Intervention Review

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Physical interventions to interrupt or reduce the spread of respiratory viruses

  1. Tom Jefferson1,*,
  2. Chris B Del Mar2,
  3. Liz Dooley2,
  4. Eliana Ferroni3,
  5. Lubna A Al-Ansary4,
  6. Ghada A Bawazeer5,
  7. Mieke L van Driel2,6,
  8. Sreekumaran Nair7,
  9. Mark A Jones8,
  10. Sarah Thorning2,
  11. John M Conly9,10

Editorial Group: Cochrane Acute Respiratory Infections Group

Published Online: 6 JUL 2011

Assessed as up-to-date: 21 OCT 2010

DOI: 10.1002/14651858.CD006207.pub4


How to Cite

Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, van Driel ML, Nair S, Jones MA, Thorning S, Conly JM. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD006207. DOI: 10.1002/14651858.CD006207.pub4.

Author Information

  1. 1

    The Cochrane Collaboration, Roma, Italy

  2. 2

    Bond University, Faculty of Health Sciences and Medicine, Gold Coast, Queensland, Australia

  3. 3

    Public Health Agency of Lazio Region, Infectious Diseases Unit, Rome, Italy

  4. 4

    College of Medicine, King Saud University, Department of Family & Community Medicine, Holder of "Shaikh Abdullah S. Bahamdan" Research Chair for Evidence-Based Health Care and Knowledge Translation, Riyadh, Saudi Arabia

  5. 5

    King Saud University, Department of Clinical Pharmacy & KKUH, Riyadh, Saudi Arabia

  6. 6

    Ghent University, Department of General Practice and Primary Health Care, Ghent, Belgium

  7. 7

    Manipal University, Department of Statistics, Manipal, Karnataka, India

  8. 8

    Centre for Healthcare Related Infection Surveillance and Prevention/School of Population Health, Queensland Health/University of Queensland, Brisbane, QLD, Australia

  9. 9

    Foothills Medical Centre, Room 930, North Tower, Calgary, Alberta, Canada

  10. 10

    WHO. Infection Prevention and Control in Health Care, Department of Global Alert and Response - Health Security and Environment, Geneva, Switzerland

*Tom Jefferson, The Cochrane Collaboration, Via Puglie 23, Roma, 00187, Italy. jefferson.tom@gmail.com. jefferson@assr.it.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 6 JUL 2011

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
 

Description of the condition

Pandemic viral infections pose a serious threat to all nations. There have been several recently, including pandemic influenza (one of which has just occurred) (Jefferson 2009; WHO 2009) and a novel coronavirus causing severe acute respiratory syndrome (SARS) (Shute 2003).

Even non-epidemic acute respiratory infections (ARIs) place a serious burden on the health of nations. In total these cause much of the 7% of total deaths in the world that are attributed to lower respiratory tract infections (representing four million deaths worldwide, mostly occurring in low-income countries). In addition there is a huge burden from ARIs on morbidity and nations' healthcare systems (www.who.int/healthinfo/global_burden_disease/estimates_regional/en/index.html).

High viral load and infectiousness probably increase the spread of acute respiratory infection outbreaks (Jefferson 2006a). Stopping the spread of virus from person to person may be effective at preventing these outbreaks. This can be achieved in a number of ways. However, single interventions (such as vaccination or antiviral drugs) may be inadequate (Jefferson 2005aJefferson 2005bJefferson 2005cJefferson 2006a).

 

Description of the intervention

There is increasing evidence (Jefferson 2005a; Jefferson 2005b; Jefferson 2005c; Jefferson 2006a; Thomas 2010) that single measures (such as the use of vaccines or antivirals) may be insufficient to interrupt the spread of influenza. However, a recent trial showed that handwashing may be effective in diminishing mortality due to respiratory disease (Luby 2005). The possible effectiveness of public health measures during the 'Spanish Flu' pandemic of 1918 to 1919 (Bootsma 2007) in US cities led us to wonder what evidence exists on the effectiveness of combined public health measures such as isolation, distancing and barriers. We also considered the major social implications for any community adopting them (CDC 2005a; CDC 2005b; WHO 2006). Given the potential global importance of interrupting viral transmission, up-to-date, concise estimates of effectiveness are necessary to inform planning and decision-making. We could find no previous systematic review of such evidence.

 

How the intervention might work

Epidemics and pandemics are more likely during antigenic shift in the virus (especially influenza), when the viral genes sufficiently alter to create a new subtype against which there is little circulating natural immunity (Smith 2006). This may happen when viruses cross from animal species such as ducks or pigs to infect humans (Bonn 1997). Minor changes in viral antigenic configurations, known as 'drift', cause local or more circumscribed epidemics (Smith 2006).

High viral load and high viral infectiousness are likely to be the drivers of such epidemics and pandemics (Jefferson 2006a).

Physical means might prevent the spread of virus by aerosols or large droplets from infected to susceptible people (such as by using masks and distancing measures) and by contact (such as by using handwashing, gloves and protective gowns). Such public health measures were widely adopted during the 'Spanish Flu' pandemic of 1918 to 1919 (Bootsma 2007).

 

Why it is important to do this review

Although the benefits of physical methods seem self-evident, they require establishing and quantifying. Physical methods have several possible advantages over other methods of suppressing acute respiratory infection outbreaks: they can be instituted rapidly and may be independent of any specific type of infective agent including novel viruses.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

To systematically review the evidence of effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We considered trials (individual-level or cluster-randomised, or quasi-randomised), observational studies (cohort and case-control designs) and any other comparative design, provided some attempt had been made to control for confounding, carried out in people of all ages.

 

Types of participants

People of all ages.

 

Types of interventions

We included any intervention to prevent viral animal-to-human or human-to-human transmission of respiratory viruses (screening at entry ports, isolation, quarantine, social distancing, barriers, personal protection and hand hygiene) compared with doing nothing or with another intervention. We excluded vaccines and antivirals.

 

Types of outcome measures

  1. Deaths.
  2. Numbers of cases of viral illness.
  3. Severity of viral illness in the compared populations. In children and healthy adults we measured burden by consequences of influenza, for example, losses in productivity due to absenteeism by parents. For the elderly in the community, we measured the burden by repeated primary healthcare contacts, hospital admissions and the risk of complications.
  4. Any proxies for these (for example, clinical symptoms as a proxy for viral illness and confirmed viral polymerase chain reaction (PCR) testing or viral serological tests).

 

Search methods for identification of studies

 

Electronic searches

In this 2010 update we searched, as we have done previously, the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 3, which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (April 2009 to October week 2, 2010), EMBASE (April 2009 to October 2010) and CINAHL (January 2009 to October 2010). Details of previous searches are in Appendix 1. In addition, to include more of the literature of low-income countries in this update, we ran searches in LILACS (2008 to October 2010), Indian MEDLARS (2008 to October 2010) and IMSEAR (2008 to October 2010).

We used the following search strategy (updated to include new and emerging respiratory viruses) to search MEDLINE and CENTRAL. We combined the MEDLINE search strategy with the Cochrane Highly Sensitive Search Strategy for identifying randomised trials in MEDLINE: sensitivity- and precision-maximising version (2008 revision) (Ovid format) (Lefebvre 2009). We also included an additional search strategy based on the work of Fraser, Murray and Burr (Fraser 2006) to identify observational studies. The search strategies were adapted for Embase.com (Appendix 2), CINAHL (Appendix 3), LILACS (Appendix 4), Indian MEDLARS (Appendix 5) and IMSEAR (Appendix 6).

 

MEDLINE (Ovid)

1 Influenza, Human/
2 exp Influenzavirus A/
3 exp Influenzavirus B/
4 Influenzavirus C/
5 (influenza* or flu).tw.
6 Common Cold/
7 common cold*.tw.
8 Rhinovirus/
9 rhinovir*.tw.
10 adenoviridae/ or mastadenovirus/ or adenoviruses, human/
11 adenoviridae infections/ or adenovirus infections, human/
12 adenovir*.tw.
13 coronavirus/ or coronavirus 229e, human/ or coronavirus oc43, human/ or infectious bronchitis virus/ or sars virus/
14 coronavir*.tw.
15 coronavirus infections/ or severe acute respiratory syndrome/
16 (severe acute respiratory syndrome* or sars).tw.
17 respiratory syncytial viruses/ or respiratory syncytial virus, human/
18 Respiratory Syncytial Virus Infections/
19 (respiratory syncytial virus* or rsv).tw.
20 Pneumovirus Infections/
21 parainfluenza virus 1, human/ or parainfluenza virus 3, human/
22 parainfluenza virus 2, human/ or parainfluenza virus 4, human/
23 (parainfluenza* or para-influenza* or para influenza).tw.
24 enterovirus a, human/ or exp enterovirus b, human/ or enterovirus c, human/ or enterovirus d, human/
25 Enterovirus Infections/
26 enterovir*.tw.
27 Human bocavirus/
28 bocavirus*.tw.
29 Metapneumovirus/
30 metapneumovir*.tw.
31 Parvovirus B19, Human/
32 parvoviridae infections/ or erythema infectiosum/
33 parvovirus*.tw.
34 Parechovirus/
35 parechovirus*.tw.
36 acute respiratory tract infection*.tw.
37 acute respiratory infection*.tw.
38 or/1-37
39 Handwashing/
40 (handwashing or hand washing or hand-washing).tw.
41 hand hygiene.tw.
42 (sanitiser* or sanitizer*).tw.
43 (cleanser* or disinfectant*).tw.
44 gloves, protective/ or gloves, surgical/
45 glov*.tw.
46 masks/ or respiratory protective devices/
47 (mask or masks or respirator or respirators).tw.
48 Protective Clothing/
49 Protective Devices/
50 Patient Isolators/
51 Patient Isolation/
52 patient isolat*.tw.
53 (barrier* or curtain* or partition*).tw.
54 negative pressure room*.tw.
55 ((reverse barrier or reverse-barrier) adj3 (nurs* or unit or isolation)).tw.
56 Cross Infection/pc [Prevention & Control]
57 (cross infection* adj2 prevent*).tw.
58 Communicable Disease Control/
59 Infection Control/
60 (school* adj3 (clos* or dismissal*)).tw.
61 temporary closur*.tw.
62 mass gathering*.tw.
63 (public adj2 (gathering* or event*)).tw.
64 (bans or banning or banned or ban).tw.
65 (outbreak adj3 control*).tw.
66 distancing*.tw.
67 Quarantine/
68 quarantine*.tw.
69 (protective adj2 (cloth* or garment* or device* or equipment)).tw.
70 ((protective or preventive) adj2 (procedure* or behaviour* or behavior*)).tw.
71 personal protect*.tw.
72 (isolation room* or isolation strateg*).tw.
73 (distance adj2 patient*).tw.
74 ((spatial or patient) adj separation).tw.
75 cohorting.tw.
76 or/39-75
77 38 and 76
78 (animals not (animals and humans)).sh.
79 77 not 78

 

Searching other resources

There were no language restrictions. Study design filters designed to retrieve RCTs, cohort case-control and cross-over studies, and before-after and time series trials were used in the original searches but we applied no filters to the searches carried out for this update. We scanned the references of all included studies to identify other potentially relevant studies. We also accessed the archives of the former MRC Common Cold Unit (Jefferson 2005d) as a possible source for interruption of transmission evidence.

 

Data collection and analysis

 

Selection of studies

We scanned the titles and abstracts after conducting the searches. We obtained full-text articles if a study appeared to meet our eligibility criteria (or when there was insufficient information to exclude it). We then used a standardised form to assess the eligibility of each study, based on the full article.

 

Data extraction and management

For this 2010 update, two review authors (TOJ, JMC) independently applied inclusion criteria to all identified and retrieved articles and extracted data. CDM checked the procedure and arbitrated. MJ carried out data analysis.

 

Assessment of risk of bias in included studies

For the 2009 update (Jefferson 2009) we contacted one trial author (Dr Michael Broderick) to better understand the risk of bias in his study (Broderick 2008). For this 2010 update Drs Aiello and Larson were contacted and provided additional information.

A common problem in these studies was a lack of reporting of viral circulation in the reference population, making interpretation and generalisability of their conclusions questionable.

 

Randomised studies

Three RCTs were poorly reported with no description of randomisation sequence, concealment or allocation in three studies (Gwaltney 1980; Turner 2004a; Turner 2004b). Satomura 2005 reported the generation of randomisation but the very nature of the intervention (gargling with water with or without povidone iodine versus standard gargling with no attempt at masking the taste of iodine) made blinding impossible. The design of two trials was so artificial that their results cannot be generalised to everyday situations (Turner 2004a; Turner 2004b). One trial (Satomura 2005) is linked to a subsequent brief report which provides contradictory information which is difficult to reconcile (Kitamura 2007).

The quality of the cluster-randomised trials varied. Only the best reported cluster coefficients and conducted analysis of data by unit of (cluster) allocation instead of by individuals (Luby 2005; Roberts 2000; Sandora 2005). Analysing cluster-randomised trials at the individual level leads to spuriously narrow confidence intervals around the estimates of effect (Grimshaw 2004). Other frequent problems were a lack of description of randomisation procedure, partial reporting of outcomes, unclear numerators or denominators and unexplained attrition (Carabin 1999; Kotch 1994; Morton 2004; White 2001), and either complete failure of double-blinding (Farr 1988a; Farr 1988b) or inappropriate choice of placebo (Longini 1988). Three cluster-randomised trials involving the use of face masks (Cowling 2008; Cowling 2009; MacIntyre 2009) by influenza-like illness (ILI) contacts had poor compliance. This shows the difficulty of conducting clinical trials using bulky equipment in the absence of the perception of a real threat. One trial (Cowling 2008) was also conducted in a period of low viral circulation and randomisation was carried out on the basis of two different sequences. The other study (MacIntyre 2009) was underpowered to detect differences in effect between different types of masks.

The cluster-randomised trial by Sandora and colleagues (Sandora 2008) is at low risk of bias with careful evaluation of compliance in the intervention arm (hand sanitiser wipes and disinfection of surfaces).

Of the four RCTs in the 2010 update, one was classified at low risk of bias (Loeb 2009), one at medium risk of bias (Aiello 2010a) and two (Jacobs 2009; Larson 2010) at high risk of bias.

 

Non-randomised studies

These were assessed for the presence of potential confounders using the appropriate Newcastle-Ottawa Scales (NOS) (Wells 2005) for case-control and cohort studies and a three-point checklist for controlled before and after and ecological studies (Khan 2000).

 

Case-control studies

We classified five of the nine case-control studies as having medium risk of bias (Lau 2004a; Seto 2003; Wu 2004; Yin 2004; Yu 2007) and two as at low risk of bias (Nishiura 2005; Teleman 2004), mostly because of inconsistencies in the text and lack of adequate description of controls. Two were at high risk of bias (Chen 2009; Liu 2009).

 

Prospective cohort studies

Six of the 16 prospective cohort studies were classified as at low risk of bias (Agah 1987; Dick 1986; Falsey 1999; Leung 2004; Madge 1992; Somogyi 2004), six as of medium risk (Broderick 2008; Dyer 2000; Kimel 1996; Murphy 1981; White 2003, Yen 2006), and four as of high risk of bias (Makris 2000; Master 1997; Niffenegger 1997; Wang 2007). One was a very brief report of a small study with insufficient details to allow assessment (Derrick 2005).

 

Retrospective cohort studies

All six retrospective cohort studies had high risk of bias (Cowling 2010, Doherty 1998; Foo 2006; Isaacs 1991; Ou 2003; Yen 2006). In general, retrospective designs are prone to recall bias.

 

Time series studies

Six of the 13 controlled before-after studies were at low risk of bias (Hall 1981a; Leclair 1987; Macartney 2000; Pang 2003; Ryan 2001; Simon 2006), two of medium risk (Krasinski 1990; Pelke 1994) and five at high risk (Gala 1986; Hall 1981b; Heymann 2004; Krilov 1996; Snydman 1988).

 

Measures of treatment effect

When possible, we performed a quantitative analysis and summarised effectiveness as odds ratio (OR) using 95% confidence intervals (CI). We expressed absolute intervention effectiveness as a percentage using the formula intervention effectiveness = 1 - OR, whenever significant. In studies which could not be pooled, we used the effect measures reported by the trial authors (such as risk ratio (RR) or incidence rate ratio (IRR) with 95% CI or, when these where not available, relevant P values).

 

Unit of analysis issues

Outcome measures varied from incidence of experimentally-induced rhinovirus infections, to the incidence of naturally occurring undifferentiated acute respiratory infections (ARIs). This was measured in a variety of ways, including numbers of ARIs per time period, or number of ARIs per household per time period. In some studies the ARIs were replaced by influenza-like illness (ILI). Other included studies focused on SARS specifically, or respiratory syncytial virus (RSV).

Proxy measures of illness included absenteeism.

 

Dealing with missing data

Whenever details of studies were unclear or studies were only known to us by abstracts or communications at meetings we corresponded with first or corresponding authors.

 

Assessment of heterogeneity

Aggregation of data was dependent on study design, types of comparisons, sensitivity and homogeneity of definitions of exposure, populations and outcomes used. We calculated the I2 statistic for each pooled estimate to assess the presence of statistical heterogeneity (Higgins 2002; Higgins 2003).

 

Assessment of reporting biases

Given the limited nature of our quantitative synthesis and the widely disparate nature of our evidence base, we limited our assessment of possible reporting biases to funnel plot visual inspection.

 

Data synthesis

We systematically described and reviewed included studies separately by study design. In other words randomised studies were described and reviewed separately from case-control studies which were described and reviewed separately from prospective cohort studies, and so on. If possible and appropriate, we combined studies within a particular study design in a meta-analysis. We used fixed-effect meta-analysis providing there was no evidence of heterogeneity, otherwise we used random-effects meta-analysis.

 

Subgroup analysis and investigation of heterogeneity

An a priori subgroup analysis was planned for:

  1. pandemic influenza outbreaks;
  2. seasonal influenza; and
  3. other epidemics (for example, SARS).

We had sufficient data to carry out only the last.

 

Sensitivity analysis

We aimed to perform a sensitivity analysis on the results of our meta-analysis. We assessed the robustness of the conclusions from the evidence of the effects of each intervention by comparing the results across the original multivariable analysis, looking for consistency of findings.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

 

Results of the search

We scanned 3775 titles, excluded 3560 and retrieved full papers of 215 studies, to include 66 papers of 67 studies.

 

Included studies

See Summary of main results section for a summary table of interventions and types of evidence.

In 2010 we included seven new studies and listed three trials as awaiting assessment. The seven newly included studies are four RCTs (Aiello 2010a; Jacobs 2009; Larson 2010; Loeb 2009), one retrospective cohort (Cowling 2010) and two case-control studies (Chen 2009; Liu 2009).

 

Excluded studies

We excluded 36 additional studies. The most frequent reasons for exclusion were no reporting of original data/non-comparative design, confounding by use of antivirals or other medication and in vitro studies (carried out without live patients).

 

Risk of bias in included studies

Three RCTs were poorly reported with no description of randomisation sequence, concealment or allocation (Gwaltney 1980; Turner 2004a; Turner 2004b). The design of two trials by one author means their results may not be generalised to everyday situations. This is due to the artefactual delivery of the interventions tested (see Quality of the evidence in the Discussion section) (Turner 2004a; Turner 2004b).

