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Jefferson T, Dooley L, Ferroni E, Al-Ansary LA, van Driel ML, Bawazeer GA, Jones MA, Hoffmann TC, Clark J, Beller EM, Glasziou PP, Conly JM. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev 2023; 1:CD006207. [PMID: 36715243 PMCID: PMC9885521 DOI: 10.1002/14651858.cd006207.pub6] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID-19 pandemic. OBJECTIVES To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. SEARCH METHODS We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cluster-RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. MAIN RESULTS We included 11 new RCTs and cluster-RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID-19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID-19 pandemic. Many studies were conducted during non-epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza-like illness (ILI)/COVID-19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate-certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory-confirmed influenza/SARS-CoV-2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate-certainty evidence). Harms were rarely measured and poorly reported (very low-certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low-certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low-certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate-certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low-certainty evidence). One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non-inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID-19 patients. Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta-analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate-certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low-certainty evidence), and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low-certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low-certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low-certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports. AUTHORS' CONCLUSIONS The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory-confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs.
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Affiliation(s)
- Tom Jefferson
- Department for Continuing Education, University of Oxford, Oxford OX1 2JA, UK
| | - Liz Dooley
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Eliana Ferroni
- Epidemiological System of the Veneto Region, Regional Center for Epidemiology, Veneto Region, Padova, Italy
| | - Lubna A Al-Ansary
- Department of Family and Community Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mieke L van Driel
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Ghada A Bawazeer
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mark A Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Tammy C Hoffmann
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Elaine M Beller
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Paul P Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - John M Conly
- Cumming School of Medicine, University of Calgary, Room AGW5, SSB, Foothills Medical Centre, Calgary, Canada
- O'Brien Institute for Public Health and Synder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Calgary Zone, Alberta Health Services, Calgary, Canada
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Abney SE, Wilson AM, Ijaz MK, McKinney J, Reynolds KA, Gerba CP. Minding the matrix: The importance of inoculum suspensions on finger transfer efficiency of virus. J Appl Microbiol 2022; 133:3083-3093. [PMID: 35916494 DOI: 10.1111/jam.15758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 01/07/2023]
Abstract
AIMS The aim of this study was to determine how the transfer efficiency of MS-2 coliphage from the toilet seat to hands and fingertip to lip differs according to the suspension of the inoculum. METHODS AND RESULTS Hands were sampled after lifting a toilet seat which was inoculated with MS-2 on the underneath side. MS-2 was suspended in a spectrum of proteinaceous and non-proteinaceous solutions. Transfer efficiencies were greatest with the ASTM tripartite soil load (3.02% ± 4.03) and lowest with phosphate-buffered saline (PBS) (1.10% ± 0.81) for hand-to-toilet seat contacts. Finger-to-lip transfer rates were significantly different (p < 0.05) depending on suspension matrix, with PBS yielding the highest transfer (52.53% ± 4.48%) and tryptose soy broth (TSB) the lowest (23.15% ± 24.27%). Quantitative microbial risk assessment was used to estimate the probability of infection from adenovirus and norovirus from finger contact with a toilet seat. CONCLUSIONS The greatest transfer as well as the largest variation of transfer were measured for finger-to-lip contacts as opposed to toilet seat-to-finger contacts. These factors influence the estimation of the probability of infection from micro-activity, that is, toilet seat adjustment. SIGNIFICANCE AND IMPACT Viruses may be transferred from various human excreta with differing transfer efficiencies, depending on the protein content.
