Physical interventions to interrupt or reduce the spread of respiratory viruses: Systematic review

Tom Jefferson, Chris Del Mar, Liz Dooley, Eliana Ferroni, Lubna A. Al-Ansary, Ghada A. Bawazeer, Mieke L. Van Driel, Ruth Foxlee, Alessandro Rivetti

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Abstract

Objective: To review systematically the evidence of effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses. Data sources: Cochrane Library, Medline, OldMedline, Embase, and CINAHL, without restrictions on language or publication. Data selection: Studies of any intervention to prevent the transmission of respiratory viruses (isolation, quarantine, social distancing, barriers, personal protection, and hygiene). A search of study designs included randomised trials, cohort, case-control, crossover, before and after, and time series studies. After scanning of the titles, abstracts and full text articles as a first filter, a standardised form was used to assess the eligibility of the remainder. Risk of bias of randomised studies was assessed for generation of the allocation sequence, allocation concealment, blinding, and follow-up. Non-randomised studies were assessed for the presence of potential confounders and classified as being at low, medium, or high risk of bias. Data synthesis: 58 papers of 59 studies were included. The quality of the studies was poor for all four randomised controlled trials and most cluster randomised controlled trials; the observational studies were of mixed quality. Meta-analysis of six case-control studies suggested that physical measures are highly effective in preventing the spread of severe acute respiratory syndrome: handwashing more than 10 times daily (odds ratio 0.45, 95% confidence interval 0.36 to 0.57; number needed to treat=4, 95% confidence interval 3.65 to 5.52), wearing masks (0.32, 0.25 to 0.40; NNT=6, 4.54 to 8.03), wearing N95 masks (0.09, 0.03 to 0.30; NNT=3, 2.37 to 4.06), wearing gloves (0.43, 0.29 to 0.65; NNT=5, 4.15 to 15.41), wearing gowns (0.23, 0.14 to 0.37; NNT=5, 3.37 to 7.12), and handwashing, masks, gloves, and gowns combined (0.09, 0.02 to 0.35; NNT=3, 2.66 to 4.97). The combination was also effective in interrupting the spread of influenza within households. The highest quality cluster randomised trials suggested that spread of respiratory viruses can be prevented by hygienic measures in younger children and within households. Evidence that the more uncomfortable and expensive N95 masks were superior to simple surgical masks was limited, but they caused skin irritation. The incremental effect of adding virucidals or antiseptics to normal handwashing to reduce respiratory disease remains uncertain. Global measures, such as screening at entry ports, were not properly evaluated. Evidence was limited for social distancing being effective, especially if related to risk of exposure - that is, the higher the risk the longer the distancing period. Conclusion: Routine long term implementation of some of the measures to interrupt or reduce the spread of respiratory viruses might be difficult. However, many simple and low cost interventions reduce the transmission of epidemic respiratory viruses. More resources should be invested into studying which physical interventions are the most effective, flexible, and cost effective means of minimising the impact of acute respiratory tract infections.

Original languageEnglish
Pages (from-to)792
Number of pages1
JournalBritish Medical Journal
Volume339
Issue number7724
DOIs
Publication statusPublished - 3 Oct 2009

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Masks
Hand Disinfection
Viruses
Randomized Controlled Trials
Confidence Intervals
Quarantine
Costs and Cost Analysis
Severe Acute Respiratory Syndrome
Numbers Needed To Treat
Social Isolation
Local Anti-Infective Agents
Information Storage and Retrieval
Hygiene
Respiratory Tract Infections
Human Influenza
Libraries
Observational Studies
Publications
Meta-Analysis
Case-Control Studies