The quality of the cluster-randomised trials varied. Only the highest quality trials (Cowling 2009; Luby 2005; Roberts 2000; Sandora 2005) reported cluster coefficients and conducted analysis of data by unit of (cluster) allocation instead of by individuals. Analysing cluster-randomised trials at the individual level leads to spuriously narrow CIs around the estimates of effect (Grimshaw 2004). Other common problems were a lack of description of randomisation procedure, partial reporting of outcomes, unclear numerators or denominators and unexplained attrition (Carabin 1999; Kotch 1994; Morton 2004; White 2001) and either complete failure of double-blinding (Farr 1988a; Farr 1988b) or inappropriate choice of placebo (Longini 1988). Jacobs 2009 is an underpowered individual randomised trial carried out in Japan. Its open design means that due to lack of accounting for drop outs and definitions of outcomes the trial is at high risk of bias. In addition, no guidance as to the generalisability of its results to other settings and countries is provided to readers.  

Aiello 2010a is at medium risk of bias. Despite logistical and design problems the trial appears to show an effectiveness gradient of mask-wearing and hand sanitation combined versus instruction on hand sanitation and mask-wearing in student halls. The last cluster-randomised trial (Larson 2010) compared the effects of education alone versus education plus the use of an alcohol-based hand sanitiser versus education plus the use of an alcohol-based hand sanitiser plus the use of medical face masks on the interruption of self-reported upper respiratory tract infection (URTI), ILI and laboratory-confirmed influenza or other viral pathogen by culture or polymerase chain reaction (PCR) in US immigrant Latino households. Due to design issues, difficulty interpreting whether there was an intention-to-treat (ITT) analysis and lack of sufficient details of dropouts and other reporting problems, we classified it at high risk of bias.

Loeb 2009 is a low risk of bias non-inferiority trial directly comparing the effects of surgical mask wearing versus N95 fit-tested respirators in nurses in acute units in Ontario Canada. The outcomes measured range from symptomatic and asymptomatic influenza to physician visits and ILI caused by non-influenza agents. This is possibly the most reliable piece of evidence available for this 2010 update.

We classified five of the nine case-control studies as having medium risk of bias (Lau 2004a; Seto 2003; Wu 2004; Yin 2004; Yu 2007) and two as at low risk of bias (Nishiura 2005; Teleman 2004), mostly because of inconsistencies in the text and lack of adequate description of controls. Two case-control studies (Chen 2009; Liu 2009) were at high risk of bias. Their interpretation is not straightforward. Both studies assess the effects of multiple factors as risk and protective measures for SARS during the epidemic in China. They appeared to be searching for associations and lacked precision with respect to conducting true matched blinded assessments.

Only live cases were considered when we know that between 10% to 20% of infected healthcare workers died in the first weeks of the epidemic (Liu 2009 mentions the high mortality rate in the Introduction). However, the studies did ascertain the cases and controls of SARS by performing confirmatory laboratory testing rather than relying on a clinical diagnosis. 

Six of the 16 prospective cohort studies were classified as at low risk of bias (Agah 1987; Dick 1986; Falsey 1999; Leung 2004; Madge 1992; Somogyi 2004), four as of medium risk (Dyer 2000; Kimel 1996; Murphy 1981; White 2003) and three as of high risk of bias (Makris 2000; Master 1997; Niffenegger 1997). One was a very brief report of a small study (Derrick 2005) and two recent studies (Broderick 2008; Wang 2007) report insufficient details to allow assessment.

Four retrospective cohort studies exploring the effect of barrier interventions (Doherty 1998; Isaacs 1991; Ou 2003; Yen 2006) and one study reporting on adverse effects of barrier interventions (Foo 2006) had a high risk of bias. The other high risk of bias retrospective cohort study is Cowling 2010, mainly due to the nature of its design, heavily dependent on web availability of information.

Six of the 13 controlled before-after studies were at low risk of bias (Hall 1981a; Leclair 1987; Macartney 2000; Pang 2003; Ryan 2001; Simon 2006), two of medium risk (Krasinski 1990; Pelke 1994) and five at high risk (Gala 1986; Hall 1981b; Heymann 2004; Krilov 1996; Snydman 1988).

The most common problem in all of these studies was a lack of reporting of viral circulation in the reference population, making interpretation and generalisability of their conclusions questionable.

The results of a GRADE evaluation (the GRADE Working Group available from http://www.gradeworkinggroup.org/index.htm) of the case-control studies categorised them as providing low to very low quality evidence and categorised the updated RCTs as very low quality with the exception of two studies which were considered of moderate quality (Appendix 7).

The overall risk of bias is presented graphically in Figure 1 and summarised in Figure 2.

 FigureFigure 1. 'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included RCTs.
 FigureFigure 2. 'Risk of bias' summary: review authors' judgements about each risk of bias item for each included RCT.

 

Effects of interventions

We scanned 3775 titles, excluded 3560 and retrieved the full papers of 215 studies, to include 66 papers of 67 studies. Four trials were listed in the Studies awaiting classification section. For one trial currently being submitted for publication we had insufficient information for assessment (Aiello 2010b). Two studies (Hubner 2009; Savolainen-Kopra 2010) assessed the effects of handwashing practices which were of less interest at this time than the use of the physical interventions featured in this update. Another study was identified after our searches had been conducted (Raboud 2010).

 

Reported results from randomised studies

Three studies tested the effects of hand-cleaning on inactivating the virus and preventing experimental rhinovirus colds. These resulted in either a reduction in the incidence of rhinovirus infection among volunteers treated using different combinations of the acids used for cleaning (P = 0.025) (Turner 2004a) or did not reach statistical significance (13% versus 30% with combined denominator of only 60) (Turner 2004b). Using iodine treatment of fingers, one out of 10 volunteers were infected compared to six out of 10 in the placebo preparation arm (P = 0.06 with Fisher's exact test) (Gwaltney 1980). One study found that gargling with water or povidone-iodine solution in addition to handwashing is effective in preventing URTIs, but not influenza-like illnesses (Satomura 2005).

Three cluster-randomised studies tested the effects of virucidal cleaning disposable handkerchief wipes on the incidence and spread of ARIs. One reported a reduced incidence of ARIs in the household over 26 weeks, from 14% to 5% (Farr 1988a). A similar study reported a small non-significant (5%) drop across families (Farr 1988b). However, since the drop in incidence was confined to primary illness, unaffected by tissue use, we might assume they were ineffective. A community trial also reported a non-significant reduction in ARI secondary attack rates (18.7% versus 11.8%) during a time of high circulation of influenza H3N2 and rhinoviruses in the community (Longini 1988). This result is likely to be an underestimate because of any barrier effect of the inert tissue wipes used in controls.

Eight cluster-randomised studies tested educational programmes to promote handwashing, with or without the adjunct of antiseptic agents, on the incidence of ARIs either in schools or in households. Because of different definitions, comparisons, lack of reporting of cluster coefficients and (in two cases) missing participant data (Carabin 1999; Kotch 1994), we judged it improper to meta-analyse the data. Two of these trials reported a lack of effect: RR for the prevention of acute respiratory illness of 0.94 (95% CI -2.43 to 0.66) (Kotch 1994); and 0.97 (95% CI 0.72 to 1.30) (Sandora 2005). Nevertheless, the highest quality trials reported a significant decrease in respiratory illness in children up to 24 months (RR 0.90, 95% CI 0.83 to 0.97), although the decrease was not significant in older children (RR 0.95, 95% CI 0.89 to 1.01) (Roberts 2000); and a 50% (95% CI -65% to -34%) lower incidence of pneumonia in children aged less than five years of age in a low-income country (Luby 2005). Another study reported a decrease of 30% to 38% in respiratory infections with additional hand-rubbing (RR for illness absence incidence 0.69, RR for absence duration 0.71) (White 2001). One study reported decreased school absenteeism of 43% with the additional use of alcohol gel as well as handwashing (Morton 2004). Two trials reported that repeated handwashing significantly reduced the incidence of colds by as much as 20% (Carabin 1999; Ladegaard 1999). One study found that in households in which interventions (handwashing with or without wearing a facemask) were implemented within 36 hours of symptom onset in the index patient, transmission of reverse transcription polymerase chain reaction (RT-PCR)-confirmed infection was reduced, an effect attributable to reductions in infection among participants using face masks plus hand hygiene (adjusted OR 0.33 (95% CI 0.13 to 0.87)) (Cowling 2009).

The findings of the cluster-randomised trial by Aiello et al (Aiello 2010a) suggest that face masks and hand hygiene may reduce respiratory illnesses in shared living settings and mitigate the impact of the influenza A (H1N1) pandemic compared to no intervention or hand sanitiser and education. This conclusion is based on a significantly lower level of ILI incidence in the mask and hand sanitiser arm compared to the other two arms after adjustment for covariates (30% to 50% less in arm one compared to controls in the last two weeks of the study). However, influenza virus circulation was very low during the study period.

The authors of Jacobs 2009 were unable to detect a difference in incidence of ILI of surgical mask wearing compared to no mask in healthcare workers in a Japanese hospital, possibly because of the study's lack of power.

The cluster-randomised trial by Larson et al (Larson 2010) tested the addition of mask and hand sanitiser use to hand sanitiser use alone to nothing other than education which was common to all three arms. Given the many biases in the design and reporting the results are difficult to interpret: the hand sanitiser group was significantly more likely to report that no household member had symptoms (P = 0.01) but there were no significant differences in rates of infection by intervention group in multivariate analyses. Knowledge improved significantly more in the hand sanitiser group (P = 0.0001).

The credible results of the individual trial by Loeb et al (Loeb 2009) report that the use of surgical masks was not inferior to the use of N95 respirators against influenza.

 

Reported results from case-control studies

Nine case-control studies assessed the impact of public health measures to curb the spread of the SARS epidemic during February to June 2003 in China, Singapore and Vietnam. Homogeneity of case definition, agent, settings and outcomes allowed meta-analysis. We pooled binary data; one of the comparisons showed significant heterogeneity (handwashing), however we used a fixed-effect model. A random-effects model made no appreciable difference to the handwashing comparison. Although continuous data were often available, the variables were different and measured in different units with standard deviations usually missing, which prevented their meta-analysis.

Studies reported that disinfection of living quarters was highly effective in preventing the spread of SARS (OR 0.30, 95% CI 0.23 to 0.39) (Lau 2004a); handwashing for a minimum of 11 times daily prevented many cases (OR 0.54, 95% CI 0.44 to 0.67) ( Analysis 1.2), based on seven studies (Chen 2009; Lau 2004a; Nishiura 2005; Seto 2003; Teleman 2004; Wu 2004; Yin 2004); simple mask-wearing was highly effective (OR 0.32, 95% CI 0.26 to 0.39) ( Analysis 1.3), based on seven studies (Chen 2009; Lau 2004a; Liu 2009; Nishiura 2005; Seto 2003; Wu 2004; Yin 2004); three studies found N95 respirator-wearing even more effective (OR 0.17, 95% CI 0.07 to 0.43) ( Analysis 1.4), (Seto 2003; Teleman 2004; Liu 2009); glove-wearing was effective (OR 0.32, 95% CI 0.23 to 0.45) ( Analysis 1.5) (Chen 2009; Liu 2009; Nishiura 2005; Seto 2003; Teleman 2004; Yin 2004); gown-wearing was also effective (OR 0.33, 95% CI 0.24 to 0.45) ( Analysis 1.6) (Chen 2009; Nishiura 2005; Seto 2003; Teleman 2004; Yin 2004); all means combined (handwashing, masks, gloves and gowns) achieved very high effectiveness (OR 0.09, 95% CI 0.02 to 0.35) ( Analysis 1.7) (Nishiura 2005; Seto 2003); use of eye protection such as goggles or masks with goggles is protective (OR 0.10, 95% CI 0.05 to 0.17) ( Analysis 1.8) (Chen 2009; Liu 2009; Yin 2004) and nose-washing was also protective (OR 0.30, 95% CI 0.16 to 0.57) ( Analysis 1.9) (Chen 2009; Liu 2009). As the data are all based on univariable analyses, they may be subject to confounding. We have separately tested how many of these measures were statistically significant in multivariable analyses ( Table 1).

These data suggest that wearing a surgical mask or a N95 mask is the measure with the most consistent and comprehensive supportive evidence. Seven out of eight studies included masks as a measure in their study and six out of seven of these studies found masks to be statistically significant in multivariable analysis. Handwashing was also included in seven of the studies with four studies showing handwashing to be statistically significant in multivariable analysis. All other measures were shown to be statistically significant in multivariable analysis on only one or two occasions.

Another case-control study from Hong Kong and Guangzhou hospital wards reported that a minimum distance between beds of less than one metre was a risk factor for transmission (Yu 2007). Disaggregated data were not reported and therefore we did not pool this study in the meta-analysis. All studies selected cases from hospitals, except for one (Lau 2004a) in which cases were people with probable SARS reported to the Department of Health in Hong Kong.

The detailed results of Chen 2009 report that avoiding face-to-face contact while caring for SARS patient (OR 0.30, 95% 0.15 to 0.60) and wearing gloves coupled with methods of ventilation are highly protective practices (various ORs for the various combinations intensity of wearing and ventilation methods, all significant). Liu 2009 reports that personal protective measures against droplet spread, such as wearing multiple layers of mask, are effective against the nosocomial spread of SARS.

 

Reported results from prospective cohort studies

Using an alcohol rub in students' communal residences resulted in significantly fewer symptoms (reductions of 14.8% to 39.9 %) and lower absenteeism (40% reduction) (White 2003). In a much-cited small experimental study, virucidal paper handkerchiefs containing citric acid interrupted the transmission of rhinovirus colds transmitted through playing cards: 42% of re-usable cotton handkerchief users developed colds compared with none using disposable virucidal tissues (Dick 1986).

Few identified studies reported interventions in the daycare setting, either in staff or patients. One staff educational programme on handwashing in a daycare centre for adults was effective over a four-year period in reducing rates of respiratory infection in daycare patients from 14.5 to 10.4 per 100 person-months to 5.7 (P < 0.001), with an accompanying decline in viral isolates. This seems to be more effective than the use of additional portable virucidal hand foam as an adjunct to handwashing (Falsey 1999). This confirmed an earlier report of the effectiveness of a handwashing programme in reducing absenteeism for ILI in a primary school (Kimel 1996).

Two high risk of bias studies reported that education, a handwashing routine and encouragement for kindergarten children, parents and staff in correct sneezing and coughing procedure were effective, although there were considerable fluctuations in incidence of infections in the control and test centres (Niffenegger 1997); but the intervention was not effective in reducing absenteeism caused by ARIs (RR 0.79, P = 0.756) (Master 1997).

Dyer and colleagues reported a prospective, cluster, open-label, cross-over cohort study. The study assessed the effectiveness of a hand sanitiser in conjunction with at will soap-and-water handwashing in a private elementary school in California. Use of the sanitiser reduced illness absenteeism by 41.9% (reduction in respiratory illnesses of 49.7% over the 10-week period of the study) (Dyer 2000).

Curiously, an infection-control education programme reinforcing handwashing and other hygienic measures in a nosocomial setting reported reducing the number of organisms present on hands and surfaces, and ARIs, although the data tabled suggested the opposite (an incidence rate of 4.15/1000 patient-days in the test homes versus 3.15/1000 in the control homes) (Makris 2000).

A study found wearing a goggle-mask apparatus in healthcare workers visiting and caring for children aged up to five with respiratory syncytial virus (RSV) and symptoms of respiratory disease was effective (5% illness rate in goggle wearers against 61% in no-goggle controls) (Agah 1987).

Rapid laboratory diagnosis, cohort nursing and the wearing of gowns and gloves for all contacts with RSV-infected children significantly reduced the risk of nosocomial RSV infection (OR 0.013 to 0.76) (Madge 1992), although another similar study reported no effect of adding the use of both gown and mask to the usual handwashing routine on the development of illness in personnel caring for infants with respiratory disease (4 out of 30 in the handwashing group alone compared to 5 out of 28 in the handwashing, gown and masking group, P > 0.20); although the authors described poor compliance with the barrier protocol (Murphy 1981).

Strict procedures of triage and infection control to stop transmission of SARS from infected children to carers and visitors of a large hospital at the height of the epidemic in 2003 in Hong Kong was reported effective at interrupting the transmission of SARS, as no healthcare worker became ill, in contrast to experiences in other institutions (Leung 2004).

A tiny study comparing the N95 respirator with paper surgical masks in volunteers found that surgical masks, even when worn in multiple layers (up to five), filtered ambient particles poorly (Derrick 2005); this principle was confirmed in another small study of air filtration to prevent droplet spread (Somogyi 2004).

 

Reported results from retrospective cohort studies

Two studies investigated isolating together children less than three years of age with suspected RSV. In one, transmission was diminished by "up to 60%" (Isaacs 1991), while the statement that nosocomial transmission "was minimised" was not supported by data in the other study (Doherty 1998).

Isolation of cases during the 2003 epidemic of SARS in China was reported to limit transmission only to those contacts who actually had home or hospital contact with a symptomatic SARS patient (attack rate 31.1%, 95% CI 20.2 to 44.4 for carers; 8.9%, 95% CI 2.9 to 22.1 for visitors; 4.6%, 95% CI 2.3 to 8.9 for those living with a SARS case) but not to contacts living in the same building, working with cases, or without contact with SARS cases during the incubation period. This suggests extending quarantine only for contacts of symptomatic SARS cases (Ou 2003).

Another brief report carried out in 2003 during the SARS epidemic, in a military hospital in Taiwan, China and 86 control hospitals, compared an integrated infection-control policy to protect healthcare workers against infection; only two from the military hospital were infected with SARS compared to 43 suspected and 50 probable cases in the control hospitals (Yen 2006).

Cowling 2010 reports a marginal (one to two weeks) non-significant benefit in delaying spread of novel A/H1N1 autochthonous pandemic influenza by various means of entry screening. The high risk of bias is mainly due to the nature of its design, heavily dependent on web availability of information. However, it is difficult to see how else a similar study could have been conducted.

 

Reported results from controlled before and after studies

Two small studies by the same first author assessed means of nosocomial transmission of RSV in small children and the effects of introducing distancing and barriers: one with low risk of bias reported effective physical distancing and room separation (0 infected out of 14 who sat away from RSV-infected infants compared with five out of seven who cuddled and four out of 10 who touched infected infants) (Hall 1981a). The second with high risk of bias reported no incremental benefits of gowns and masks (32% infection versus 41%) (Hall 1981b). Adding disposable plastic eye-nose goggles to other respiratory infection-control procedures (isolating infected from uninfected people, handwashing) also reduced transmission of RSV (6% versus 42% of controls) (Gala 1986). Screening and subsequent isolation of infected from uninfected people ('cohorting') also reduced nosocomial RSV transmission in older children (from 5.33 infections per 1000/patient days of care to 1.23 infections per 1000/patient days after introduction of screening) (Krasinski 1990). A similar study reported that increased compliance with a policy of glove and gown isolation precautions reduced the high rate of nosocomial RSV transmission on an infant and toddler ward (RR for pre- and post-intervention periods infection rates 2.9, 95% CI 1.5 to 5.7) (Leclair 1987).

A study of protective gowning did not protect neonatal intensive care unit infants from RSV or any other type of infection, or affect mortality (1.21 per 100 patient-days of gowning compared to 1.38 of none), although selection bias was likely with 17% of participating children lost to follow up (Pelke 1994).