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Affiliation(s)
- Sarah E Abney
- Department of Environmental Science, University of Arizona, Tucson, Arizona, USA
| | - Amanda M Wilson
- Department of Community, Environment, and Policy, University of Arizona, Tucson, Arizona, USA
| | - M Khalid Ijaz
- Global Research & Development for Lysol and Dettol, Reckitt Benckiser LLC, Montvale, New Jersey, USA.,Department of Biology, Medgar Evers College of the City University of New York (CUNY), Brooklyn, New York, USA
| | - Julie McKinney
- Global Research & Development for Lysol and Dettol, Reckitt Benckiser LLC, Montvale, New Jersey, USA
| | - Kelly A Reynolds
- Department of Environmental Science, University of Arizona, Tucson, Arizona, USA.,Department of Community, Environment, and Policy, University of Arizona, Tucson, Arizona, USA
| | - Charles P Gerba
- Department of Environmental Science, University of Arizona, Tucson, Arizona, USA
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El-Heneidy A, Ware RS, Robson JM, Cherian SG, Lambert SB, Grimwood K. Respiratory virus detection during the COVID-19 pandemic in Queensland, Australia. Aust N Z J Public Health 2021; 46:10-15. [PMID: 34648214 PMCID: PMC8652525 DOI: 10.1111/1753-6405.13168] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 08/01/2021] [Accepted: 08/01/2021] [Indexed: 11/28/2022] Open
Abstract
Objective: To determine if non‐pharmaceutical interventions (NPIs) impacted on respiratory virus detections in Queensland, Australia, during the COVID‐19 pandemic year of 2020. Methods: We analysed weekly counts of influenza, human metapneumovirus, parainfluenza, respiratory syncytial virus, rhinovirus, and adenovirus available from a Queensland laboratory network for the year 2020. These were compared with averaged counts from 2015 to 2019. Results: Overall, 686,199 tests were performed. The timing of NPI implementation was associated with a sharp and sustained decline in influenza, where during the typical annual influenza season (weeks 23–40) no cases were detected from 163,296 tests compared with an average of 26.1% (11,844/45,396) of tests positive in 2015–2019. Similar results were observed for human metapneumovirus and parainfluenza. Respiratory syncytial virus detections also declined but increased in weeks 48–52 (5.6%; 562/10,078) to exceed the 2015–2019 average (2.9%; 150/5,018). Rhinovirus detections increased after schools reopened, peaking in weeks 23–27 (57.4%; 36,228/63,115), exceeding the 2017–2019 detections during that period (21.9%; 8,365/38,072). Conclusions: NPIs implemented to control COVID‐19 were associated with altered frequency and proportions of respiratory virus detections. Implications for public health: NPIs derived from influenza pandemic plans were associated with profound decreases in influenza detections during 2020.
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Affiliation(s)
- Asmaa El-Heneidy
- School of Medicine and Dentistry and Menzies Health Institute Queensland, Griffith University Gold Coast Campus, Queensland
| | - Robert S Ware
- School of Medicine and Dentistry and Menzies Health Institute Queensland, Griffith University Gold Coast Campus, Queensland
| | - Jennifer M Robson
- Department of Microbiology, Sullivan Nicolaides Pathology, Queensland
| | - Sarah G Cherian
- Department of Microbiology, Sullivan Nicolaides Pathology, Queensland
| | | | - Keith Grimwood
- School of Medicine and Dentistry and Menzies Health Institute Queensland, Griffith University Gold Coast Campus, Queensland.,Departments of Paediatrics and Infectious Diseases, Gold Coast Health, Queensland
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Association of environmental surface contamination with hand hygiene and infections in nursing homes: a prospective cohort study. Infect Prev Pract 2021; 3:100129. [PMID: 34368746 PMCID: PMC8335935 DOI: 10.1016/j.infpip.2021.100129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/17/2021] [Indexed: 11/23/2022] Open
Abstract
Background Little is known about the presence of infections in nursing home residents, the causative micro-organisms, how hand hygiene (HH) influences the presence of infections in residents, and the extent to which environmental contamination is associated with the incidence of infection among residents. Aims To establish if environmental contamination can be used as an indicator for HH compliance, and if environmental contamination is associated with the incidence of infection. Methods Environmental surface samples (ESS) were collected in an exploratory study as part of a HH intervention in 60 nursing homes. ESS results from three distinct surfaces (nurses' station, communal toilet and residents' shared living area) were compared with nurses' HH compliance and the incidence of infection among residents. Real-time polymerase chain reaction assays were used to detect norovirus genogroup I and II, rhinovirus and Escherichia coli. HH compliance was measured by direct observation. The incidence of infection was registered weekly. Findings Rhinovirus (nurses' station: 41%; toilet: 14%; living area: 29%), norovirus (nurses' station: 18%; toilet: 12%; living area: 16%) and E. coli (nurses' station: 14%; toilet: 58%; living area: 54%) were detected. No significant (P<0.05) associations were found between HH compliance and the presence of micro-organisms. An association was found between E. coli contamination and the incidence of disease in general (P=0.04). No other associations were found between micro-organisms and the incidence of disease. Conclusion Rhinovirus, norovirus and E. coli were detected on surfaces in nursing homes. No convincing associations were found between environmental contamination and HH compliance or the incidence of disease. This study provides reference data about surface contamination.