Cite this

Jefferson, T., Del Mar, C., Dooley, L., Ferroni, E., Al-Ansary, L. A., Bawazeer, G. A., ... Rivetti, A. (2009). Physical interventions to interrupt or reduce the spread of respiratory viruses: Systematic review. British Medical Journal, 339(7724), 792. https://doi.org/10.1136/bmj.b3675
Jefferson, Tom ; Del Mar, Chris ; Dooley, Liz ; Ferroni, Eliana ; Al-Ansary, Lubna A. ; Bawazeer, Ghada A. ; Van Driel, Mieke L. ; Foxlee, Ruth ; Rivetti, Alessandro. / Physical interventions to interrupt or reduce the spread of respiratory viruses : Systematic review. In: British Medical Journal. 2009 ; Vol. 339, No. 7724. pp. 792.
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abstract = "Objective: To review systematically the evidence of effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses. Data sources: Cochrane Library, Medline, OldMedline, Embase, and CINAHL, without restrictions on language or publication. Data selection: Studies of any intervention to prevent the transmission of respiratory viruses (isolation, quarantine, social distancing, barriers, personal protection, and hygiene). A search of study designs included randomised trials, cohort, case-control, crossover, before and after, and time series studies. After scanning of the titles, abstracts and full text articles as a first filter, a standardised form was used to assess the eligibility of the remainder. Risk of bias of randomised studies was assessed for generation of the allocation sequence, allocation concealment, blinding, and follow-up. Non-randomised studies were assessed for the presence of potential confounders and classified as being at low, medium, or high risk of bias. Data synthesis: 58 papers of 59 studies were included. The quality of the studies was poor for all four randomised controlled trials and most cluster randomised controlled trials; the observational studies were of mixed quality. Meta-analysis of six case-control studies suggested that physical measures are highly effective in preventing the spread of severe acute respiratory syndrome: handwashing more than 10 times daily (odds ratio 0.45, 95{\%} confidence interval 0.36 to 0.57; number needed to treat=4, 95{\%} confidence interval 3.65 to 5.52), wearing masks (0.32, 0.25 to 0.40; NNT=6, 4.54 to 8.03), wearing N95 masks (0.09, 0.03 to 0.30; NNT=3, 2.37 to 4.06), wearing gloves (0.43, 0.29 to 0.65; NNT=5, 4.15 to 15.41), wearing gowns (0.23, 0.14 to 0.37; NNT=5, 3.37 to 7.12), and handwashing, masks, gloves, and gowns combined (0.09, 0.02 to 0.35; NNT=3, 2.66 to 4.97). The combination was also effective in interrupting the spread of influenza within households. The highest quality cluster randomised trials suggested that spread of respiratory viruses can be prevented by hygienic measures in younger children and within households. Evidence that the more uncomfortable and expensive N95 masks were superior to simple surgical masks was limited, but they caused skin irritation. The incremental effect of adding virucidals or antiseptics to normal handwashing to reduce respiratory disease remains uncertain. Global measures, such as screening at entry ports, were not properly evaluated. Evidence was limited for social distancing being effective, especially if related to risk of exposure - that is, the higher the risk the longer the distancing period. Conclusion: Routine long term implementation of some of the measures to interrupt or reduce the spread of respiratory viruses might be difficult. However, many simple and low cost interventions reduce the transmission of epidemic respiratory viruses. More resources should be invested into studying which physical interventions are the most effective, flexible, and cost effective means of minimising the impact of acute respiratory tract infections.",
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Jefferson, T, Del Mar, C, Dooley, L, Ferroni, E, Al-Ansary, LA, Bawazeer, GA, Van Driel, ML, Foxlee, R & Rivetti, A 2009, 'Physical interventions to interrupt or reduce the spread of respiratory viruses: Systematic review' British Medical Journal, vol. 339, no. 7724, pp. 792. https://doi.org/10.1136/bmj.b3675

Physical interventions to interrupt or reduce the spread of respiratory viruses : Systematic review. / Jefferson, Tom; Del Mar, Chris; Dooley, Liz; Ferroni, Eliana; Al-Ansary, Lubna A.; Bawazeer, Ghada A.; Van Driel, Mieke L.; Foxlee, Ruth; Rivetti, Alessandro.

In: British Medical Journal, Vol. 339, No. 7724, 03.10.2009, p. 792.

Research output: Contribution to journalArticleResearchpeer-review

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T2 - Systematic review

AU - Jefferson, Tom

AU - Del Mar, Chris

AU - Dooley, Liz

AU - Ferroni, Eliana

AU - Al-Ansary, Lubna A.

AU - Bawazeer, Ghada A.

AU - Van Driel, Mieke L.

AU - Foxlee, Ruth

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N2 - Objective: To review systematically the evidence of effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses. Data sources: Cochrane Library, Medline, OldMedline, Embase, and CINAHL, without restrictions on language or publication. Data selection: Studies of any intervention to prevent the transmission of respiratory viruses (isolation, quarantine, social distancing, barriers, personal protection, and hygiene). A search of study designs included randomised trials, cohort, case-control, crossover, before and after, and time series studies. After scanning of the titles, abstracts and full text articles as a first filter, a standardised form was used to assess the eligibility of the remainder. Risk of bias of randomised studies was assessed for generation of the allocation sequence, allocation concealment, blinding, and follow-up. Non-randomised studies were assessed for the presence of potential confounders and classified as being at low, medium, or high risk of bias. Data synthesis: 58 papers of 59 studies were included. The quality of the studies was poor for all four randomised controlled trials and most cluster randomised controlled trials; the observational studies were of mixed quality. Meta-analysis of six case-control studies suggested that physical measures are highly effective in preventing the spread of severe acute respiratory syndrome: handwashing more than 10 times daily (odds ratio 0.45, 95% confidence interval 0.36 to 0.57; number needed to treat=4, 95% confidence interval 3.65 to 5.52), wearing masks (0.32, 0.25 to 0.40; NNT=6, 4.54 to 8.03), wearing N95 masks (0.09, 0.03 to 0.30; NNT=3, 2.37 to 4.06), wearing gloves (0.43, 0.29 to 0.65; NNT=5, 4.15 to 15.41), wearing gowns (0.23, 0.14 to 0.37; NNT=5, 3.37 to 7.12), and handwashing, masks, gloves, and gowns combined (0.09, 0.02 to 0.35; NNT=3, 2.66 to 4.97). The combination was also effective in interrupting the spread of influenza within households. The highest quality cluster randomised trials suggested that spread of respiratory viruses can be prevented by hygienic measures in younger children and within households. Evidence that the more uncomfortable and expensive N95 masks were superior to simple surgical masks was limited, but they caused skin irritation. The incremental effect of adding virucidals or antiseptics to normal handwashing to reduce respiratory disease remains uncertain. Global measures, such as screening at entry ports, were not properly evaluated. Evidence was limited for social distancing being effective, especially if related to risk of exposure - that is, the higher the risk the longer the distancing period. Conclusion: Routine long term implementation of some of the measures to interrupt or reduce the spread of respiratory viruses might be difficult. However, many simple and low cost interventions reduce the transmission of epidemic respiratory viruses. More resources should be invested into studying which physical interventions are the most effective, flexible, and cost effective means of minimising the impact of acute respiratory tract infections.

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