A German study conducted over three seasons reported a decrease of nosocomial RSV infections, from 1.67/1000 patient-days in the first season to 0.18/1000 patient-days in the last season, after instituting enhanced surveillance and feedback, rapid diagnosis, barriers and isolation, and disinfection of surfaces (Simon 2006). A similar study but with high risk of bias reported a decrease from eight confirmed RSV cases per 1000 patient-days to none (Snydman 1988). A better conducted study over eight years implemented a combination of education with high index of suspicion for case-finding (contact precautions), with barriers (but no goggles or masks) and handwashing for patients and staff reduced RSV infections in a hospital in Philadelphia, USA: RR 0.61, 95% CI 0.53 to 0.69 (Macartney 2000).

One small study with serious potential biases assessed training and a sanitary programme (handwashing, disinfection of school buses, appliances and toys) in a special-needs daycare facility for children with Downs Syndrome, a pupil to staff ratio of five or six to one, and reported reductions in: respiratory illnesses from a mean of 0.67 to 0.42 per child per month (P < 0.07); physician visits from 0.50 to 0.33 (P < 0.05); mean courses of antibiotics prescribed from 0.33 to 0.28 (P < 0.05); and days of school missed because of respiratory infections from 0.75 to 0.40 (P < 0.05) (Krilov 1996).

A very large study of military recruits reported that a structured top-down programme of handwashing at least five times daily nearly halved the incidence of ARIs. Recruits who handwashed less frequently reported more episodes of ARIs (OR 1.5, 95% CI 1.2 to 1.8), which represents a difference of 4.7 versus 3.2 mean infections per recruit per year, and more hospitalisations (OR 10.9, 95% CI 2.7 to 46.2). However, implementation was difficult (Ryan 2001).

An ecological study analysed the effects of quarantine and port of entry screening on the SARS epidemic in early 2003 in Beijing, China, from data collected centrally. Hospitals were the initial sources of transmission of the SARS virus. The shape of the epidemic suggests these measures may have reduced SARS transmission although only 12 cases identified out of over 13 million people screened puts in doubt the direct effectiveness of entry port checks at airports and railway stations, and screening was probably more important (Pang 2003).

An Israeli study of 186,094 children aged six to 12 years reported that school closure was temporally associated with a 42% decreased morbidity from respiratory tract infections, a consequent 28% decrease in visits to physicians and to emergency departments, and a 35% reduction in purchase of medications (Heymann 2004).

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
 

Quality issues

Several features need consideration before drawing generalisations from these studies.

The settings of the studies, conducted over four decades, were heterogeneous and ranged from suburban schools (Carabin 1999; Dyer 2000; Heymann 2004; Niffenegger 1997) to military barracks (Ryan 2001), emergency departments, intensive care units and paediatric wards (Gala 1986; Leclair 1987; Loeb 2009) in high-income countries; slums in low-income countries (Luby 2005); an upper Manhattan immigrant Latino neighbourhood (Larson 2010) and special-needs daycare centres with a very high teacher to pupil ratio (Krilov 1996). Few attempts were made to obtain socio-economic diversity by (for example) involving more schools in the evaluations of the same programme (Dyer 2000). We were able to identify few studies from low-income countries where the vast majority of the burden lies, and where cheap interventions are so critical. Even in high-income countries, such as Israel, the dramatic fall in ARIs subsequent to school closure may have been related to that country's high child population (34%). Additionally, limited availability of over-the-counter medications and national universal comprehensive health insurance provided with consequent physician prescription of symptomatic treatment may further limit generalisability of findings (Heymann 2004).

The variable quality of the methods of these studies is striking. Hasty design of interventions for public health crises, particularly the SARS case-control studies, is understandable but less so when no randomisation - not even of clusters - was carried out in several unhurried cohort and before and after studies. Randomisation could often have involved minimal disruption to service delivery. Inadequate reporting especially made interpretation difficult of before-after studies. Incomplete or no reporting of randomisation (Turner 2004a), blinding (Farr 1988a; Farr 1988b), numerators and denominators (Carabin 1999; Kotch 1994), interventions, outcomes (White 2003), participant attrition (Makris 2000), confidence intervals (CIs) (Madge 1992) and cluster coefficients in the relevant trials (Carabin 1999) led to a considerable loss of information. Potential biases (such as cash incentives given to participants (White 2003)) were not discussed. Some trial authors even confused cohort with before-after designs to elaborate conclusions unsupported by their data (Makris 2000). Methodological quality was sometimes eroded by the need to deliver behavioural interventions in the midst of service delivery (Niffenegger 1997).

Nonetheless, even when suboptimal designs were selected, trial authors rarely attempted to articulate potential confounders. A commonly ignored confounder, specific to this area, is the huge variability in viral incidence (Heymann 2004; Isaacs 1991). Sometimes this was addressed in the study design (Falsey 1999), even in controlled before and after studies (one attempted correlation between respiratory syncytial virus (RSV) admissions and RSV circulating in the community) (Krasinski 1990). Another attempted linking exposure (measured as nasal excretion) and infection rate in the pre- and post-intervention periods (Leclair 1987).

Inappropriate placebos caused design problems. In some studies the placebo probably carried sufficient intervention effect apparently to dilute the intervention effects (Longini 1988). Two valiant attempts probably failed because placebo handkerchiefs were impregnated with a dummy compound which stung the users' nostrils (Farr 1988a; Farr 1988b).

Some studies used impractical interventions. Volunteers subjected to the intervention hand cleaner (organic acids) were not allowed to use their hands between cleaning and virus challenge, so the effect of normal use of the hands on the intervention remains unknown (Turner 2004a; Turner 2004b). Two per cent aqueous iodine painted on the hands, although a successful antiviral intervention, causes unacceptable cosmetic staining, impractical for all but those at the highest risk of epidemic contagion (Gwaltney 1980).

Compliance with interventions, especially educational programmes, was a problem for several studies despite the importance of many such low-cost interventions. Overall the logistics of carrying out trials in immigrant neighbourhoods or students' halls of residence are demanding and recognition should be given to all those who planned and carried out studies in very difficult circumstances (as in the middle of an epidemic).

 

The evidence

The highest quality cluster-randomised trials indicate most effect on preventing respiratory virus spread from hygienic measures in younger children. Perhaps this is because younger children are least capable of hygienic behaviour themselves (Roberts 2000), and have longer-lived infections and greater social contact, thereby acting as portals of infection into the household (Monto 1969). Additional benefit from reduced transmission from them to other members of the household is broadly supported by the results of other study designs where the potential for confounding is greater.

The pooled case-control studies, which focused on the SARS coronavirus (SARS CoV), suggest that implementing barriers to transmission, isolation and hygienic measures are effective with the use of relatively cheap interventions to contain respiratory virus epidemics. We found limited evidence of the superior effectiveness of devices such as the N95 respirator over simple surgical masks. This evidence is supported by a high quality hospital-based trial (Loeb 2009) which reports non-inferiority between face barriers. Overall masks were the best performing intervention across populations, settings and threats. More expensive and uncomfortable (especially if worn for long periods) than simple surgical masks, N95 respirators may be useful in very high-risk situations but additional studies are required to define these situations.

It is uncertain whether the incremental effect of adding virucidals or antiseptics to normal handwashing actually decreased the respiratory disease burden outside the confines of the rather atypical studies, upon which we reported. The extra benefit may have been, at least in part, accrued by confounding additional routines.

Studies preventing transmission of RSV and similar viruses appeared to be closer to real life and suggest good effectiveness. However, methodological quality concerns of the controlled before and after studies, mentioned previously, suggest benefits may have been due to population differences, especially virus infection rates. These were poorly reported in most studies.

Routine long-term implementation of some of the measures assessed in this review would be problematic, particularly maintaining strict hygiene and barrier routines for long periods of time. This would probably only be feasible in highly motivated environments, such as hospitals, without a real threat of a looming epidemic. Most of the trial authors commented on the major logistic burden that barrier routines imposed at the community level. However, the threat of a looming epidemic may provide stimulus for their inception.

A disappointing finding was the lack of proper evaluation of global and highly resource-intensive measures such as screening at entry ports and social distancing. The handful of studies (mostly conducted during the SARS epidemic) do not allow us to reach any firm conclusions. It is remarkable that despite a long lead time to the declaration of a pandemic, an international, prospective study to evaluate entry screening practices was not set up. The study by Cowling et al is a good contribution to our evidence base but no substitute for a well designed and conducted trial (Cowling 2010). Finally, few studies reported harms from the interventions studied. Harms affect compliance, which may decrease even if the intervention is merely cumbersome (such as a mask) and the threat is unclear.

 

Summary of main results

See  Table 2.

 

Overall completeness and applicability of evidence

See Discussion.

 

Quality of the evidence

See Discussion.

 

Potential biases in the review process

Through the World Health Organization (WHO), we made inquiries to identify a list of manufacturers of the interventions assessed in this review. However, no such list appears to exist. The low-tech (i.e. locally manufacturable) nature of some of the interventions, the lack of effective regulation in some settings and the possible endless number of manufacturers make the compilation and updating of such a list in a satisfactory manner very difficult. As a consequence it is impossible to gauge the existence of unpublished data. Low-tech device marketing is poorly regulated and incompletely understood.

 

Agreements and disagreements with other studies or reviews

We are not aware of systematic reviews of the same evidence.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

 

Implications for practice

The following effective interventions should be implemented, preferably in a combined fashion, to reduce transmission of viral respiratory disease:

  1. frequent handwashing with or without adjunct antiseptics;
  2. barrier measures such as gloves, gowns and masks with filtration apparatus; and
  3. suspicion diagnosis with isolation of likely cases.

Special efforts should be focused on implementing the three above interventions in order to reduce transmission from young children, who are generally the most fecund sources of respiratory viruses.

 
Implications for research

Public health measures can be highly effective, especially when they are part of a structured programme that includes instruction and education and when they are delivered together. There is a clear requirement to carry out further large, pragmatic trials to evaluate the best combinations in the community and in healthcare settings and with other respiratory viruses. RCTs with a pragmatic design, similar to the Luby et al trial, should be carried out whenever possible (Luby 2005). Nevertheless, this systematic review of the available research does provide some important insights. Perhaps the impressive effect of the hygienic measures aimed at younger children derives from the children's poor capability with their own hygiene. The variable quality and small scale of some studies is known from descriptive studies (Aiello 2002; Fung 2006; WHO 2006) and systematic reviews of selected interventions (Meadows 2004). More research is needed to evaluate the most effective strategies to implement successful physical interventions in practice, both on a small scale and at a population level. More attention should be paid to describing and quantifying the harms of the interventions assessed in this review and their relationship with compliance.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

Thanks to the following people for commenting on the draft protocol and review: Anne Lyddiatt, Stephanie Kondos, Tom Sandora, Kathryn Glass, Max Bulsara, Rick Shoemaker and Allen Cheng. Thanks also to the following people for translating non-English language trials for the draft review: Jørgen Lous for translating a Danish paper and extracting data, Ryuki Kassai who translated a Japanese paper, and Taixiang Wu who translated several Chinese papers. We thank the following people for commenting on the 2009, 2010 and 2011 updated reviews, respectively, for 2009: Anne Lyddiatt, Thomas Sandora, Michael Broderick, Sree Nair and Allen Cheng; for 2010: Carmem Pessoa da Sailva, Sergey Eremin; and for 2011: Amy Zelmer, Tom Sandora, Sree Nair and Allen Cheng. Drs Aiello and Larson provided additional information on their trials for the 2010 update. Dr V Shukla, Dr J Conly and K Lee prepared the GRADE tables using the GRADE Profiler software. Drs Carmem Pessoa da Silva and Thomas Haustein provided linguistic assistance for the 2010 update.

We gratefully acknowledge funding for this 2009 update from the UK National Institute for Health Research (NIHR) and the National Health and Research Council (NHMRC) of Australia and from WHO for the 2010 update. We also thank Ruth Foxlee and Alex Rivetti for constructing the search strategies for the previous review versions and Bill Hewak and Adi Prabhala for extracting data in the original review.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
Download statistical data

 
Comparison 1. Case-control studies

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Thorough disinfection of living quarters1990Odds Ratio (M-H, Fixed, 95% CI)0.30 [0.23, 0.39]

 2 Frequent handwashing72825Odds Ratio (M-H, Fixed, 95% CI)0.54 [0.44, 0.67]

 3 Wearing mask73216Odds Ratio (M-H, Fixed, 95% CI)0.32 [0.26, 0.39]

 4 Wearing N95 respirator3817Odds Ratio (M-H, Fixed, 95% CI)0.17 [0.07, 0.43]

 5 Wearing gloves61836Odds Ratio (M-H, Fixed, 95% CI)0.32 [0.23, 0.45]

 6 Wearing gowns51460Odds Ratio (M-H, Fixed, 95% CI)0.33 [0.24, 0.45]

 7 All interventions2369Odds Ratio (M-H, Fixed, 95% CI)0.09 [0.02, 0.35]

 8 Use of eye protection (mask/goggles)31482Odds Ratio (M-H, Fixed, 95% CI)0.10 [0.05, 0.17]

 9 Nose wash21225Odds Ratio (M-H, Fixed, 95% CI)0.30 [0.16, 0.57]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
 

Appendix 1. Previous search strategy

(Details of the search strategy used in the original review and the 2009 search strategy updates for MEDLINE, CENTRAL, EMBASE and CINAHL)

In the first publication of this review we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, issue 4); MEDLINE (1966 to November 2006); OLDMEDLINE (1950 to 1965); EMBASE (1990 to November 2006) and CINAHL (1982 to November 2006). The MEDLINE search terms were modified for OLDMEDLINE, EMBASE and CINAHL.

In this 2009 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 2); Ovid MEDLINE (2006 to May Week 1 2009); OLDMEDLINE (1950 to 1965); Ovid EMBASE (2006 to Week 18, 2009) and Ovid CINAHL (2006 to May Week 1 2009).

Ovid MEDLINE
1 exp Influenza/
2 influenza.tw.
3 flu.tw.
4 exp Common Cold/
5 common cold.tw.
6 exp Rhinovirus/
7 rhinovirus*.tw.
8 exp Adenoviridae/
9 adenovirus*.tw.
10 exp Coronavirus/
11 exp Coronavirus Infections/
12 coronavirus*.tw.
13 exp Respiratory Syncytial Viruses/
14 exp Respiratory Syncytial Virus Infections/
15 respiratory syncytial virus*.tw.
16 respiratory syncythial virus.tw.
17 exp Parainfluenza Virus 1, Human/
18 exp Parainfluenza Virus 2, Human/
19 exp Parainfluenza Virus 3, Human/
20 exp Parainfluenza Virus 4, Human/
21 (parainfluenza or para-influenza or para influenza).tw.
22 exp Severe Acute Respiratory Syndrome/
23 (severe acute respiratory syndrome or SARS).tw.
24 acute respiratory infection*.tw.
25 acute respiratory tract infection*.tw.
26 or/1-25 (59810)
27 exp Hand Washing/
28 (handwashing or hand washing or hand-washing).tw.
29 hand hygiene.tw.
30 (sanitizer* or sanitiser*).tw.
31 (cleanser* or disinfectant*).tw.
32 exp Gloves, Protective/
33 exp Gloves, Surgical/
34 glov*.tw.
35 exp Masks/
36 mask*1.tw.
37 exp Patient Isolators/
38 exp Patient Isolation/
39 patient isolat*.tw.
40 (barrier* or curtain* or partition*).tw.
41 negative pressure room*.tw.
42 reverse barrier nursing.tw.
43 Cross Infection/pc [Prevention]
44 school closure*.tw.
45 (clos* adj3 school*).tw.
46 mass gathering*.tw.
47 public gathering*.tw.
48 (ban or bans or banned or banning).tw.
49 (outbreak* adj3 control*).tw.
50 distancing.tw.
51 exp Quarantine/
52 quarantine*.tw.
53 or/27-49
54 26 and 53
55 (animals not (humans and animals)).sh.
56 54 not 55

 
CENTRAL search strategy

#1 MeSH descriptor Influenza, Human explode all trees
#2 influenza:ti,ab,kw
#3 flu:ti,ab,kw
#4 MeSH descriptor Common Cold explode all trees
#5 "common cold":ti,ab,kw
#6 MeSH descriptor Rhinovirus explode all trees
#7 rhinovirus*:ti,ab,kw
#8 MeSH descriptor Adenoviridae explode all trees
#9 adenovirus*:ti,ab,kw
#10 MeSH descriptor Coronavirus explode all trees
#11 MeSH descriptor Coronavirus Infections explode all trees
#12 coronavirus*:ti,ab,kw
#13 MeSH descriptor Respiratory Syncytial Viruses explode all trees
#14 MeSH descriptor Respiratory Syncytial Virus Infections explode all trees
#15 respiratory syncytial virus*:ti,ab,kw
#16 respiratory syncythial virus*:ti,ab,kw
#17 MeSH descriptor Parainfluenza Virus 1, Human explode all trees
#18 MeSH descriptor Parainfluenza Virus 2, Human explode all trees
#19 MeSH descriptor Parainfluenza Virus 3, Human explode all trees
#20 MeSH descriptor Parainfluenza Virus 4, Human explode all trees
#21 (parainfluenza or para-influenza or para influenza):ti,ab,kw
#22 MeSH descriptor Severe Acute Respiratory Syndrome explode all trees
#23 (severe acute respiratory syndrome or SARS):ti,ab,kw
#24 acute respiratory infection*:ti,ab,kw
#25 acute respiratory tract infection*:ti,ab,kw
#26 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25)
#27 MeSH descriptor Handwashing explode all trees
#28 (handwashing or hand washing or hand-washing):ti,ab,kw
#29 hand hygiene:ti,ab,kw
#30 (sanitizer* or sanitiser*):ti,ab,kw
#31 (cleanser* or disinfectant*):ti,ab,kw
#32 MeSH descriptor Gloves, Protective explode all trees
#33 MeSH descriptor Gloves, Surgical explode all trees
#34 glov*:ti,ab,kw
#35 MeSH descriptor Masks explode all trees
#36 mask*:ti,ab,kw
#37 MeSH descriptor Patient Isolators explode all trees
#38 MeSH descriptor Patient Isolation explode all trees
#39 (barrier* or curtain* or partition*):ti,ab,kw
#40 negative NEXT pressure NEXT room*:ti,ab,kw
#41 "reverse barrier nursing":ti,ab,kw
#42 MeSH descriptor Cross Infection explode all trees with qualifier: PC
#43 school NEXT closure*:ti,ab,kw
#44 (clos* NEAR/3 school*):ti,ab,kw
#45 mass NEXT gathering*:ti,ab,kw
#46 public NEXT gathering*:ti,ab,kw
#47 ("ban" or "bans" or banned or banning):ti,ab,kw
#48 (outbreak* NEAR/3 control*):ti,ab,kw
#49 distancing:ti,ab,kw
#50 MeSH descriptor Quarantine explode all trees
#51 quarantine*:ti,ab,kw
#52 (#27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44 OR #45 OR #46 OR #47 OR #48 OR #49 OR #50 OR #51)
#53 (#26 AND #52)

