. Winch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Leanne Unicomb
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
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12
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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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13
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Wichaidit W, Naknual S, Kleangkert N, Liabsuetrakul T. Installation of pedal-operated alcohol gel dispensers with behavioral nudges and changes in hand hygiene behaviors during the COVID-19 pandemic: A hospital-based quasi-experimental study. J Public Health Res 2020; 9:1863. [PMID: 33150146 PMCID: PMC7607228 DOI: 10.4081/jphr.2020.1863] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/28/2020] [Indexed: 12/31/2022] Open
Abstract
We conducted a quasi-experimental study and compared hand hygiene behaviors at potential pathogen transmission events among outpatient visitors (according to structured observations a trained enumerator) before and after installation of 12 pedal-operated alcohol gel dispensers with behavioral nudges (signs attached to the dispensers) at a tertiary hospital in southern Thailand during the COVID-19 pandemic. The enumerator observed 243 events during the pre-intervention period and 223 events during the postintervention period. Prevalence of hand hygiene was significantly different between the pre-intervention and post-intervention periods (0 vs 24 events, or 0% vs 11%, respectively; p-value <0.001). However, 21 of 24 hand hygiene events were of participants who came from outside the observation area, used the dispensers, then left. Nonetheless, the intervention might have helped to increase access to hand hygiene materials and created opportunities for hand hygiene among hospital visitors in general. Significance for public health This study compared hand hygiene behaviors after installation of pedal-operated alcohol gel dispensers compared to hand hygiene behaviors before the installation. Prevalence of observed hand hygiene was higher after installation compared to before installation, which suggested that the installation might have eliminated some barriers to hand hygiene. However, use of the alcohol gel might not necessarily indicate proper hand disinfection, and the prevalence of hand hygiene remained low, which highlighted the ongoing need to improve hand hygiene at potential pathogen transmission events (including transmission of COVID-19) at health facilities. Future studies should aim to understand the reasons(s) for missed hand hygiene opportunities and consider incorporating interventions that have shown effectiveness in improving hand hygiene behaviors among healthcare workers, as well as materials from the World Health Organization’s Guidelines on hand hygiene in health care.
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Affiliation(s)
- Wit Wichaidit
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai
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Munn Z, Tufanaru C, Lockwood C, Stern C, McAneney H, Barker TH. Rinse-free hand wash for reducing absenteeism among preschool and school children. Cochrane Database Syst Rev 2020; 4:CD012566. [PMID: 32270476 PMCID: PMC7141998 DOI: 10.1002/14651858.cd012566.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Illness-related absenteeism is an important problem among preschool and school children for low-, middle- and high- income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse-free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness-related absenteeism in preschool and school children. OBJECTIVES 1. To assess the effectiveness of rinse-free hand washing for reducing absenteeism due to illness in preschool and school children compared to no hand washing, conventional hand washing with soap and water or other hand hygiene strategies. 2. To determine which rinse-free hand washing products are the most effective (if head-to-head comparisons exist), and what effect additional strategies in combination with rinse-free hand washing have on the outcomes of interest. SEARCH METHODS In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied. SELECTION CRITERIA Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse-free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions. DATA COLLECTION AND ANALYSIS Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings. MAIN RESULTS This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day-care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most-notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse-free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low-certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse-free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse-free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low-certainty evidence), which indicates rinse-free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse-free' group (eight days absent per 1000). There may be little to no difference between rinse-free hand washing and 'no rinse-free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low-certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very-low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse-free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very-low certainty evidence). AUTHORS' CONCLUSIONS The findings of this review may have identified a small yet potentially beneficial effect of rinse-free hand washing regimes on illness-related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse-free hand washing regimens in order to provide more conclusive, higher-certainty evidence regarding its impact. When considering the use of a rinse-free hand washing program in a local setting, there needs to be consideration of the current rates of illness-related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings.
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Affiliation(s)
- Zachary Munn
- The University of AdelaideJoanna Briggs Institute, Faculty of Health Sciences55 King William RoadAdelaideSouth AustraliaAustralia5005
| | - Catalin Tufanaru
- Macquarie UniversityAustralian Institute of Health Innovation75 Talavera RdSydneyNew South Wales (NSW)Australia2113
| | - Craig Lockwood
- The University of AdelaideJoanna Briggs Institute, Faculty of Health Sciences55 King William RoadAdelaideSouth AustraliaAustralia5005
| | - Cindy Stern
- The University of AdelaideJoanna Briggs Institute, Faculty of Health Sciences55 King William RoadAdelaideSouth AustraliaAustralia5005
| | - Helen McAneney
- Queen's University BelfastMedicine, Dentistry and Biomedical Sciences97 Lisburn RoadHealth Sciences BuildingBelfastUKBT9 7BL
| | - Timothy H Barker
- The University of AdelaideJoanna Briggs Institute, Faculty of Health Sciences55 King William RoadAdelaideSouth AustraliaAustralia5005
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