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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, Marie van Driel UGent, Ruth Foxlee and Alessandro Rivetti (2009) BRITISH MEDICAL JOURNAL. 339.
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. Nonrandomised 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.
Please use this url to cite or link to this publication:
author
organization
year
type
journalArticle (review)
publication status
published
subject
journal title
BRITISH MEDICAL JOURNAL
Br. Med. J.
volume
339
pages
b3675 -
Web of Science type
Article
Web of Science id
000270231500007
ISSN
0959-8146
DOI
10.1136/bmj.b3675
language
English
UGent publication?
yes
classification
A1
copyright statement
I don't know the status of the copyright for this publication
id
904189
handle
http://hdl.handle.net/1854/LU-904189
date created
2010-03-15 11:52:07
date last changed
2016-12-19 15:41:04
@article{904189,
  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. Nonrandomised
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.},
  author       = {Jefferson, Tom and Del Mar, Chris and Dooley, Liz and Ferroni, Eliana and Al-Ansary, Lubna A and Bawazeer, Ghada A and van Driel, Marie and Foxlee, Ruth and Rivetti, Alessandro},
  issn         = {0959-8146},
  journal      = {BRITISH MEDICAL JOURNAL},
  language     = {eng},
  title        = {Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review},
  url          = {http://dx.doi.org/10.1136/bmj.b3675},
  volume       = {339},
  year         = {2009},
}

Chicago
Jefferson, Tom, Chris Del Mar, Liz Dooley, Eliana Ferroni, Lubna A Al-Ansary, Ghada A Bawazeer, Marie van Driel, Ruth Foxlee, and Alessandro Rivetti. 2009. “Physical Interventions to Interrupt or Reduce the Spread of Respiratory Viruses: Systematic Review.” British Medical Journal 339: b3675.
APA
Jefferson, T., Del Mar, C., Dooley, L., Ferroni, E., Al-Ansary, L. A., Bawazeer, G. A., van Driel, M., et al. (2009). Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. BRITISH MEDICAL JOURNAL, 339, b3675.
Vancouver
1.
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. BRITISH MEDICAL JOURNAL. 2009;339:b3675.
MLA
Jefferson, Tom, Chris Del Mar, Liz Dooley, et al. “Physical Interventions to Interrupt or Reduce the Spread of Respiratory Viruses: Systematic Review.” BRITISH MEDICAL JOURNAL 339 (2009): b3675. Print.