 
Ovid EMBASE search strategy

1 exp Influenza/
2 influenza.tw.
3 flu.tw.
4 exp Common Cold/
5 common cold.tw.
6 exp Human Rhinovirus/
7 rhinovirus*.tw.
8 exp Adenovirus/
9 adenovirus*.tw.
10 exp Coronavirus/
11 coronavirus*.tw.
12 exp Respiratory Syncytial Pneumovirus/
13 respiratory syncytial virus*.tw.
14 respiratory syncythial virus.tw.
15 (parainfluenza or para-influenza or para influenza).tw.
16 exp Severe Acute Respiratory Syndrome/
17 (severe acute respiratory syndrome or SARS).tw.
18 acute respiratory infection*.tw.
19 acute respiratory tract infection*.tw.
20 or/1-19
21 exp Hand Washing/
22 (handwashing or hand washing or hand-washing).tw.
23 hand hygiene.tw.
24 (sanitizer$ or sanitiser$).tw.
25 (cleanser$ or disinfectant$).tw.
26 exp Glove/
27 exp Surgical Glove/
28 glov*.tw.
29 exp Mask/
30 mask*1.tw.
31 patient isolat*.tw.
32 (barrier* or curtain* or partition*).tw.
33 negative pressure room*.tw.
34 reverse barrier nursing.tw.
35 Cross Infection/pc [Prevention]
36 school closure*.tw.
37 (clos* adj3 school*).tw.
38 mass gathering*.tw.
39 public gathering*.tw. (5)
40 (ban or bans or banned or banning).tw.
41 (outbreak* adj3 control*).tw.
42 distancing.tw.
43 quarantine*.tw.
44 or/21-43
45 20 and 44

 
EBSCO CINAHL search strategy

S26 S10 and S24
S25 S10 and S24
S24 S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22 or 23 or S24
S23 TI outbreak* N3 control* or AB outbreak* N3 control*
S22 TI ( school closure* or mass gathering* or public gathering* or ban or bans or banned or banning or distancing or quarantine* ) or AB ( school closure* or mass gathering* or public gathering* or ban or bans or banned or banning or distancing or quarantine* )
S21 TI ( patient isolat* or barrier* or curtain* or partition* or negative pressure room* or reverse barrier nursing) or AB ( patient isolat* or barrier* or curtain* or partition* or negative pressure room* or reverse barrier nursing)
S20 TI ( glov* or mask* ) or AB ( glov* or mask* )
S19 TI ( handwashing or hand washing or hand-washing or hand hygiene ) or AB (handwashing or hand washing or hand-washing or hand hygiene )
S18 (MH "Quarantine")
S17 (MM "Cross Infection")
S16 (MH "Isolation, Reverse")
S15 (MH "Patient Isolation+")
S14 (MH "Respiratory Protective Devices")
S13 (MH "Masks")
S12 (MH "Gloves")
S11 (MH "Handwashing+")
S10 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9
S9 TI ( influenza or flu or rhinovirus* or adenovirus* or coronavirus* or respiratory syncytial virus* or respiratory syncythial virus* or parainfluenza or para-influenza or para influenza or severe acute respiratory syndrome or SARS or respiratory viral infection* or viral respiratory infection* ) or AB ( influenza or flu or rhinovirus* or adenovirus* or coronavirus* or respiratory syncytial virus* or respiratory syncythial virus* or parainfluenza or para-influenza or para influenza or severe acute respiratory syndrome or SARS or respiratory viral infection* or viral respiratory
infection* )TI ( influenza or flu or rhinovirus* or adenovirus* or coronavirus* or respiratory syncytial virus* or respiratory syncythial virus* or parainfluenza or para-influenza or para influenza or severe acute respiratory (syndrome or SARS or respiratory viral infection* or viral respiratory infection*) or AB (influenza or flu or rhinovirus* or adenovirus* or coronavirus* or respiratory syncytial virus* or respiratory syncythial virus* or parainfluenza or para-influenza or para influenza or severe acute respiratory syndrome or SARS or respiratory viral infection* or viral
respiratory infection* )
S8 (MH "SARS Virus")
S7 (MH "Severe Acute Respiratory Syndrome")
S6 (MH "Respiratory Syncytial Virus Infections")
S5 (MH "Respiratory Syncytial Viruses")
S4 (MH "Coronavirus+")
S3 (MH "Coronavirus Infections+")
S2 (MH "Common Cold")
S1 (MH "Influenza+")

 

Appendix 2. Embase.com search strategy, October 2010

The search strategy was broadened in 2010 to be more inclusive of new and emerging viruses.

'influenza'/exp AND [embase]/lim OR ('influenza virus a'/exp OR 'influenza virus b'/de OR 'influenza virus c'/de AND [embase]/lim) OR (influenza*:ab,ti OR flu:ab,ti AND [embase]/lim) OR ('common cold'/de AND [embase]/lim) OR ('common cold':ab,ti OR 'common colds':ab,ti AND [embase]/lim) OR ('human rhinovirus'/de AND [embase]/lim) OR (rhinovir*:ab,ti AND [embase]/lim) OR ('rhinovirus infection'/de AND [embase]/lim) OR ('adenovirus'/de OR 'human adenovirus'/exp AND [embase]/lim) OR ('human adenovirus infection'/exp AND [embase]/lim) OR (adenovir*:ab,ti AND [embase]/lim) OR ('coronavirus'/de OR 'sars coronavirus'/de AND [embase]/lim) OR (coronavir*:ab,ti AND [embase]/lim) OR ('coronavirus infection'/de AND [embase]/lim) OR ('severe acute respiratory syndrome'/de AND [embase]/lim) OR ('severe acute respiratory syndrome':ab,ti OR sars:ab,ti AND [embase]/lim) OR ('respiratory syncytial pneumovirus'/de AND [embase]/lim) OR ('respiratory syncytial virus infection'/de AND [embase]/lim) OR ('respiratory syncytial virus':ab,ti OR 'respiratory syncytial viruses':ab,ti OR rsv:ab,ti OR 'respiratory syncytial pneumovirus':ab,ti OR 'respiratory syncytial pneumoviruses':ab,ti AND [embase]/lim) OR ('parainfluenza virus'/exp AND [embase]/lim) OR (parainfluenza*:ab,ti OR 'para influenza':ab,ti OR 'para-influenza':ab,ti AND [embase]/lim) OR ('enterovirus'/de OR 'enterovirus infection'/de AND [embase]/lim) OR (enterovir*:ab,ti AND [embase]/lim) OR ('human parvovirus b19'/de OR 'bocavirus'/de AND [embase]/lim) OR (parvovirus*:ab,ti OR bocavirus*:ab,ti AND [embase]/lim) OR ('human metapneumovirus'/de AND [embase]/lim) OR (metapneumovir*:ab,ti AND [embase]/lim) OR ('parechovirus'/de AND [embase]/lim) OR (parechovirus*:ab,ti AND [embase]/lim) OR ('acute respiratory infection':ab,ti OR 'acute respiratory infections':ab,ti OR 'acute respiratory tract infection':ab,ti OR 'acute respiratory tract infections':ab,ti AND [embase]/lim) AND ('hand washing'/de AND [embase]/lim OR (handwashing:ab,ti OR 'hand washing':ab,ti OR 'hand-washing':ab,ti AND [embase]/lim) OR ('hand hygiene':ab,ti AND [embase]/lim) OR (sanitiser*:ab,ti OR sanitizer*:ab,ti OR cleanser*:ab,ti OR disinfectant*:ab,ti AND [embase]/lim) OR ('glove'/de OR 'surgical glove'/de AND [embase]/lim) OR (glov*:ab,ti AND [embase]/lim) OR ('mask'/de OR 'face mask'/de OR 'surgical mask'/de AND [embase]/lim) OR (mask:ab,ti OR masks:ab,ti OR respirator:ab,ti OR respirators:ab,ti AND [embase]/lim) OR ('protective clothing'/de OR 'protective equipment'/de AND [embase]/lim) OR ('patient isolator':ab,ti OR 'patient isolators':ab,ti OR 'patient isolation':ab,ti AND [embase]/lim) OR (cohorting:ab,ti OR 'cohort isolation':ab,ti AND [embase]/lim) OR (barrier*:ab,ti OR curtain*:ab,ti OR partition*:ab,ti AND [embase]/lim) OR ('negative pressure room':ab,ti OR 'negative pressure rooms':ab,ti AND [embase]/lim) OR ('reverse barrier nursing':ab,ti OR 'reverse-barrier nursing':ab,ti OR 'reverse barrier unit':ab,ti OR 'reverse-barrier unit':ab,ti AND [embase]/lim) OR (('cross infection' NEAR/2 prevent*):ab,ti AND [embase]/lim) OR ('infection control'/de AND [embase]/lim) OR ((school* NEAR/3 (clos* OR dismissal*)):ab,ti AND [embase]/lim) OR ('temporary closure':ab,ti OR 'temporary closures':ab,ti AND [embase]/lim) OR ('mass gathering':ab,ti OR 'mass gatherings':ab,ti AND [embase]/lim) OR ((public NEAR/2 (gathering* OR event*)):ab,ti AND [embase]/lim) OR (bans:ab,ti OR banning:ab,ti OR banned:ab,ti OR ban:ab,ti AND [embase]/lim) OR ((outbreak* NEAR/3 control*):ab,ti AND [embase]/lim) OR (distancing*:ab,ti AND [embase]/lim) OR (quarantine*:ab,ti AND [embase]/lim) OR ((protective NEAR/2 (cloth* OR garment* OR gown* OR device* OR equipment)):ab,ti AND [embase]/lim) OR (((protective OR preventive) NEAR/2 (procedure* OR behavior* OR behaviour*)):ab,ti AND [embase]/lim) OR ('personal protective':ab,ti OR 'personal protection':ab,ti AND [embase]/lim) OR ('isolation room':ab,ti OR 'isolation rooms':ab,ti OR 'isolation strategy':ab,ti OR 'isolation strategies':ab,ti AND [embase]/lim) OR ((distance NEAR/2 patient*):ab,ti AND [embase]/lim) OR (((spatial OR patient) NEAR/1 separation):ab,ti AND [embase]/lim)) AND ('randomized controlled trial'/exp OR 'single blind procedure'/exp OR 'double blind procedure'/exp OR 'crossover procedure'/exp AND [embase]/lim OR (random*:ab,ti OR placebo*:ab,ti OR factorial*:ab,ti OR crossover*:ab,ti OR 'cross over':ab,ti OR 'cross-over':ab,ti OR volunteer*:ab,ti OR assign*:ab,ti OR allocat*:ab,ti OR ((singl* OR doubl*) NEAR/2 (blind* OR mask*)):ab,ti AND [embase]/lim) OR ('controlled study'/de OR 'treatment outcome'/de OR 'major clinical study'/de OR 'clinical trial'/de AND [embase]/lim) OR (chang*:ab,ti OR evaluat*:ab,ti OR reviewed:ab,ti OR baseline:ab,ti OR compare*:ab,ti OR compara*:ab,ti OR consecutive:ab,ti OR retrospective:ab,ti AND [embase]/lim))

 

Appendix 3. CINAHL (EBSCO) search strategy, October 2010

The search strategy was broadened in 2010 to be more inclusive of new and emerging viruses.

S54 S32 and S53
S53 S44 or S52
S52 S45 or S46 or S47 or S48 or S49 or S50 or S51
S51 TI observational stud* or AB observational stud*
S50 TI cohort stud* or AB cohort stud*
S49 (MH "Cross Sectional Studies")
S48 (MH "Nonconcurrent Prospective Studies")
S47 (MH "Correlational Studies")
S46 (MH "Case Control Studies+")
S45 (MH "Prospective Studies")
S44 S33 or S34 or S35 or S36 or S37 or S38 or S39 or S40 or S41 or S42 or S43
S43 TI allocat* N1 random* or AB allocat* N1 random*
S42 (MH "Quantitative Studies")
S41 TI placebo* or AB placebo*
S40 (MH "Placebos")
S39 TI random* allocation* or AB random* allocation*
S38 (MH "Random Assignment")
S37 TI ( randomised control* trial* or randomized control* trial* ) or AB ( randomised control* trial* or randomized control* trial )
S36 TI ( (singl* W1 blind*) or (singl* W1 mask*) or (doubl* W1 blind*) or (doubl* W1 mask*) or (trebl* W1 blind*) or (trebl* W1 mask*) or (tripl* W1 blind*) or (tripl* W1 mask*) ) or AB ( (singl* W1 blind*) or (singl* W1 mask*) or (doubl* W1 blind*) or (doubl* W1 mask*) or (trebl* W1 blind*) or (trebl* W1 mask*) or (tripl* W1 blind*) or (tripl* W1 mask*) )
S35 TI clinic* W1 trial* or AB clinic* W1 trial*
S34 PT clinical trial
S33 (MH "Clinical Trials+")
S32 S15 and S31
S31 S16 or S17 or S18 or S19 or S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29 or S30
S30 TI ( bans or banning or banned or ban or "outbreak control" or "outbreak controls" or distancing* or quarantine* or "protective clothing" or "protective garment" or "protective garments" or "protective gown" or "protective gowns" or "protective device" or "protective devices" or "protective equipment" or "protective behaviour" or "protective behavior" or "protective behaviours" or "protective behaviors" or "protective procedure" or "protective procedures" or "preventive behaviours" or "preventive behaviour" or "preventive behavior" or "preventive behaviors" or "preventive procedure" or "preventive procedures" or "personal protective" or "isolation room" or "isolation rooms" or "isolation strategy" or "isolation strategies" or "patient distance" or "patient distancing" or "patient separation" or "spatial separation" ) or AB (handwashing or "hand washing" or hand-washing or "hand hygiene" or sanitiser or sanitizer or cleanser* or disinfectant* or glov* or mask or masks or respirator or respirators or "patient isolation" or "patient isolators" or barrier* or curtain* or partition* or "negative pressure room" or "negative pressure rooms" or "reverse barrier nursing" or "reverse barrier unit" or "reverse barrier isolation" or "cross infection" or "infection control" or "disease control" or "school closure" or "school closures" or "school dismissal" or "school dismissals" or "temporary closure" or "temporary closures" or "mass gathering" or "mass gatherings" or "public gathering" or "public gatherings" or "public event" or "public events" )
S29 TI ( handwashing or "hand washing" or hand-washing or "hand hygiene" or sanitiser or sanitizer or cleanser* or disinfectant* or glov* or mask or masks or respirator or respirators or "patient isolation" or "patient isolators" or barrier* or curtain* or partition* or "negative pressure room" or "negative pressure rooms" or "reverse barrier nursing" or "reverse barrier unit" or "reverse barrier isolation" or "cross infection" or "infection control" or "disease control" or "school closure" or "school closures" or "school dismissal" or "school dismissals" or "temporary closure" or "temporary closures" or "mass gathering" or "mass gatherings" or "public gathering" or "public gatherings" or "public event" or "public events" ) or AB ( handwashing or "hand washing" or hand-washing or "hand hygiene" or sanitiser or sanitizer or cleanser* or disinfectant* or glov* or mask or masks or respirator or respirators or "patient isolation" or "patient isolators" or barrier* or curtain* or partition* or "negative pressure room" or "negative pressure rooms" or "reverse barrier nursing" or "reverse barrier unit" or "reverse barrier isolation" or "cross infection" or "infection control" or "disease control" or "school closure" or "school closures" or "school dismissal" or "school dismissals" or "temporary closure" or "temporary closures" or "mass gathering" or "mass gatherings" or "public gathering" or "public gatherings" or "public event" or "public events" )
S28 (MH "Sterilization and Disinfection")
S27 (MH "Quarantine")
S26 (MH "Area Restriction (Iowa NIC)") OR (MH "Infection Protection (IowaNIC)")
S25 (MH "Infection Control")
S24 (MH "Cross Infection/PC")
S23 (MH "Isolation, Reverse")
S22 (MH "Patient Isolation")
S21 (MH "Protective Devices")
S20 (MH "Protective Clothing")
S19 (MH "Respiratory Protective Devices")
S18 (MH "Masks")
S17 (MH "Gloves")
S16 (MH "Handwashing+")
S15 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12 or S13 or S14
S14 TI ( "acute respiratory tract infection" or "acute respiratory tract infections" or "acute respiratory infection" or "acute respiratory
infections" ) or AB ( influenza* or flu or "common cold" or "common colds" or rhinovir* or adenovir* or coronavir* or sars or "severe acute respiratory syndrome" or "respiratory syncytial virus" or "respiratory syncytial viruses" or rsv or pneumovir* or parainfluenza* or "para influenza" or para-influenza or enterovir* or bocavir* or metapneumovir* or parvovir* or parechovir* )
S13 TI ( influenza* or flu or "common cold" or "common colds" or rhinovir* or adenovir* or coronavir* or sars or "severe acute respiratory syndrome" or "respiratory syncytial virus" or "respiratory syncytial viruses" or rsv or pneumovir* or parainfluenza* or "para influenza" or para-influenza or enterovir* or bocavir* or metapneumovir* or parvovir* or parechovir* ) or AB ( influenza* or flu or "common cold" or "common colds" or rhinovir* or adenovir* or coronavir* or sars or "severe acute respiratory syndrome" or "respiratory syncytial virus" or "respiratory syncytial viruses" or rsv or pneumovir* or parainfluenza* or "para influenza" or para-influenza or enterovir* or bocavir* or metapneumovir* or parvovir* or parechovir* )
S12 (MH "Respiratory Tract Infections+")
S11 (MH "Parvovirus Infections+")
S10 (MH "Enterovirus Infections+")
S9 (MH "Enteroviruses+")
S8 (MH "Respiratory Syncytial Virus Infections")
S7 (MH "Respiratory Syncytial Viruses")
S6 (MH "SARS Virus")
S5 (MH "Severe Acute Respiratory Syndrome")
S4 (MH "Coronavirus Infections+")
S3 (MH "Coronavirus+") OR (MH "Coronavirus Infections")
S2 (MH "Common Cold")
S1 (MH "Influenza+") OR (MH "Influenza A H5N1") OR (MH "Influenza A

 