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Abstract
Human respiratory virus infections lead to a spectrum of respiratory symptoms and disease severity, contributing to substantial morbidity, mortality and economic losses worldwide, as seen in the COVID-19 pandemic. Belonging to diverse families, respiratory viruses differ in how easy they spread (transmissibility) and the mechanism (modes) of transmission. Transmissibility as estimated by the basic reproduction number (R0) or secondary attack rate is heterogeneous for the same virus. Respiratory viruses can be transmitted via four major modes of transmission: direct (physical) contact, indirect contact (fomite), (large) droplets and (fine) aerosols. We know little about the relative contribution of each mode to the transmission of a particular virus in different settings, and how its variation affects transmissibility and transmission dynamics. Discussion on the particle size threshold between droplets and aerosols and the importance of aerosol transmission for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and influenza virus is ongoing. Mechanistic evidence supports the efficacies of non-pharmaceutical interventions with regard to virus reduction; however, more data are needed on their effectiveness in reducing transmission. Understanding the relative contribution of different modes to transmission is crucial to inform the effectiveness of non-pharmaceutical interventions in the population. Intervening against multiple modes of transmission should be more effective than acting on a single mode.
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Affiliation(s)
- Nancy H. L. Leung
- grid.194645.b0000000121742757WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
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6
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Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, van Driel ML, Jones MA, Thorning S, Beller EM, Clark J, Hoffmann TC, Glasziou PP, Conly JM. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev 2020; 11:CD006207. [PMID: 33215698 PMCID: PMC8094623 DOI: 10.1002/14651858.cd006207.pub5] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review published in 2007, 2009, 2010, and 2011. The evidence summarised in this review does not include results from studies from the current COVID-19 pandemic. OBJECTIVES To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. SEARCH METHODS We searched CENTRAL, PubMed, Embase, CINAHL on 1 April 2020. We searched ClinicalTrials.gov, and the WHO ICTRP on 16 March 2020. We conducted a backwards and forwards citation analysis on the newly included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cluster-RCTs of trials investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, and gargling) to prevent respiratory virus transmission. In previous versions of this review we also included observational studies. However, for this update, there were sufficient RCTs to address our study aims. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Three pairs of review authors independently extracted data using a standard template applied in previous versions of this review, but which was revised to reflect our focus on RCTs and cluster-RCTs for this update. We did not contact trialists for missing data due to the urgency in completing the review. We extracted data on adverse events (harms) associated with the interventions. MAIN RESULTS We included 44 new RCTs and cluster-RCTs in this update, bringing the total number of randomised trials to 67. There were no included studies conducted during the COVID-19 pandemic. Six ongoing studies were identified, of which three evaluating masks are being conducted concurrent with the COVID pandemic, and one is completed. Many studies were conducted during non-epidemic influenza periods, but several studies were conducted during the global H1N1 influenza pandemic in 2009, and others in epidemic influenza seasons up to 2016. Thus, studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Compliance with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included nine trials (of which eight were cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and seven in the community). There is low certainty evidence from nine trials (3507 participants) that wearing a mask may make little or no difference to the outcome of influenza-like illness (ILI) compared to not wearing a mask (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.82 to 1.18. There is moderate certainty evidence that wearing a mask probably makes little or no difference to the outcome of laboratory-confirmed influenza compared to not wearing a mask (RR 0.91, 95% CI 0.66 to 1.26; 6 trials; 3005 participants). Harms were rarely measured and poorly reported. Two studies during COVID-19 plan to recruit a total of 72,000 people. One evaluates medical/surgical masks (N = 6000) (published Annals of Internal Medicine, 18 Nov 2020), and one evaluates cloth masks (N = 66,000). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). There is uncertainty over the effects of N95/P2 respirators when compared with medical/surgical masks on the outcomes of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; very low-certainty evidence; 3 trials; 7779 participants) and ILI (RR 0.82, 95% CI 0.66 to 1.03; low-certainty evidence; 5 trials; 8407 participants). The evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirator compared to a medical/surgical mask probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; moderate-certainty evidence; 5 trials; 8407 participants). Restricting the pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies. One ongoing study recruiting 576 people compares N95/P2 respirators with medical surgical masks for healthcare workers during COVID-19. Hand hygiene compared to control Settings included schools, childcare centres, homes, and offices. In a comparison of hand hygiene interventions with control (no intervention), there was a 16% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.84, 95% CI 0.82 to 0.86; 7 trials; 44,129 participants; moderate-certainty evidence), suggesting a probable benefit. When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.98, 95% CI 0.85 to 1.13; 10 trials; 32,641 participants; low-certainty evidence) and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials; 8332 participants; low-certainty evidence) suggest the intervention made little or no difference. We pooled all 16 trials (61,372 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. The pooled data showed that hand hygiene may offer a benefit with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.84 to 0.95; low-certainty evidence), but with high heterogeneity. Few trials measured and reported harms. There are two ongoing studies of handwashing interventions in 395 children outside of COVID-19. We identified one RCT on quarantine/physical distancing. Company employees in Japan were asked to stay at home if household members had ILI symptoms. Overall fewer people in the intervention group contracted influenza compared with workers in the control group (2.75% versus 3.18%; hazard ratio 0.80, 95% CI 0.66 to 0.97). However, those who stayed at home with their infected family members were 2.17 times more likely to be infected. We found no RCTs on eye protection, gowns and gloves, or screening at entry ports. AUTHORS' CONCLUSIONS The high risk of bias in the trials, variation in outcome measurement, and relatively low compliance with the interventions during the studies hamper drawing firm conclusions and generalising the findings to the current COVID-19 pandemic. There is uncertainty about the effects of face masks. The low-moderate certainty of the evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of randomised trials did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks during seasonal influenza. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, especially in those most at risk of ARIs.
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Affiliation(s)
- Tom Jefferson
- Centre for Evidence Based Medicine, University of Oxford, Oxford, UK
| | - Chris B Del Mar
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Liz Dooley
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Eliana Ferroni
- Epidemiological System of the Veneto Region, Regional Center for Epidemiology, Veneto Region, Padova, Italy
| | - Lubna A Al-Ansary
- Department of Family and Community Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ghada A Bawazeer
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mieke L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Mark A Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Sarah Thorning
- GCUH Library, Gold Coast Hospital and Health Service, Southport, Australia
| | - Elaine M Beller
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Tammy C Hoffmann
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Paul P Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - John M Conly
- Cumming School of Medicine, University of Calgary, Room AGW5, SSB, Foothills Medical Centre, Calgary, Canada
- O'Brien Institute for Public Health and Synder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Calgary Zone, Alberta Health Services, Calgary, Canada
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Azor-Martinez E, Garcia-Fernandez L, Strizzi JM, Cantarero-Vallejo MD, Jimenez-Lorente CP, Balaguer-Martinez JV, Torres-Alegre P, Yui-Hifume R, Sanchez-Forte M, Gimenez-Sanchez F. Effectiveness of a hand hygiene program to reduce acute gastroenteritis at child care centers: A cluster randomized trial. Am J Infect Control 2020; 48:1315-1321. [PMID: 32303373 DOI: 10.1016/j.ajic.2020.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/09/2020] [Accepted: 03/12/2020] [Indexed: 12/15/2022]
Abstract
We aimed to assess the effectiveness of an educational and hand hygiene program in daycare centers (DCCs) and homes on acute gastroenteritis (AGE) incidence in children attending DCCs. METHODS A randomized, controlled, and open study of 911 children aged 0-3 years attending 24 DCCs in Almería (Spain) with an 8-month follow-up was employed. Two intervention groups of DCCs families performed educational and hand hygiene measures, 1 with soap and water (soap and water group; n = 274), another with hand sanitizer (hand sanitizer group [HSG]; n = 339), and the control group (CG; n = 298) followed usual handwashing procedures. We compared AGE episode rates with Poisson regression model. RESULTS seven hundred fourteen AGE episodes were registered, significant differences between HSG and CG children were found during December and January. A multivariate model was applied and the adjusted incidence rate ratios by rotavirus vaccination found significant differences when children were previously vaccinated, the children in the soap and water group had a higher risk of AGE episodes (incidence rate ratio: 1.28, 95% confidence interval:1.0-1.64), compared with those in the HSG. CONCLUSIONS This study demonstrated that hand hygiene programs that included hand sanitizer were most effective in the winter months. Further, the largest reduction of AGE episodes occurred in the children that followed hand hygiene programs including hand sanitizer and educational measures for DCC staff, parents, and children, and were vaccinated for rotavirus.