Appendix 4. LILACS (Latin America and Caribbean) search strategy

Tw acute respiratory tract infection$ or Tw acute respiratory infection$ or Mh human influenza or Mh influenza a virus or Mh influenza a virus, h1n1 subtype or Mh influenza a virus, h3n2 subtype or Mh influenza a virus, h3n8 subtype or Mh influenza a virus, h5n1 subtype or Mh influenza b virus or Mh influenza c virus or Mh influenza in humans or Mh influenza viruses type a or Mh influenza viruses type b or Mh influenza viruses type c or Mh influenza, human or Tw influenza$ or Tw flu or Mh influenzavirus a or Mh influenzavirus b or Mh influenzavirus c or Mh adenoviridae or Mh adenoviridae infections or Mh adenovirus infections or Mh adenovirus infections, human or Mh adenoviruses, human or Tw rhinovir$ or Tw adenovir$ or Tw common cold$ or Tw resfriado comum or Tw resfriado comun or Mh coronavirus or Mh sars-associated coronavirus or Mh human coronavirus 229e or Mh coronavirus 229e, human or Mh coronavirus infections or Tw coronavir$ or Mh severe acute respiratory syndrome or Mh severe acute respiratory syndrome virus or Tw severe acute respiratory syndrome or Tw sars or Tw sindrome respirat$ agudo grave or Mh human respiratory syncytial virus or Mh respiratory syncytial virus infections or Mh respiratory syncytial virus, human or Mh respiratory syncytial viruses or Tw respiratory syncytial virus$ or Tw rsv or Tw virus sincitiales respiratorios or Tw virus sinciciais respiratorios or Mh pneumovirus or Tw pneumovir$ or Mh human parainfluenza virus 1 or Mh parainfluenza virus 1, human or Mh human parainfluenza virus 2 or Mh parainfluenza virus 2, human or Mh human parainfluenza virus 3 or Mh parainfluenza virus 3, human or Mh parainfluenza virus infections Tw parainfluenza$ or Tw para influenza or Tw para-influenza or Mh enterovirus or Mh human enterovirus b or Mh enterovirus b, human or Mh enterovirus infections or Tw enterovir$ or Mh bocavirus or Tw bocavir$ or Mh metapneumovirus or Mh human metapneumovirus or Mh metapneumovirus, human or Tw metapneumovir$ or Mh parvovirus or Mh human parvovirus b19 or Mh parvovirus b19, human or Mh parvovirus infections or Tw parvovir$ or Mh parvoviridae or Mh parvoviridae infections or Tw parechovir$ [Words] 

and 

Mh Handwashing or Tw handwashing or Tw hand washing or Tw hand-washing or Tw lavado de manos or Tw lavagem de maos or Tw hand hygiene or Tw higiene or Tw sanitiser$ or Tw sanitizer or Tw cleanser$ or Tw disinfectant$ or Tw esteriliza$ or Tw desinfectar$ or Mh protective gloves or Mh surgical gloves or Mh gloves, protective or Mh gloves, surgical or Tw glov$ or Tw guantes or Tw luvas or Mh masks or Mh facial masks or Tw mask or Tw masks or Tw mascaras or Mh respiratory protective devices or Tw respirator or Tw respirators or Mh protective clothing or Mh protective devices or Mh patient isolation or Tw patient isolat$ or Tw aisladores de pacientes or Tw aislamiento de pacientes or Tw isoladores de pacientes or Tw isolamento de pacientes or Tw barrier$ or Tw curtain$ or Tw partition$ or Tw barrera or Tw barreira or Tw cortina or Tw tabique or Tw protective clothing or Tw protective devices or Tw ropa de protec$ or Tw equipos de seguridad or Tw roupa de prote$ or Tw equipamentos de prote$ or Mh cross infection or Tw cross infection or Tw infec$ hospital$ or Tw infection control$ or Tw control$ de infec$ or Mh communicable disease control or Tw communicable disease control or Tw control de enfermedades transmisibles or Tw controle de doen$ transmiss$ or Mh infection control or Mh quarantine Tw quarantine$ or Tw cuarentena or Tw quarentena or Tw protective devices or Tw dispositivos de prtoecc$ or Tw personal protect$ or Tw equipamentos de protec$ or Tw equipo de protecc$ or Tw isolation room or Tw sala de aislamiento or Tw quarto de isolamento or Tw patient distance or Tw distancia del paciente or Tw spatial separation or Tw separa$ especial or Tw cohort isolation or Tw cohort$ or Tw ban or Tw bans or Tw banning or Tw banned or Tw prohibici$ or Tw proibi$ or Tw outbreak control or Tw distanc$ or Tw school closure or Tw temporary closure or Tw cierre de la escuela or Tw fechamento da escola or Tw public gathering or Tw reunion publica or Tw reuni$ publica or Tw reverse barrier nursing or Tw reverse barrier unit or Tw reverse barrier isolation or Tw negative pressure room$ or Tw patient separation [Words]

 

Appendix 5. Indian MEDLARS search strategy

(influenza$ or flu or common cold$ or rhinovir$ or coronavir$ or adenovir$ or severe acute respiratory syndrome$ or sars or respiratory syncytial virus$ or rsv or parainfluenza$ or enterovir$ or metapneumovir$ or parvovir$ or bocavir$ or parechovir$) and (handwashing or hand washing or mask$ or glov$ or protect$ or isolat$ or barrier$ or curtain$ or partition$ or cross infection$ or infection control$ or disease control$ or school$ or quarantine$ or ban$ or cohort$ or distanc$ or spatial separation$)

 

Appendix 6. IMSEAR (Index Medicus for the South East Asia Region) search strategy

(influenza or flu or common cold or rhinovirus or coronavirus or adenovirus or severe acute respiratory syndrome or sars or respiratory syncytial virus or rsv or parainfluenza or enterovirus or bocavirus or metapneumovirus or parvovirus or parechovirus) and (handwashing or hand washing or hand hygiene or sanitiser or sanitizer or cleanser or disinfectant or gloves or masks or mask or protective clothing or protective devices or patient isolation or barrier or curtain or partition or cross infection or disease control or infection control or school or schools or bans or banning or banned or ban or distancing or quarantine or isolation or spatial separation or cohorting or cohort isolation)

 

Appendix 7. GRADE evidence profiles physical barriers/handwashing and related interventions in hospital and community settings

Author(s): J Conly MD, Vijay K. Shukla Ph.D, R.Ph (Reviewer)
Date: 8 March 2011
Question: should standard procedure mask versus standard procedure mask plus alcohol gel for handwashing versus nothing be used for reducing influenza-like illness (ILI) and laboratory-confirmed influenza virus infection?
Settings: in a university residence setting
Bibliography: Aiello AE, Murray GF, Perez V, Coulborn RM, Davis BM, Uddin M, et al. Mask use, hand hygiene, and seasonal influenza-like illness among young adults: a randomized intervention trial. J Infect Dis. 2010 Feb 15;201(4):491-8


Quality assessmentSummary of findingsImportance

No of patientsEffectQuality



No of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther considerationsStandard procedure mask versus standard procedure mask plus alcohol gel for handwashingNothingRelative
(95% CI)
Absolute

ILI (follow up 6 weeks; surveys 1,2)

1Randomised trialsNo serious limitations3No serious inconsistencyNo serious indirectnessSerious4None99/378 (26.2%)177/552 (32.1%)RR 0.82 (0.66 to 1)558 fewer per 1000 (from 109 fewer to 0 more)㊉㊉㊉◯
MODERATE
CRITICAL

ILI (follow up 6 weeks; surveys2,6)

1Randomised trialsNo serious limitations3No serious inconsistencyNo serious indirectnessSerious4None92/367 (25.1%)177/522 (33.9%)RR 0.78 (0.63 to 0.97)575 fewer per 1000 (from 10 fewer to 125 fewer)㊉㊉㊉◯
MODERATE
CRITICAL



1 Masks only ILI + 99/378; 5 with laboratory-confirmed influenza versus 2 in control group.
2 Neither face mask use and hand hygiene nor face mask use alone was associated with a significant reduction in the rate of ILI cumulatively.
3 Students were away during spring break and did not carry on the intervention.
4 Relatively wide confidence intervals (CIs).
5 Significant reductions in ILI occurred during weeks 4 to 6 in the mask and hand hygiene group, compared with the control group, ranging from 35% (confidence interval 9% to 53%) to 51% (CI 13% to 73%), after adjusting for vaccination and other covariates.
6 Masks plus sanitiser 92/367; 2 with laboratory-confirmed influenza versus 2 in control group.

Author(s): J Conly MD, Vijay K. Shukla Ph.D, R.Ph (Reviewer)
Date: 8 March 2011
Question: should standard surgical face masks be worn while on hospital property versus no face masks while on hospital property be used for reducing upper respiratory infection (URI) symptoms ?
Settings: hospital
Bibliography: Jacobs JL, Ohde S, Takahashi O, Tokuda Y, Omata F, Fukui T. Use of surgical face masks to reduce the incidence of the common cold among healthcare workers in Japan: a randomized controlled trial. Am J Infect Control. 2009 Jun;37(5):417-9. Epub 2009 Feb 12


Quality assessmentSummary of findingsImportance

No of patientsEffectQuality



No of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther considerationsStandard surgical face masks be worn while on hospital propertyNo face masks while on hospital propertyRelative
(95% CI)
Absolute

URI symptoms using a modified Jackson score (MJS) criteria (follow up 77 days; 8 self-recorded URI symptoms with a 4-point severity rating scale )

1Randomised trialsVery serious1,2SeriousSerious3Very serious4None1/15 (6.7%)52/17 (11.8%)5RR 1.13 (0.12 to 10.7)15 more per 1000 (from 104 fewer to 1141 more)㊉◯◯◯
VERY LOW
IMPORTANT

0%0 more per 1000 (from 0 fewer to 0 more)

0%0 more per 1000 (from 0 fewer to 0 more)



1 Very low recruitment and no power calculation.
2 Nurses made up the majority of the recruited hospital personnel.
3 No attempts to consider exposures outside of the hospital.
4 No CONSORT diagram is provided and use of Jackson criteria may be questioned for its precision.
5 A separate analysis demonstrated that having children in the household under 16 years of age was significantly (P = 0.02) associated with a mean MJS above the median of 28.5.

Author(s): J Conly MD, Vijay K. Shukla Ph.D, R.Ph (Reviewer)
Date: 8 March 2011
Question: should education with hand sanitiser versus education with hand sanitiser and face masks versus education alone be used for prevention of URI, ILI and laboratory-confirmed influenza?
Settings: community
Bibliography: Larson EL, Ferng YH, Wong-McLoughlin J, Wang S, Haber M, Morse SS. Impact of non-pharmaceutical interventions on URIs and influenza in crowded, urban households. Public Health Rep. 2010 Mar-Apr;125(2):178-91


Quality assessmentSummary of findingsImportance

No of patientsEffectQuality



No of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther considerationsEducation with hand sanitiser versus education with hand sanitiser and face masksEducation aloneRelative
(95% CI)
Absolute

Self-reported URI, ILI and laboratory-confirmed influenza (follow up 19 months; self-reports, home visits, telephone calls, laboratory tests1)

1Randomised trialsVery serious2Serious3Serious4Serious5None79/859 (9.2%)105/889 (11.8%)RR 0.80 (0.6 to 1.05)24 fewer per 1000 (from 47 fewer to 6 more)㊉◯◯◯
VERY LOW
IMPORTANT

Self-reported URI, ILI and laboratory-confirmed influenza (follow up 19 months; self-reports, home visits, telephone calls, laboratory tests6)

1Randomised trialsVery serious2Serious3Serious4Serious5None94/946 (9.9%)105/944 (11.1%)RR 0.94 (0.72 to 1.22)7 fewer per 1000 (from 31 fewer to 24 more)㊉◯◯◯
VERY LOW
IMPORTANT



1 ILI in mask plus sanitiser plus education versus education; only ILI reported; no significant differences in URI rates or laboratory-confirmed cases.
2 Difficult to follow flow of consented and non-consented patients throughout the trial to assess all outcomes ; major intervention bias which may have contaminated the entire study as the "control" since it was reported that 56.95% of households (number of persons not stated) and 44.2% of households (number of persons not stated) used hand sanitiser within the previous 24 hours or at some point during the course of the study.
3 Appear to have analysed only those who were randomised and had complete home visits and unclear if intention-to-treat (ITT) completed.
4 Very difficult community environment setting in which to conduct the trial.
5 Cannot distinguish if the "dropped "category represents individual participants or households.
6 ILI in mask plus education versus education group; no significant differences in the URI rates or laboratory-confirmed cases.

Author(s): J Conly MD, V Shukla PhD (Reviewer)
Date: 8 March 2011
Question: should N95 respirators versus surgical masks be used for prevention of influenza?
Settings: healthcare workers
Bibliography: Loeb M, Dafoe N, Mahony J, John M, Sarabia A, Glavin V, et al. Surgical mask versus N95 respirator for preventing influenza among health care workers: a randomized trial. JAMA. 2009 Nov 4;302(17):1865-71


Quality assessmentSummary of findingsImportance

No of patientsEffectQuality



No of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther considerationsN95 respiratorsSurgical masksRelative
(95% CI)
Absolute

Laboratory-confirmed influenza (follow up 7 months; reverse transcription polymerase chain reaction (RT-PCR) or serology)

1Randomised trialsNo serious limitations1No serious inconsistencyNo serious indirectnessNo serious imprecision2,3,4Reporting bias548/210 (22.9%)50/212 (23.6%)RR 0.97 (0.73 to 1.46)7 fewer per 1000 (from 64 fewer to 108 more)㊉㊉㊉◯
MODERATE
CRITICAL



1 Non-inferiority trial design but the established criteria for non-inferiority were met.
2 Absolute risk difference -0.73% (95% CI -0.88 to 7.3).
3 Audits were done to assess compliance.
4 Results similar for per protocol (PP) and ITT analysis.
5 Authors may have been aware of other similar studies which were ongoing at the time of conduct of this trial.

Author(s): Vijay K. Shukla Ph.D, R.Ph. Reviewed by: John Conly, MD Karen Lee, MA
Date: 1 March 2011
Question: should physical barriers versus not using physical barriers be used in healthcare workers or the general public exposed to respiratory viruses (SARS CoV (SARS coronavirus) in these settings)?
Settings: hospital or community
Bibliography: Jefferson T et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews March 2011. Search conducted 22 October 2010


Quality assessmentSummary of findingsImportanceNo of patientsEffectQualityNo of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther considerationsPhysical barriers











Not using physical barriersRelative
(95% CI)
AbsoluteWearing gowns (follow up 10 to 58 days1; number of people wearing gowns)5Observational studies2Very serious3










No serious inconsistencyNo serious indirectnessN serious imprecisionVery strong association4242/0 (0%)0%5OR 0.33 (0.24 to 0.45)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉㊉◯◯
LOW
0%50 fewer per 1000 (from 0 fewer to 0 fewer)Wearing gloves (follow up 10 to 90 days1,6; number of people wearing gloves)






6Observational studies2Very serious3No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association4272/0 (0%)0%OR 0.32 (0.23 to 0.45)0 fewer per 1000 (from 0 fewer to 0 fewer)5㊉㊉◯◯O
LOW
Wearing masks (follow up 10 to 90 days1,7; number of people wearing masks)





















7Observational studies2Very serious3No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association4681/0 (0%)0%5OR 0.32 (0.26 to 0.39)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉㊉◯◯
LOW
Wearing N95 respirator (follow up 10 to 22 days1,8; number of people wearing N95 respirators)














3Observational studies2Very serious3No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association4100/0 (0%)0%5OR 0.17 (0.07 to 0.43)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉㊉◯◯
LOW
Use of eye protection (mask/goggles) (follow up 90 days9; number of people wearing mask/goggles)














3Observational studies2Very serious3No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association4219/0 (0%)0%5OR 0.10 (0.05 to 0.17)0 fewer per 1,000,000 (from 0 fewer to 0 fewer)㊉㊉◯◯
LOW



1 This is the period for which the study was conducted. Exposure time is not reported.
2 Case-control.
3 Case-control study which is a weak observational study design.
4 Very large effect size.
5 These risks are not available from case-control studies.
6 For 2 studies (Yin 2004 and Liu 2009) duration of study and duration of follow up is not reported.
7 For one study (Yin 2004) duration of study or follow up not reported.
8 For one study (Liu 2009) duration of study or duration of follow up is not reported.
9 One study (Chen 2009) reported duration.

Author(s): Vijay K. Shukla R.Ph, Ph.D Reviewed by: John Conly, MD Karen Lee, MA
Date: 3 March 2011
Question: should washing or related interventions versus no washing and related interventions be used in healthcare workers or the general public exposed to respiratory viruses (SARS CoV (SARS coronavirus) in these studies)?
Settings: community or hospital
Bibliography: Jefferson T et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews 2011. Literature search done up to 22 October 2010


Quality assessmentSummary of findingsImportance

No of patientsEffectQuality



No of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther considerationsWashing or related interventionsNo washing and related interventionsRelative
(95% CI)
Absolute

Frequent handwashing (follow up 10 to 90 days1; number of people frequently washing hands)

7Observational studies2Very serious3Serious4No serious indirectnessNo serious imprecisionStrong association5666/0 (0%)0%6OR 0.54 (0.44 to 0.67)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉◯◯◯
VERY LOW

Nose wash (number of people washing nose)

2Observational studies2Very serious3No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association7142/0 (0%)0%6OR 0.3 (0.16 to 0.57)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉㊉◯◯
LOW

Thorough disinfection of living quarters (follow up 66 days8; number of people living in thoroughly disinfected houses)

1Observational studies2Very serious3No serious inconsistencyNo serious indirectnessNo serious imprecisionReporting bias8
very strong association7
330/0 (0%)0%6OR 0.30 (0.23 to 0.39)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉◯◯◯
VERY LOW



1 For one study (Yin 2004) duration of study or follow up is not reported.
2 Case-control.
3 Case-control study which is a weak observational study design.
4 Variation patient population, duration of exposure not reported.
5 Effect size is relatively large (OR 0.54, 95% CI 0.44 to 0.67).
6 Baseline risks are not available from case control studies.
7 Effect size large (i.e. OR < 0.5).
8 Single study.

Author(s): Vijay K. Shukla Ph.D, R.Ph Reviewed by: John Conly, MD Karen Lee MA
Date: 8 March 2011
Question: should physical barriers versus not using physical barriers be used in healthcare workers in hospital setting?
Settings: hospital1
Bibliography: Jefferson et al. Physical interventions to interrupt the spread of respiratory viruses. Cochrane Database of Systematic Reviews March 2011. Search conducted: 22 October 2010


Quality assessmentSummary of findingsImportance

No of patientsEffectQuality



No of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther considerationsPhysical barriersNot using physical barriersRelative
(95% CI)
Absolute

Wearing gowns (Copy) (follow up 10 to 58 days2; number of people wearing gowns)

5Observational studies3Very serious4No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association5242/0 (0%)0%6OR 0.33 (0.24 to 0.45)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉㊉◯◯
LOW

0%60 fewer per 1000 (from 0 fewer to 0 fewer)0 fewer per 1000 (from 0 fewer to 0 fewer)

Wearing gloves (Copy) (follow up 10 to 90 days2,7; number of people wearing gloves)

6Observational studies3Very serious4No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association5272/0 (0%)0%OR 0.32 (0.23 to 0.45)0 fewer per 1000 (from 0 fewer to 0 fewer)6㊉㊉◯◯
LOW

Wearing masks (number of people wearing masks)

5Observational studies3Very serious4No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association5257/0 (0%)0%OR 0.34 (0.24 to 0.47)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉㊉◯◯
LOW

Wearing N95 respirator (Copy) (follow-up 10 to 22 days2,8; Number of people wearing N95 respirators)

3Observational studies3Very serious4No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association5100/0 (0%)0%6OR 0.17 (0.07 to 0.43)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉㊉◯◯
LOW

Use of eye protection (mask/goggles) (Copy) (follow up 90 days9; number of people wearing mask/goggles)

3Observational studies3Very serious4No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association5219/0 (0%)0%6OR 0.10 (0.05 to 0.17)0 fewer per 1,000,000 (from 0 fewer to 0 fewer)㊉㊉◯◯
LOW



1 Separate data analysis was done for hospital setting from Jefferson et al review.
2 This is the period for which study was conducted. Exposure time is not reported.
3 Case-control.
4 Case-control study which is a weak observational study design.
5 Very large effect size.
6 These risks are not available from case-control studies.
7 For 2 studies (Yin 2004 and Liu 2009) duration of study and duration of follow up is not reported.
8 For one study (Liu 2009) duration of study or duration of follow up is not reported.
9 One study (Chen 2009) reported duration.

Author(s): Vijay K. Shukla Ph. D, R.Ph Reviewed by: John Conly MD Karen Lee MA
Date: 9 March 2011
Question: should physical barriers versus not using physical barriers be used in healthcare workers or the general public?
Settings: community
Bibliography: Jefferson T et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews March 2011. Searches conducted 22 October 2010


Quality assessmentSummary of findingsImportance

No of patientsEffectQuality



No of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther considerationsPhysical barriersNot using physical barriersRelative
(95% CI)
Absolute

Wearing masks (follow up 42 to 66 days1; number of people wearing masks)

2Observational studies2Very serious3No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association4424/0 (0%)0%OR 0.31 (0.25 to 0.4)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉㊉◯◯
LOW



1 This is the period for which study was conducted. Exposure time is not reported.
2 Case-control.
3 Case-control studies which have a weak study design.
4 Very large effect size.

Author(s): Vijay K. Shukla Ph.D, R.Ph. Reviewed by: John Conly MD, Karen Lee MA
Date: 8 March 2011
Question: should washing or related interventions versus no handwashing and related interventions be used in healthcare workers in hospital setting?
Settings: hospital
Bibliography: Jefferson T et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews 2011. Literature search done up to 22 October 2010


Quality assessmentSummary of findingsImportance

No of patientsEffectQuality



No of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther considerationsWashing or related interventionsNo handwashing and related interventionsRelative
(95% CI)
Absolute

Frequent handwashing (follow up 22 to 90 days1; number of people frequently washing hands)

5Observational studies2Very serious3Serious4No serious indirectnessNo serious imprecisionStrong association5242/0 (0%)0%OR 0.70 (0.52 to 0.94)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉◯◯◯
VERY LOW

Nose wash (Copy) (number of people washing nose)

2Observational studies2Very serious6No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association7142/0 (0%)0%8OR 0.3 (0.16 to 0.57)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉㊉◯◯
LOW



1 One study (Yin 2004) has not reported duration or follow up.
2 Case-control.
3 Case-control study which is a weak study design.
4 Wide variation is effect size (from no significant effect to significant effect).
5 Effect size is relatively large (OR 0.70, 95% CI 0.52 to 0.94).
6 Case-control study which is very weak observational study design.
7 Effect size large (i.e. OR < 0.5).
8 Baseline risks are not available from case-control studies.

Author(s): Vijay K. Shukla Ph.D, R.Ph. Reviewed by: John Conly MD Karen Lee MA
Date: 9 March 2011
Question: should handwashing or related interventions versus no handwashing and related interventions be used in healthcare workers or general public?
Settings: community setting
Bibliography: Jefferson T et al. Physical interventions to interrupt or reduce the spread of viruses. Cochrane Database of Systematic Reviews March 2011. Literature search conducted: 22 October 2010


Quality assessmentSummary of findingsImportance

No of patientsEffectQuality



No of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther considerationsHandwashing or related interventionsNo handwashing and related interventionsRelative
(95% CI)
Absolute

Frequent handwashing (follow up 42 to 66 days1; number of people frequently washing hands)

2Observational studies2Very serious3No serious inconsistencyNo serious indirectnessNo serious imprecisionVery strong association4424/0 (0%)0%OR 0.44 (0.33 to 0.58)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉㊉◯◯
LOW

Thorough disinfection of living quarters (Copy) (follow up 66 days5; number of people living in thoroughly disinfected houses)

1Observational studies2Very serious6No serious inconsistencyNo serious indirectnessNo serious imprecisionReporting bias5
very strong association7
330/0 (0%)0%8OR 0.30 (0.23 to 0.39)0 fewer per 1000 (from 0 fewer to 0 fewer)㊉㊉◯◯
VERY LOW



1 This is the period for which study was conducted. Exposure time is not reported.
2 Case-control.
3 Case-control study which is a weak observational study design.
4 Very large effect size.
5 Single study.
6 Case-control study which is a weak observational study design.
7 Effect size large (i.e. OR < 0.5).
8 Baseline risks are not available from case-control studies.

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

Last assessed as up-to-date: 21 October 2010.


DateEventDescription

22 October 2010New search has been performedSearches conducted. We included seven new trials; four randomised controlled trials and three non-randomised comparative studies. We excluded 36 new trials.

22 October 2010New citation required but conclusions have not changedWe updated the review again at the behest of the World Health Organization (WHO). External sources of support amended. External support from the WHO. The WHO interim guidelines document on 'Infection Prevention and Control of Epidemic and Pandemic Prone Acute Respiratory Diseases in Health Care' was published in 2007 to provide infection control guidance to help prevent the transmission of acute respiratory diseases (ARD) in health care. The update of these guidelines will be evidence-based and an update of this review was requested to assist in informing the evidence base for the revision of the WHO guidelines. Dr John Conly, Dr Mark Jones and Sarah Thorning joined the review team.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

Protocol first published: Issue 4, 2006
Review first published: Issue 4, 2007


DateEventDescription

7 May 2009New search has been performedFor the 2009 update we included three cluster-randomised controlled trials (Sandora 2008; Cowling 2009; MacIntyre 2009) and one individual randomised controlled trial (Satomura 2005, with its linked publication Kitamura 2007). We also included one retrospective cohort study (Foo 2006), one case-control study (Yu 2007) and two prospective cohort studies (Wang 2007; Broderick 2008).

The content and conclusions of the 2007 review changed little, but the additional eight studies add more information and certainty. Our meta-analysis remains unchanged as there were no new studies for pooling.

30 April 2009New citation required but conclusions have not changedNew author joined the review team.

8 July 2008AmendedConverted to new review format.

20 August 2007AmendedReview first published Issue 4, 2007.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

Tom Jefferson (TOJ), Chris Del Mar (CDM) and Liz Dooley (LD) were responsible for drafting the protocol.
TOJ, Eliana Ferroni (EF), Bill Hewak (BH) and Adi Prabhala (AP) extracted study data and Sree Nair (SN) performed the analyses in the original review.

TOJ, EF, Lubna A Al-Ansary (LA), Ghada A Bawazeer (GB) and CDM adjudicated in data extraction in the 2009 update, and Mieke van Driel (MvD) assisted in the writing, construction of the summary of results table and updating with the most recent studies. All 2009 review authors contributed to the final report.

For the 2010 update TOJ and John Conly (JMC) extracted data and CDM checked extractions and arbitrated. All three checked the search strategy terms. Sarah Thorning designed and carried out the searches. All 2010 review authors contributed to the final report.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

Chris Del Mar provided expert advice to GlaxoSmithKline about vaccination against acute otitis media in 2008-2009. He receives royalties from books published through Blackwell, BMJ Books and Elsevier.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
 

Internal sources

  • The Cochrane Collaboration Steering Group, UK.

 

External sources

  • National Institute of Health Research (NIHR), UK.
    Competitive grant awarded through the Cochrane Collaboration
  • National Health and Medical Research Council (NHMRC), Australia.
    Competitive grant to Chris Del Mar and Tom Jefferson, 2009
  • Sabbatical year for John Conly while at the WHO in Geneva, Switzerland was supported by the University of Calgary, Calgary, Canada.
  • World Health Organization, Geneva, Switzerland.
    Requested and provided support to the Cochrane Collaboration for current update

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

None, apart from the change in the title (see Published notes, below).

 

Notes

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

In Issue 1, 2010, the title was changed from Interventions for the interruption or reduction of the spread of respiratory viruses to Physical interventions to interrupt or reduce the spread of respiratory viruses.

The original review was subsequently published as Jefferson T, Foxlee R, Del Mar C, Dooley L, Ferroni E, Hewak B, Prabhala A, Nair S, Rivetti A. Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. BMJ 2008;336:77-80 and Jefferson T, Del Mar C, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, van Driel ML, Foxlee R, Rivetti A. Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. BMJ 2009 Sep 21;339:b3675. doi: 10.1136/bmj.b3675.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
  24. References to other published versions of this review
Agah 1987 {published data only}
  • Agah R, Cherry JD, Garakian AJ, Chapin M. Respiratory syncytial virus (RSV) infection rate in personnel caring for children with RSV infections. Routine isolation procedure vs routine procedure supplemented by use of masks and goggles. American Journal of Diseases of Children 1987;141(6):695-7.
Aiello 2010a {published data only}
  • Aiello AE, Murray GF, Perez V, Coulborn RM, Davis BM, Uddin M, et al. Mask use, hand hygiene, and seasonal influenza-like illness among young adults: a randomized intervention trial. Journal of Infectious Diseases 2010;201(4):491-8.
Broderick 2008 {published data only}
  • Broderick MP, Hansen CJ, Russell KL. Exploration of the effectiveness of social distancing on respiratory pathogen transmission implicates environmental contributions. Journal of Infectious Diseases 2008;198(10):1420-6.
Carabin 1999 {published data only}
  • Carabin H, Gyorkos TW, Soto JC, Joseph L, Payment P, Collet JP. Effectiveness of a training program in reducing infections in toddlers attending day care centers. Epidemiology 1999;10(3):219-27.
Chen 2009 {published data only}
Cowling 2008 {published data only}
  • Cowling BJ, Fung RO, Cheng CK, Fang VJ, Chan KH, Seto WH, et al. Preliminary findings of a randomized trial of non-pharmaceutical interventions to prevent influenza transmission in households. PLoS ONE 2008;3(5):e2101.
Cowling 2009 {published data only}
  • Cowling BJ, Chan KH, Fang VJ, Cheng CKY, Fung ROP, Wai W, et al. Facemasks and hand hygiene to prevent influenza transmission in households. A randomized trial. Annals of Internal Medicine 2009;151(7):437-46.
Cowling 2010 {published data only}
  • Cowling BJ, Lau LLH, Wu P, Wong HWC, Fang VJ, Riley S, et al. Entry screening to delay local transmission of 2009 pandemic influenza A (H1N1). BMC Infectious Diseases 2010;10:82.
Derrick 2005 {published data only}
Dick 1986 {published data only}
  • Dick EC, Hossain SU, Mink KA, Meschievitz CK, Schultz SB, Raynor WJ, et al. Interruption of transmission of rhinovirus colds among human volunteers using virucidal paper handkerchiefs. Journal of Infectious Diseases 1986;153(2):352-6.
Doherty 1998 {published data only}
Dyer 2000 {published data only}
Falsey 1999 {published data only}
  • Falsey AR, Criddle MM, Kolassa JE, McCann RM, Brower CA, Hall WJ. Evaluation of a handwashing intervention to reduce respiratory illness rates in senior day-care centers. Infection Control and Hospital Epidemiology 1999;20(3):200-2.
Farr 1988a {published data only}
  • Farr BM, Hendley JO, Kaiser DL, Gwaltney JM. Two randomised controlled trials of virucidal nasal tissues in the prevention of natural upper respiratory infections. American Journal of Epidemiology 1988;128:1162-72.
Farr 1988b {published data only}
  • Farr BM, Hendley JO, Kaiser DL, Gwaltney JM. Two randomised controlled trials of virucidal nasal tissues in the prevention of natural upper respiratory infection. American Journal of Epidemiology 1988;128:1162-72.
Foo 2006 {published data only}
Gala 1986 {published data only}
Gwaltney 1980 {published data only}
Hall 1981a {published data only}
Hall 1981b {published data only}
Heymann 2004 {published data only}
  • Heymann A, Chodick G, Reichman B, Kokia E, Laufer J. Influence of school closure on the incidence of viral respiratory diseases among children and on health care utilization. Pediatric Infectious Disease Journal 2004;23(7):675-7.
  • Heymann AD, Hoch I, Valinsky L, Kokia E, Steinberg DM. School closure may be effective in reducing transmission of respiratory viruses in the community. Epidemiology and Infection 2009;137(10):1369-76.
Isaacs 1991 {published data only}
  • Isaacs D, Dickson H, O'Callaghan C, Sheaves R, Winter A, Moxon ER. Handwashing and cohorting in prevention of hospital acquired infections with respiratory syncytial virus. Archives of Disease in Childhood 1991;66(2):227-31.
Jacobs 2009 {published data only}
  • Jacobs JL, Ohde S, Takahashi O, Tokuda Y, Omata F, Fukui T. Use of surgical face masks to reduce the incidence of the common cold among health care workers in Japan: a randomized controlled trial. American Journal of Infection Control 2009;37(5):417-9.
Kimel 1996 {published data only}
  • Kimel LS. Handwashing education can decrease illness absenteeism. Journal of School Nursing 1996;12(2):14-6, 8.
Kotch 1994 {published data only}
  • Kotch JB, Weigle KA, Weber DJ, Clifford RM, Harms TO, Loda FA, et al. Evaluation of an hygienic intervention in child day-care centers. Pediatrics 1994;94(6 Pt 2):991-4.
Krasinski 1990 {published data only}
  • Krasinski K, LaCouture R, Holzman RS, Waithe E, Bonk S, Hanna B. Screening for respiratory syncytial virus and assignment to a cohort at admission to reduce nosocomial transmission. Journal of Pediatrics 1990;116(6):894-8.
Krilov 1996 {published data only}
Ladegaard 1999 {published data only}
  • Ladegaard MB, Stage V. Hand hygiene and sickness among small children attending day care centres. An interventional study. Ukesgrift von Laeger 1999;161:4396-400.
Larson 2010 {published data only}
  • Larson EL, Ferng Y, Wong-McLoughlin J, Wang S, Haber M, Morse SS. Impact of non-pharmaceutical interventions on URIs and influenza in crowded, urban households. Public Health Reports 2010;125(2):178-91.
Lau 2004a {published data only}
Leclair 1987 {published data only}
  • Leclair JM, Freeman J, Sullivan BF, Crowley CM, Goldmann DA. Prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions. New England Journal of Medicine 1987;317(6):329-34.
Leung 2004 {published data only}
  • Leung TF, Ng PC, Cheng FW, Lyon DJ, So KW, Hon EK, et al. Infection control for SARS in a tertiary paediatric centre in Hong Kong. Journal of Hospital Infection 2004;3:215-22.
Liu 2009 {published data only}
Loeb 2009 {published data only}
  • Loeb M, Dafoe N, Mahony J, John M, Sarabia A, Glavin V, et al. Surgical mask vs N95 respirator for preventing influenza among health care workers: a randomized trial. JAMA 2009;302(17):1865-71.
Longini 1988 {published data only}
  • Longini IM Jr, Monto AS. Efficacy of virucidal nasal tissues in interrupting familial transmission of respiratory agents. A field trial in Tecumseh, Michigan. American Journal of Epidemiology 1988;128(3):639-44.
Luby 2005 {published data only}
Macartney 2000 {published data only}
  • Macartney KK, Gorelick MH, Manning ML, Hodinka RL, Bell LM. Nosocomial respiratory syncytial virus infections: the cost-effectiveness and cost-benefit of infection control. Pediatrics 2000;106(3):520-6.
MacIntyre 2009 {published data only}
  • MacIntyre CR, Cauchemez S, Dwyer DE, Seale H, Cheung P, Browne G, et al. Face mask use and control of respiratory virus transmission in households. Emerging Infectious Diseases 2009;15(2):233-41.
Madge 1992 {published data only}
  • Madge P, Paton JY, McColl JH, Mackie PL. Prospective controlled study of four infection-control procedures to prevent nosocomial infection with respiratory syncytial virus. Lancet 1992;340(8827):1079-83.
Makris 2000 {published data only}
  • Makris AT, Morgan L, Gaber DJ. Effect of a comprehensive infection control program on the incidence of infections in long-term care facilities. American Journal of Infection Control 2000;28(1):3-7.
Master 1997 {published data only}
  • Master D, Longe SH, Dickson H. Scheduled hand washing in an elementary school population. Family Medicine 1997;29:336-9.
Morton 2004 {published data only}
  • Morton JL, Schultz AA. Healthy hands: use of alcohol gel as an adjunct to handwashing in elementary school children. Journal of School Nursing 2004;20(3):161-7.
Murphy 1981 {published data only}
Niffenegger 1997 {published data only}
  • Niffenegger JP. Proper handwashing promotes wellness in child care. Journal of Pediatric Health Care 1997;11(1):26-31.
Nishiura 2005 {published data only}
  • Nishiura H, Kuratsuji T, Quy T, Phi NC, Van Ban V, Ha LE, et al. Rapid awareness and transmission of severe acute respiratory syndrome in Hanoi French Hospital, Vietnam. American Journal of Tropical Medicine & Hygiene 2005;73(1):17-25.
Ou 2003 {published data only}
  • Centers for Disease Control and Prevention (CDC). Efficiency of quarantine during an epidemic of severe acute respiratory syndrome - Beijing, China, 2003. Morbidity & Mortality Weekly Report 2003;52(43):1037-40.
  • Ou JM, Dun Zhe, Li Q, Qin AL, Zeng G. Efficiency of the quarantine system during the epidemic of severe acute respiratory syndrome in Beijing, 2003. Chung-Hua Liu Hsing Ping Hsueh Tsa Chih [Chinese Journal of Epidemiology] 2003;24(12):1093-5.
Pang 2003 {published data only}
Pelke 1994 {published data only}
  • Pelke S, Ching D, Easa D, Melish ME. Gowning does not affect colonization or infection rates in a neonatal intensive care unit. Archives of Pediatrics & Adolescent Medicine 1994;148(10):1016-20.
Roberts 2000 {published data only}
  • Roberts L, Smith W, Jorm L, Patel M, Douglas RM, McGilchrist C. Effect of infection control measures on the frequency of upper respiratory infection in child care: a randomised controlled study. Pediatrics 2000;105:738-42.
Ryan 2001 {published data only}
Sandora 2005 {published data only}
  • Sandora TJ, Taveras EM, Shih MC, Resnick EA, Lee GM, Ross-Degnan D, et al. A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home. Pediatrics 2005;116(3):587-94.
Sandora 2008 {published data only}
  • Sandora TJ, Shih MC, Goldmann DA. Reducing absenteeism from gastrointestinal and respiratory illness in elementary school students: a randomized, controlled trial of an infection-control intervention. Pediatrics 2008;121(6):e1555-62.
Satomura 2005 {published data only}
  • Kitamura T, Satomura K, Kawamura T, Yamada S, Takashima K, Suganuma N, et al. Can we prevent influenza-like illnesses by gargling?. Internal Medicine 2007;46(18):1623-4.
  • Satomura K, Kitamura T, Kawamura T, Shimbo T, Watanabe M, Kamei M, et al. Prevention of upper respiratory tract infections by gargling: a randomized trial. American Journal of Preventive Medicine 2005;29(4):302-7.
Seto 2003 {published data only}
  • Seto WH, Tsang D, Yung RW, Ching TY, Ng TK, Ho M, et al. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet 2003;361(9368):1519-20.
Simon 2006 {published data only}
  • Simon A, Khurana K, Wilkesmann A, Muller A, Engelhart S, Exner M, et al. Nosocomial respiratory syncytial virus infection: impact of prospective surveillance and targeted infection control. International Journal of Hygiene and Environmental Health 2006;209(4):317-24.
Snydman 1988 {published data only}
  • Snydman DR, Greer C, Meissner HC, McIntosh K. Prevention of nosocomial transmission of respiratory syncytial virus in a newborn nursery. Infection Control and Hospital Epidemiology 1988;9(3):105-8.
Somogyi 2004 {published data only}
  • Somogyi R, Vesely AE, Azami T, Preiss D, Fisher J, Correia J, et al. Dispersal of respiratory droplets with open vs closed oxygen delivery masks: implications for the transmission of severe acute respiratory syndrome. Chest 2004;125(3):1155-7.
Teleman 2004 {published data only}
  • Teleman MD, Boudville IC, Heng BH, Zhu D, Leo YS. Factors associated with transmission of severe acute respiratory syndrome among health-care workers in Singapore. Epidemiology and Infection 2004;135(5):797-803.
Turner 2004a {published data only}
  • Turner RB, Biedermann KA, Morgan JM, Keswick B, Ertel KD, Barker MF. Efficacy of organic acids in hand cleansers for prevention of rhinovirus infections. Antimicrobial Agents and Chemotherapy 2004;48(7):2595-8.
Turner 2004b {published data only}
  • Turner RB, Biedermann KA, Morgan JM, Keswick B, Ertel KD, Barker MF. Efficacy of organic acids in hand cleansers for prevention of rhinovirus infections. Antimicrobial Agents and Chemotherapy 2004;48(7):2595-8.
Wang 2007 {published data only}
  • Wang TH, Wei KC, Hsiung CA, Maloney SA, Eidex RB, Posey DL, et al. Optimizing severe acute respiratory syndrome response strategies: lessons learned from quarantine. American Journal of Public Health 2007;97(Suppl):1541-8.
White 2001 {published data only}
  • White CG, Shinder FS, Shinder AL, Dyer DL. Reduction of illness absenteeism in elementary schools using and alcohol-free instant hand sanitizer. Journal of School Nursing 2001;17(5):258-65.
White 2003 {published data only}
  • White C, Kolble R, Carlson R, Lipson N, Dolan M, Ali Y, et al. The effect of hand hygiene on illness rate among students in university residence halls. American Journal of Infection Control 2003;31(6):364-70.
Wu 2004 {published data only}
  • Wu J, Xu F, Zhou W, Feikin DR, Lin CY, He X. Risk factors for SARS among persons without known contact with SARS patients, Beijing, China. Emerging Infectious Diseases 2004;10(2):210-6.
Yen 2006 {published data only}
  • Yen MY, Lin YE, Su IJ, Huang FY, Huang FY, Ho MS, et al. Using an integrated infection control strategy during outbreak control to minimize nosocomial infection of severe acute respiratory syndrome among healthcare workers. Journal of Hospital Infection 2006;62(2):195-9.
Yin 2004 {published data only}
  • Yin WW, Gao LD, Lin WS, Gao LD, Lin WS, Du L, et al. Effectiveness of personal protective measures in prevention of nosocomial transmission of severe acute respiratory syndrome. Chung-Hua Liu Hsing Ping Hsueh Tsa Chih (Chinese Journal of Epidemiology) 2004;25(1):18-22.
Yu 2007 {published data only}
  • Yu IT, Xie ZH, Tsoi KK, Chiu YL, Lok SW, Tang XP, et al. Why did outbreaks of severe acute respiratory syndrome occur in some hospital wards but not in others?. Clinical Infectious Diseases 2007;44(8):1017-25.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
  24. References to other published versions of this review
Abou El Hassan 2004 {published data only}
  • Abou El Hassan MA, van der Meulen-Muileman I, Abbas S, Kruyt FA. Conditionally replicating adenoviruses kill tumor cells via a basic apoptotic machinery-independent mechanism that resembles necrosis-like programmed cell death. Journal of Virology 2004;78(22):12243-51.
Amirav 2005 {published data only}
  • Amirav I, Oron A, Tal G, Cesar K, Ballin A, Houri S, et al. Aerosol delivery in respiratory syncytial virus bronchiolitis: hood or face mask?. Journal of Pediatrics 2005;147(5):627-31.
Anderson 2004 {published data only}
  • Anderson RM, Fraser C, Ghani AC, Donnelly CA, Riley S, Ferguson NM, et al. Epidemiology, transmission dynamics and control of SARS: the 2002-2003 epidemic. Philosophical Transactions of the Royal Society of London - Series B: Biological Sciences 2004;359(1447):1091-105.
Anonymous 2002 {published data only}
  • Anonymous. Antiseptic skin cleansers may prevent rhinovirus transmission. Clinical Infectious Diseases 2002;34(3):ii.
Anonymous 2003 {published data only}
  • Anonymous. Use of quarantine to prevent transmission of severe acute respiratory syndrome - Taiwan, 2003. Morbidity & Mortality Weekly Report 2003;52(52):29.
Anonymous 2004 {published data only}
  • Anonymous. Can antiviral tissues prevent the spread of colds?. Consumer Reports 2004;69(12):56.
Anonymous 2005a {published data only}
  • Anonymous. Antiviral Kleenex. Medical Letter on Drugs & Therapeutic 2005;47(1199):3-4.
Anonymous 2005b {published data only}
  • Anonymous. Focusing on this year's flu...use healthy handwashing...and when soap and water aren't handy, hand gels work well, too. Child Health Alert 2005;23:1-2.
Anonymous 2005c {published data only}
  • Anonymous. How long is a cold contagious? Is there any way to prevent transmitting a cold?. Johns Hopkins Medical Letter, Health After 50 2005; Vol. 17, issue 10:8.
Apisarnthanarak 2009 {published data only}
  • Apisarnthanarak A, Apisarnthanarak P, Cheevakumjorn B, Mundy LM. Intervention with an infection control bundle to reduce transmission of influenza-like illnesses in a Thai preschool. Infection Control and Hospital Epidemiology 2009;30(9):817-22.
Apisarnthanarak 2010 {published data only}
  • Apisarnthanarak A, Uyeki TM, Puthavathana P, Kitphati R, Mundy LM. Reduction of seasonal influenza transmission among healthcare workers in an intensive care unit: a 4-year intervention study in Thailand. Infection Control and Hospital Epidemiology 2010;31(10):996-1003.
Aragon 2005 {published data only}
  • Aragon D, Sole ML, Brown S. Outcomes of an infection prevention project focusing on hand hygiene and isolation practices. AACN Clinical Issues 2005;16(2):121-3.
Barros 1999 {published data only}
Bauer 2009 {published data only}
  • Bauer G, Bossi L, Santoalla M, Rodríguez S, Fariña D, Speranza AM. Impacto de un programa de prevención de infecciones respiratorias en lactantes prematuros de alto riesgo: estudio prospectivo y multicéntrico. Archivos Argentinos de Pediatria 2009;107(2):111-8.
Bell 2004 {published data only}
Bellissimo-Rodrigues 2009 {published data only}
  • Bellissimo-Rodrigues F, Bellissimo-Rodrigues WT, Viana JM, Teixeira GCA, Nicolini E, Auxiliadora-Martins M, et al. Effectiveness of oral rinse with chlorhexidine in preventing nosocomial respiratory tract infections among intensive care unit patients. Infection Control and Hospital Epidemiology 2009;30(10):952-8.
Ben-Abraham 2002 {published data only}
  • Ben-Abraham R, Keller N, Szold O, Vardi A, Weinberg M, Barzilay Z, et al. Do isolation rooms reduce the rate of nosocomial infections in the pediatric intensive care unit?. Journal of Critical Care 2002;17(3):176-80.
Black 1981 {published data only}
  • Black RE, Dykes AC, Anderson KE, Wells JG, Sinclair SP, Gary GW, et al. Handwashing to prevent diarrhea in day-care centers. American Journal of Epidemiology 1981;113(4):445-51.
Borkow 2010 {published data only}
Bouadma 2010 {published data only}
  • Bouadma L, Mourvillier B, Deiler V, Le Corre B, Lolom I, Régnier B, et al. A multifaceted program to prevent ventilator-associated pneumonia: impact on compliance with preventive measures. Critical Care Medicine 2010;38(3):789-96.
Breugelmans 2004 {published data only}
Cai 2009 {published data only}
  • Cai W, Schweiger B, Buchholz U, Buda S, Littmann M, Heusler J, et al. Protective measures and H5N1-seroprevalence among personnel tasked with bird collection during an outbreak of avian influenza A/H5N1 in wild birds, Ruegen, Germany, 2006. BMC Infectious Diseases 2009;9:170.
Cantagalli 2010 {published data only}
  • Cantagalli MR, Alvim VF, Andrade EC, Leite ICG. Associação entre desnutrição energético-protéica e infecção respiratória aguda em crianças na atenção primária à saúde. Revista de APS 2010;13(1):26-33.
Carbonell-Estrany 2008 {published data only}
  • Carbonell-Estrany X, Bont L, Doering G, Gouyon JB, Lanari M. Clinical relevance of prevention of respiratory syncytial virus lower respiratory tract infection in preterm infants born between 33 and 35 weeks gestational age. European Journal of Clinical Microbiology and Infectious Diseases 2008;27(10):891-9.
Carter 2002 {published data only}
Castillo-Chavez 2003 {published data only}
Cava 2005a {published data only}
Cava 2005b {published data only}
CDC 2003 {published data only}
  • Centers for Disease Control and Prevention (CDC). Cluster of severe acute respiratory syndrome cases among protected health-care workers - Toronto, Canada, April 2003. MMWR - Morbidity & Mortality Weekly Report 2003;52(19):433-6.
Chai 2005 {published data only}
  • Chai LY, Ng TM, Habib AG, Singh K, Kumarasinghe G, Tambyah PA. Paradoxical increase in methicillin-resistant Staphylococcus aureus acquisition rates despite barrier precautions and increased hand washing compliance during an outbreak of severe acute respiratory syndrome. Clinical Infectious Diseases 2005;40(4):623-3.
Chaovavanich 2004 {published data only}
  • Chaovavanich A, Wongsawat J, Dowell SF, Inthong Y, Sangsajja C, Sanguanwongse N, et al. Early containment of severe acute respiratory syndrome (SARS); experience from Bamrasnaradura Institute, Thailand. Journal of the Medical Association of Thailand 2004;87(10):1182-7.
Chau 2003 {published data only}
  • Chau PH, Yip PS. Monitoring the severe acute respiratory syndrome epidemic and assessing effectiveness of interventions in Hong Kong Special Administrative Region. Journal of Epidemiology and Community Health 2003;57(10):766-9.
Chau 2008 {published data only}
  • Chau JPC, Thompson DR, Twinn S, Lee DTF, Lopez V, Ho LSY. An evaluation of SARS and droplet infection control practices in acute and rehabilitation hospitals in Hong Kong. Hong Kong Medical Journal 2008;14(Suppl 4):44-7.
Chen 2007 {published data only}
Cheng 2010 {published data only}
  • Cheng VCC, Tai JWM, Wong LMW, Chan JFW, Li IWS, To KKW, et al. Prevention of nosocomial transmission of swine-origin pandemic influenza virus A/H1N1 by infection control bundle. Journal of Hospital Infection 2010;74(3):271-7.
Chia 2005 {published data only}
  • Chia SE, Koh D, Fones C, Qian F, Ng V, Tan BH, et al. Appropriate use of personal protective equipment among healthcare workers in public sector hospitals and primary healthcare polyclinics during the SARS outbreak in Singapore. Occupational and Environmental Medicine 2005;62(7):473-7.
Clynes 2010 {published data only}
Cowling 2007 {published data only}
  • Cowling BJ, Muller MP, Wong IO, Ho LM, Louie M, McGeer A, et al. Alternative methods of estimating an incubation distribution: examples from severe acute respiratory syndrome. Epidemiology 2007;18(2):253-9.
Daniels 2010 {published data only}
  • Daniels TL, Talbot TR. Unmasking the confusion of respiratory protection to prevent influenza-like illness in crowded community settings. Journal of Infectious Diseases 2010;201(4):483-5.
Daugherty 2008 {published data only}
  • Daugherty EL. Health care worker protection in mass casualty respiratory failure: infection control, decontamination, and personal protective equipment. Respiratory Care 2008;53(2):201-12; discussion 212-4.
Davies 1994 {published data only}
Day 1993 {published data only}
  • Day RA, St Arnaud S, Monsma M. Effectiveness of a handwashing program. Clinical Nursing Research 1993;2(1):24-40.
Day 2006 {published data only}
Dell'Omodarme 2005 {published data only}
Desenclos 2004 {published data only}
  • Desenclos JC, van der Werf S, Bonmarin I, Levy-Bruhl D, Yazdanpanah Y, Hoen B, et al. Introduction of SARS in France, March-April, 2003. Emerging Infectious Diseases 2004;10(2):195-200.
DiGiovanni 2004 {published data only}
  • DiGiovanni C, Conley J, Chiu D, Zaborski J. Factors influencing compliance with quarantine in Toronto during the 2003 SARS outbreak. Biosecurity and Bioterrorism 2004;2(4):265-72.
Doebbeling 1992 {published data only}
  • Doebbeling BN, Stanley GL, Sheetz CT. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. New England Journal of Medicine 1992;327(2):88-92.
Dwosh 2003 {published data only}
  • Dwosh HA, Hong HH, Austgarden D, Herman S, Schabas R. Identification and containment of an outbreak of SARS in a community hospital. Canadian Medical Association Journal 2003;168(11):1415-20.
Edmonds 2010 {published data only}
  • Edmonds S, Dzyakanava V, Macinga D. Efficacy of hand hygiene products against pandemic H1N1 influenza. American Journal of Infection Control 2010;38(5):E132-3.
Fendler 2002 {published data only}
  • Fendler EJ, Ali Y, Hammond BS, Lyons MK, Kelley MB, Vowell NA. The impact of alcohol hand sanitizer use on infection rates in an extended care facility. American Journal of Infection Control 2002;30(4):226-33.
Flint 2003 {published data only}
  • Flint J, Burton S, Macey JF, Deeks SL, Tam TW, King A, et al. Assessment of in-flight transmission of SARS - results of contact tracing. Canadian Communicable Disease Report 2003;29(12):105-10.
Fung 2004 {published data only}
  • Fung CP, Hsieh TL, Tan KH, Loh CH, Wu JS, Li CC, et al. Rapid creation of a temporary isolation ward for patients with severe acute respiratory syndrome in Taiwan. Infection Control and Hospital Epidemiology 2004;25(12):1026-32.
Garcia 2010 {published data only}
  • Garcia MC. The protection against influenza provided by surgical masks is not inferior to what the FFP2 (N95) respiratory protector can give. FMC Formacion Medica Continuada en Atencion Primaria 2010;17(5):365.
Gaydos 2001 {published data only}
Gensini 2004 {published data only}
Giroud 2002 {published data only}
  • Giroud E, Loyeay S, Legrand S, et al. Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. BMJ 2002;325:362-5.
Glass 2006 {published data only}
Goel 2007 {published data only}
  • Goel S, Gupta AK, Singh A, Lenka SR. Preparations and limitations for prevention of severe acute respiratory syndrome in a tertiary care centre of India. Journal of Hospital Infection 2007;66(2):142-7.
Gomersall 2006 {published data only}
  • Gomersall CD, Joynt GM, Ho OM, Ip M, Yap F, Derrick JL, et al. Transmission of SARS to healthcare workers. The experience of a Hong Kong ICU. Intensive Care Medicine 2006;32(4):564-9.
Gore 2001 {published data only}
  • Gore J, Lambert JA. Does use of an instant hand sanitizer reduce elementary school illness absenteeism?. Journal of Family Practice 2001;50(1):64.
Gostin 2003 {published data only}
  • Gostin LO, Bayer R, Fairchild AL. Ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats. JAMA 2003;290(24):3229-37.
Gralton 2010 {published data only}
Guinan 2002 {published data only}
Gupta 2005 {published data only}
Gwaltney 1982 {published data only}
  • Gwaltney JM Jr, Hendley JO. Transmission of experimental rhinovirus infection by contaminated surfaces. American Journal of Epidemiology 1982;116:828-33.
Han 2003 {published data only}
  • Han H, Li X, Qu W, Shen T, Xu F, Gao D, et al. The building and practice of the emergency isolation radiology information system at the department of radiology in polyclinic during the epidemic outbreak stage of SARS. Beijing Da Xue Xue Bao [Journal of Peking University] 2003;35(Suppl):86-8.
Hayden 1985 {published data only}
  • Hayden GF, Hendley JO, Gwaltney JM Jr. The effect of placebo and virucidal paper handkerchiefs on viral contamination of the hand and transmission of experimental rhinoviral infection. Journal of Infectious Diseases 1985;152(2):403-7.
Hendley 1988 {published data only}
  • Hendley JO, Gwaltney JM Jr. Mechanisms of transmission of rhinovirus infections. Epidemiologic Reviews 1988;10:243-58.
Hens 2009 {published data only}
  • Hens N, Ayele GM, Goeyvaerts N, Aerts M, Mossong J, Edmunds JW, et al. Estimating the impact of school closure on social mixing behaviour and the transmission of close contact infections in eight European countries. BMC Infectious Diseases 2009;9:187.
Heymann 2009 {published data only}
  • Heymann AD, Hoch I, Valinsky L, Kokia E, Steinberg DM. School closure may be effective in reducing transmission of respiratory viruses in the community. Epidemiology and Infection 2009;137(10):1369-76.
Hilburn 2003 {published data only}
  • Hilburn J, Hammond BS, Fendler EJ, Groziak PA. Use of alcohol hand sanitizer as an infection control strategy in an acute care facility. American Journal of Infection Control 2003;31(2):109-16.
Hilmarsson 2007 {published data only}
  • Hilmarsson H, Traustason BS, Kristmundsdottir T, Thormar H. Virucidal activities of medium- and long-chain fatty alcohols and lipids against  respiratory syncytial virus and parainfluenza virus type 2: comparison at different pH levels. Archives of Virology 2007;152(1):2225-36.
Hirsch 2006 {published data only}
  • Hirsch HH, Steffen I, Francioli P, Widmer AF. Respiratory syncytial virus infections: measures in immunocompromised patients [Respiratorisches Syncytial-virus (RSV)-Infektion: Massnahmen beim immunsupprimierten Patienten]. Praxis 2006;95(3):61-6.
Ho 2003 {published data only}
  • Ho AS, Sung JJ, Chan-Yeung M. An outbreak of severe acute respiratory syndrome among hospital workers in a community hospital in Hong Kong. Annals of Internal Medicine 2003;139(7):564-7.
Hsieh 2007 {published data only}
  • Hsieh YH, King CC, Chen CW, Ho MS, Hsu SB, Wu YC. Impact of quarantine on the 2003 SARS outbreak: a retrospective modeling study. Journal of Theoretical Biology 2007;244(4):729-36.
Hugonnet 2007 {published data only}
  • Hugonnet S, Legros D, Roth C, Pessoa-Silva CL. Nosocomial transmission of severe acute respiratory syndrome: better quality of evidence is needed. Clinical Infectious Diseases 2007;45(12):1651.
Jiang 2003 {published data only}
  • Jiang S, Huang L, Chen X, Wang J, Wu W, Yin S. Ventilation of wards and nosocomial outbreak of severe acute respiratory syndrome among healthcare workers. Chinese Medical Journal 2003;116(9):1293-7.
  • Jiang SP, Huang LW, Wang JF, Wu W, Yin SM, Chen WX. A study of the architectural factors and the infection rates of healthcare workers in isolation units for severe acute respiratory syndrome. Chung-Hua Chieh Ho Ho Hu Hsi Tsa Chih (Chinese Journal of Tuberculosis & Respiratory Diseases) 2003;26(10):594-7.
Johnson 2009 {published data only}
  • Johnson DF, Druce JD, Birch C, Grayson ML. A quantitative assessment of the efficacy of surgical and N95 masks to filter influenza virus in patients with acute influenza infection. Clinical Infectious Diseases 2009;49(2):275-7.
Jones 2005 {published data only}
  • Jones EW. "Co-operation in All Human Endeavour": quarantine and immigrant disease vectors in the 1918-1919 influenza pandemic in Winnipeg. Canadian Bulletin of Medical History 2005;22(1):57-82.
Kaydos-Daniels 2004 {published data only}
  • Kaydos-Daniels SC, Olowokure B, Chang HJ, Barwick RS, Deng JF, Lee ML, et al. Body temperature monitoring and SARS fever hotline, Taiwan. Emerging Infectious Diseases 2004;10(2):373-6.
Kelso 2009 {published data only}
  • Kelso JK, Milne GJ, Kelly H. Simulation suggests that rapid activation of social distancing can arrest epidemic development due to a novel strain of influenza. BMC Public Health 2009;9:117.
Khaw 2008 {published data only}
  • Khaw KS, Ngan Kee WD, Tam YH, Wong MK, Lee SW. Survey and evaluation of modified oxygen delivery devices used for suspected severe acute respiratory syndrome and other high-risk patients in Hong Kong. Hong Kong Medical Journal 2008;14(Suppl 5):27-31.
Kilabuko 2007 {published data only}
  • Kilabuko JH, Nakai S. Effects of cooking fuels on acute respiratory infections in children in Tanzania. International Journal of Environmental Research and Public Health 2007;4(4):283-8.
Kosugi 2004 {published data only}
  • Kosugi Y, Ishikawa T, Chimura Y, Annaka M, Shibazaki S, Adachi K, et al. Control of hospital infection of influenza: administration of neuraminidase inhibitor and cohort isolation of influenza patients. Kansenshogaku Zasshi [Journal of the Japanese Association for Infectious Diseases] 2004;78(12):995-9.
Lam 2004 {published data only}
Lange 2004 {published data only}
Larson 2004 {published data only}
  • Larson EL, Lin SX, Gomez-Pichardo C, Della-Latta P. Effect of antibacterial home cleaning and handwashing products on infectious disease symptoms: a randomized, double-blind trial. Annals of Internal Medicine 2004;140(5):321-9.
Larson 2005 {published data only}
  • Larson EL, Cimiotti J, Haas J, Parides M, Nesin M, Della-Latta P, et al. Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units. Archives of Pediatrics & Adolescent Medicine 2005;159(4):377-83.
Lau 2004b {published data only}
  • Lau JT, Yang X, Tsui HY, Pang E. SARS related preventive and risk behaviours practised by Hong Kong-mainland China cross border travellers during the outbreak of the SARS epidemic in Hong Kong. Journal of Epidemiology and Community Health 2004;58(12):988-96.
Lau 2005 {published data only}
  • Lau JT, Leung PC, Wong EL, Fong C, Cheng KF, Zhang SC, et al. The use of an herbal formula by hospital care workers during the severe acute respiratory syndrome epidemic in Hong Kong to prevent severe acute respiratory syndrome transmission, relieve influenza-related symptoms, and improve quality of life: a prospective cohort study. Alternative & Complementary Medicine 2005;11(1):49-55.
Lee 2005 {published data only}
  • Lee GM, Salomon JA, Friedman JF, Hibberd PL, Ross-Degnan D, Zasloff E, et al. Illness transmission in the home: a possible role for alcohol-based hand gels. Pediatrics 2005;115(4):852-60.
Lee 2010 {published data only}
  • Lee VJ, Yap J, Cook AR, Chen MI, Tay JK, Barr I, et al. Effectiveness of public health measures in mitigating pandemic influenza spread: a prospective sero-epidemiological cohort study. Journal of Infectious Diseases 2010;202(9):1319-26.
Lipsitch 2003 {published data only}
Luckingham 1984 {published data only}
  • Luckingham B. To mask or not to mask: a note on the 1918 Spanish influenza epidemic in Tucson. The Journal of Arizona History 1984;25(2):191-204.
Ma 2004 {published data only}
  • Ma HJ, Wang HW, Fang LQ, Jiang JF, Wei MT, Liu W, et al. A case-control study on the risk factors of severe acute respiratory syndromes among health care workers. Chung-Hua Liu Hsing Ping Hsueh Tsa Chih [Chinese Journal of Epidemiology] 2004;25(9):741-4.
MacIntyre 2010 {published data only}
  • MacIntyre CR. Cluster randomised controlled trial: hand hygiene and face mask use within 36 hours of index patient symptom onset reduces flu transmission to household contacts. Evidence-Based Medicine 2010;15(2):48-9.
Malone 2009 {published data only}
  • Malone JD, Brigantic R, Muller GA, Gadgil A, Delp W, McMahon BH, et al. U.S. airport entry screening in response to pandemic influenza: modeling and analysis. Travel Medicine and Infectious Disease 2009;7(4):181-91.
Marin 1991 {published data only}
  • Marin J, Dragas AZ, Mavsar B. Virus permeability of protective gloves used in medical practice. Zentralblatt fur Hygiene und Umweltmedizin (International Journal of Hygiene and Environmental Medicine) 1991;191(5-6):516-22.
McSweeny 2007 {published data only}
  • McSweeny K, Colman A, Fancourt N, Parnell M, Stantiall S, Rice G, et al. Was rurality protective in the 1918 influenza pandemic in New Zealand?. New Zealand Medical Journal 2007;120(1256):2579.
Mielke 2009 {published data only}
  • Mielke M, Nassauer A. Pandemic influenza: nonpharmaceutical protective measures in ambulatory care. Fortschritte der Medizin 2009;151(40):32-4.
Mikolajczyk 2008 {published data only}
Monsma 1992 {published data only}
Nishiura 2009 {published data only}
O'Callaghan 1993 {published data only}
Olsen 2003 {published data only}
Ooi 2005 {published data only}
Orellano 2010 {published data only}
  • Orellano PW, Grassi A, Reynoso JI, Palmieri A, Uez O, Carlino O. Impact of school closings on the influenza A (H1N1) outbreak in Tierra del Fuego, Argentina. Pan American Journal of Public Health 2010;27(3):226-9.
Panchabhai 2009 {published data only}
  • Panchabhai TS, Dangayach NS, Krishnan A, Kothari VM, Karnad KR. Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open-label randomized trial with 0.01% potassium permanganate as control. Chest 2009;135(5):1150-6.
Pang 2004 {published data only}
  • Pang XH, Liu DL, Gong XH, Xu FJ, Liu ZJ, Zhang Z, et al. Study on the risk factors related to severe acute respiratory syndrome among close contactors in Beijing. Chung-Hua Liu Hsing Ping Hsueh Tsa Chih Chinese Journal of Epidemiology 2004;25(8):674-6.
Pittet 2000 {published data only}
  • Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme (Erratum in: Lancet 2000 Dec 23-30;356(9248):2196). Lancet 2000;356(9238):1307-12.
Prasad 2004 {published data only}
Rabenau 2005 {published data only}
Reynolds 2008 {published data only}
  • Reynolds DL, Garay JR, Deamond SL, Moran MK, Gold W, Styra R. Understanding, compliance and psychological impact of the SARS quarantine experience. Epidemiology and Infection 2008;136(7):997-1007.
Richardson 2010 {published data only}
  • Richardson A, Hofacre K. Comparison of filtration efficiency of a N95 filtering facepiece respirator and surgical mask against viral aerosols. American Journal of Infection Control 2010;38(5):E20.
Riley 2003 {published data only}
  • Riley S, Fraser C, Donnelly CA, Ghani AC, Abu-Raddad LJ, Hedley AJ. Transmission dynamics of the etiological agent of SARS in Hong Kong: impact of public health interventions. Science 2003;300(5627):1961-6.
Rodriguez 2009 {published data only}
  • Rodriguez CV, Rietberg K, Baer A, Kwan-Gett T, Duchin J. Association between school closure and subsequent absenteeism during a seasonal influenza epidemic. Epidemiology 2009;20(6):787-92.
Rosenthal 2005 {published data only}
  • Rosenthal VD, Guzman S, Safdar N. Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina. American Journal of Infection Control 2005;33(7):392-7.
Safiulin 1972 {published data only}
  • Safiulin AA. UV sanitation of the air and surfaces for the purpose of preventing in-hospital viral respiratory infections. Gigiena i Sanitariia 1972;37(10):99-101.
Sandrock 2008 {published data only}
Satter 2000 {published data only}
  • Sattar SA, Abebe M, Bueti AJ, Jampani H, Newman J, Hua S. Activity of an alcohol-based hand gel against human adeno-, rhino-, and rotaviruses using the fingerpad method. Infection Control and Hospital Epidemiology 2000;21(8):516-9.
Schull 2007 {published data only}
  • Schull MJ, Stukel TA, Vermeulen MJ, Zwarenstein M, Alter DA, Manuel DG, et al. Effect of widespread restrictions on the use of hospital services during an outbreak of severe acute respiratory syndrome. CMAJ 2007;176(13):1827-32.
Seal 2010 {published data only}
  • Seal LA, Slade B, Cargill I, Aust D. Persistence factors in handwashes. American Journal of Infection Control 2010;38(5):E18-9.
Seale 2009 {published data only}
  • Seale H, Corbett S, Dwyer DE, MacIntyre CR. Feasibility exercise to evaluate the use of particulate respirators by emergency department staff during the 2007 influenza season. Infection Control and Hospital Epidemiology 2009;30(7):710-2.
Sizun 1996 {published data only}
Stebbins 2009 {published data only}
  • Stebbins S, Downs JS, Vukotich CJ. Using nonpharmaceutical interventions to prevent influenza transmission in elementary school children: parent and teacher perspectives. Journal of Public Health Management and Practice 2009;15(2):112-7.
Stoner 2007 {published data only}
Stukel 2008 {published data only}
  • Stukel TA, Schull MJ, Guttmann A, Alter DA, Li P, Vermeulen MJ, et al. Health impact of hospital restrictions on seriously ill hospitalized patients: lessons from the Toronto SARS outbreak. Medical Care 2008;46(9):991-7.
Svoboda 2004 {published data only}
  • Svoboda T, Henry B, Shulman L, Kennedy E, Rea E, Ng W, et al. Public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in Toronto. New England Journal of Medicine 2004;350(23):2353-61.
Tracht 2010 {published data only}
Ueno 1990 {published data only}
  • Ueno T, Saijo K. Prevention of adenovirus infection and antiviral activity of a hand disinfectant, Welpas. Nippon Ganka Gakkai Zasshi 1990;94(1):44-8.
van der Sande 2008 {published data only}
Viscusi 2009a {published data only}
  • Viscusi DJ, Bergman M, Sinkule E, Shaffer RE. Evaluation of the filtration performance of 21 N95 filtering face piece respirators after prolonged storage. American Journal of Infection Control 2009;37(5):381-6.
Viscusi 2009b {published data only}
Wang 2003 {published data only}
  • Wang JX, Feng HY, Liu D, Zhang ZL, Shan AL, Zhu XJ, et al. Epidemiological characteristics of severe acute respiratory syndrome in Tianjin and the assessment of effectiveness on measures of control. Chung-Hua Liu Hsing Ping Hsueh Tsa Chih [Chinese Journal of Epidemiology] 2003;24(7):565-9.
Wang 2005 {published data only}
  • Wang HW, He J, Zhang PH, Tang F, Wang TB, Luan YH, et al. A case-control study on the mxA polymorphisms and susceptibility to severe acute respiratory syndromes. Chung-Hua Liu Hsing Ping Hsueh Tsa Chih [Chinese Journal of Epidemiology] 2005;26(8):574-7.
Weber 2004 {published data only}
Wen 2010 {published data only}
  • Wen Z, Lu J, Li J, Li N, Zhao J, Wang J, et al. Determining the filtration efficiency of half-face medical protection mask (N99) against viral aerosol. Aerobiologia 2010;26(3):245-51.
White 2005 {published data only}
  • White C, Kolble R, Carlson R, Lipson N. The impact of a health campaign on hand hygiene and upper respiratory illness among college students living in residence halls. Journal of American College Health 2005;53(4):175-81.
Wilczynski 1997 {published data only}
  • Wilczynski J, Torbicka E, Brzozowska-Binda A, Szymanska U. Breast feeding for prevention of viral acute respiratory diseases in infants. Medycyna Doswiadczalna i Mikrobiologia 1997;49(3-4):199-206.
Wilder-Smith 2003 {published data only}
Wilder-Smith 2005 {published data only}
  • Wilder-Smith A, Low JG. Risk of respiratory infections in health care workers: lessons on infection control emerge from the SARS outbreak. Southeast Asian Journal of Tropical Medicine and Public Health 2005;36(2):481-8.
Wong 2005 {published data only}
  • Wong TW, Tam WW. Handwashing practice and the use of personal protective equipment among medical students after the SARS epidemic in Hong Kong. American Journal of Infection Control 2005;33(10):580-6.
Yen 2010 {published data only}
  • Yen M-Y, Lu Y-C, Huang P-H, Chen C-M, Chen Y-C, Lin YE. Quantitative evaluation of infection control models in the prevention of nosocomial transmission of SARS virus to healthcare workers: implication to nosocomial viral infection control for healthcare workers. Scandinavian Journal of Infectious Diseases 2010;42(6-7):510-5.
Yu 2004 {published data only}
Zamora 2006 {published data only}
Zhai 2007 {published data only}
  • Zhai S, Liu W, Yan B. Recent patents on treatment of severe acute respiratory syndrome (SARS). Recent Patents on Anti-infective Drug Discovery 2007;2(1):1-10.
Zhao 2003 {published data only}
  • Zhao Z, Zhang F, Xu M, Huang K, Zhong W, Cai W, et al. Description and clinical treatment of an early outbreak of severe acute respiratory syndrome (SARS) in Guangzhou, PR China. Journal of Medical Microbiology 2003;52(8):715-20.

References to studies awaiting assessment

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
  24. References to other published versions of this review
Aiello 2010b {published data only}
  • Aiello AE, Coulborn RM, Perez V, Davis BM, Uddin M, Murray GF, et al. A randomized intervention trial of mask use and hand hygiene to reduce seasonal influenza-like illness and influenza infections among young adults in a university setting. International Journal of Infectious Diseases 2010;14:e320.
Hubner 2009 {published data only}
  • Hubner NO, Hubner C, Wodny M, Kampf G, Kramer A. Effectiveness of alcohol-based hand disinfectants in a public administration: impact on health and work performance related to acute respiratory symptoms and diarrhoea. BMC Infectious Diseases 2009;9:10.
Raboud 2010 {published data only}
  • Raboud J, Shigayeva A, McGeer A, Bontovics E, Chapman M, Gravel D. Risk factors for SARS transmission from patients requiring intubation: a multicentre investigation in Toronto, Canada. PLoS 2010;5(5):e10717.
Savolainen-Kopra 2010 {published data only}
  • Savolainen-Kopra C, Haapakoski J, Peltola P A, Ziegler T, Korpela T, Anttila P, et al. STOPFLU: is it possible to reduce the number of days off in office work by improved hand-hygiene?. Trials 2010;11:69.

Additional references

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
  24. References to other published versions of this review
Aiello 2002
Bonn 1997
Bootsma 2007
  • Bootsma MCJ, Ferguson NM. The effect of public health measures on the 1918 influenza pandemic in U.S. cities. Proceedings of the National Academy of Sciences of the United States of America (PNAS) 2007; Vol. Early edition:1-6. [: doi:10.1073 /pnas.0611071104]
CDC 2005a
  • Centers for Disease Control and Prevention. Infection Control Guidance for the Prevention and Control of Influenza in Acute-Care Facilities. http://www.cdc.gov/flu/professionals/infectioncontrol/healthcarefacilities.htm (accessed 3 March 2006).
CDC 2005b
  • Centers for Disease Control and Prevention. 2004-2005 Interim Guidance for the Use of Masks to Control Influenza Transmission. http://www.cdc.gov/flu/professionals/infectioncontrol/maskguidance.htm (accessed 3 March 2006).
Fraser 2006
  • Fraser C, Murray A, Burr J. Identifying observational studies of surgical interventions in MEDLINE and EMBASE. BMC Medical Research Methodology 2006;6:41.
Fung 2006
Grimshaw 2004
  • Grimshaw JM, Thomas RE, Maclennan G, Fraser C, Ramsay CR, Vale R, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment 2004;8(6:iii-iv):1-72.
Higgins 2002
Higgins 2003
Jefferson 2005a
  • Jefferson T, Smith S, Demicheli V, Harnden A, Rivetti A, Di Pietrantonj C. Assessment of the efficacy and effectiveness of influenza vaccines in healthy children: systematic review. Lancet 2005;365(9461):773-80.
Jefferson 2005b
Jefferson 2005c
Jefferson 2005d
Jefferson 2006a
  • Jefferson T, Demicheli V, Rivetti D, Jones M, Di Pietrantonj C, Rivetti A. Antivirals for influenza in healthy adults: systematic review. Lancet 2006;367(9507):303-13. [: DOI: 10.1016/S0140-6736(06) 67970-1]
Khan 2000
  • Khan SK, ter Riet G, Popay J, Nixon J, Kleijnen J. Stage II Conducting the review: Phase 5: Study quality assessment. In: Khan SK, ter Riet G, Glanville J, Sowden AJ, Kleijnen J editor(s). Undertaking Systematic Reviews of Research on Effectiveness. CRD's guidance for carrying out or commissioning reviews. CRD Report No 4. 2nd Edition. York: NHS Centre for Reviews and Dissemination, University of York, 2000:2.5.1-2.5.10.
Kitamura 2007
Lefebvre 2009
  • Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Higgins JPT, Green S (editors) editor(s). Cochrane Handbook for Systematic Reviews of Interventions. Version 5.0.2 (updated September 2009). The Cochrane Collaboration. Available from www.cochrane-handbook.org. Chichester, UK: Wiley-Blackwell, 2009.
Meadows 2004
  • Meadows E, Le Saux N. A systematic review of the effectiveness of antimicrobial rinse-free hand sanitizers for prevention of illness-related absenteeism in elementary school children. BMC Public Health 2004;4:50. [: doi:10.1186/1471-2458-4-50]
Monto 1969
  • Monto AS, Davenport FM, Napier JA, Francis T Jr. Effect of vaccination of a school-age population upon the course of an A2-Hong Kong influenza epidemic. Bulletin of the World Health Organization 1969;41(3):537-42.
Shute 2003
  • Shute N. SARS hit home. US News & World Report 2003;134(15):38-42.
Smith 2006
Thomas 2010
WHO 2006
  • World Health Organization Writing Group. Non pharmaceutical interventions for pandemic influenza, national and community measures. Emerging Infectious Diseases 2006;12(1):88-94.
WHO 2009
  • World Health Organization. Pandemic H1N1. http://www.who.int/csr/disease/swineflu/en/ 2009 (accessed 22 July 2009).

References to other published versions of this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
  24. References to other published versions of this review
Jefferson 2007
Jefferson 2009
  • Jefferson T, Del Mar C, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. BMJ online 2009;339:b.3657. [DOI: 10.1136/bmj.b367]