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Golin AP, Choi D, Ghahary A. Hand sanitizers: A review of ingredients, mechanisms of action, modes of delivery, and efficacy against coronaviruses. Am J Infect Control 2020; 48:1062-1067. [PMID: 32565272 PMCID: PMC7301780 DOI: 10.1016/j.ajic.2020.06.182] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/14/2020] [Accepted: 06/15/2020] [Indexed: 12/13/2022]
Abstract
Background The emergence of the novel virus, SARS-CoV-2, has posed unprecedented challenges to public health around the world. Currently, strategies to deal with COVID-19 are purely supportive and preventative, aimed at reducing transmission. An effective and simple method for reducing transmission of infections in public or healthcare settings is hand hygiene. Unfortunately, little is known regarding the efficacy of hand sanitizers against SARS-CoV-2. Methods In this review, an extensive literature search was performed to succinctly summarize the primary active ingredients and mechanisms of action of hand sanitizers, compare the effectiveness and compliance of gel and foam sanitizers, and predict whether alcohol and non-alcohol hand sanitizers would be effective against SARS-CoV-2. Results Most alcohol-based hand sanitizers are effective at inactivating enveloped viruses, including coronaviruses. With what is currently known in the literature, one may not confidently suggest one mode of hand sanitizing delivery over the other. When hand washing with soap and water is unavailable, a sufficient volume of sanitizer is necessary to ensure complete hand coverage, and compliance is critical for appropriate hand hygiene. Conclusions By extrapolating effectiveness of hand sanitizers on viruses of similar structure to SARS-CoV-2, this virus should be effectively inactivated with current hand hygiene products, though future research should attempt to determine this directly.
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Azor-Martinez E, Yui-Hifume R, Muñoz-Vico FJ, Jimenez-Noguera E, Strizzi JM, Martinez-Martinez I, Garcia-Fernandez L, Seijas-Vazquez ML, Torres-Alegre P, Fernández-Campos MA, Gimenez-Sanchez F. Effectiveness of a Hand Hygiene Program at Child Care Centers: A Cluster Randomized Trial. Pediatrics 2018; 142:peds.2018-1245. [PMID: 30297500 DOI: 10.1542/peds.2018-1245] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Respiratory infections (RIs) are an important cause of morbidity and excessive antibiotic prescriptions in children attending day care centers (DCCs). We aimed to assess the effectiveness of an educational and hand hygiene program in DCCs and homes in reducing RI incidence and antibiotic prescriptions in children. METHODS A cluster, randomized, controlled, and open study of 911 children aged 0 to 3 years attending 24 DCCs in Almería (Spain) with an 8-month follow-up. Two intervention groups of DCC families performed educational and hand hygiene measures, 1 with soap and water (SWG; n = 274), another with hand sanitizer (HSG; n = 339), and the control group (CG; n = 298) followed usual hand-washing procedures. RI episode rates were compared through multilevel Poisson regression models. The percentage of days missed were compared with Poisson exact tests. RESULTS There were 5211 RI episodes registered. Children in the HSG had less risk of RI episodes (incidence rate ratio [IRR]: 0.77; 95% confidence interval [CI]: 0.68-0.88) and antibiotic prescriptions (IRR: 0.69; 95% CI: 0.57-0.84) compared with the those in the CG. Children in the SWG had a higher risk of RI episodes (IRR: 1.21; 95% CI: 1.06-1.39) and antibiotic prescriptions (IRR: 1.31; 95% CI: 1.08-1.56) than those in the HSG. Pupils missed 5186 DCC days because of RIs, and the percentage of days absent was significantly lower in the HSG compared with the CG (P < .001) and the SWG (P < .001). CONCLUSIONS Hand hygiene programs that include hand sanitizer and educational measures for DCC staff, children, and parents, reduce absent days, RIs, and antibiotic prescriptions for these infections in children at DCCs.
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Affiliation(s)
| | | | | | | | | | | | - Llenalia Garcia-Fernandez
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Seplin Soluciones Estadísticas, Granada, Spain; and
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Azor-Martinez E, Cobos-Carrascosa E, Seijas-Vazquez ML, Fernández-Sánchez C, Strizzi JM, Torres-Alegre P, Santisteban-Martínez J, Gimenez-Sanchez F. Hand Hygiene Program Decreases School Absenteeism Due to Upper Respiratory Infections. THE JOURNAL OF SCHOOL HEALTH 2016; 86:873-881. [PMID: 27866386 DOI: 10.1111/josh.12454] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 03/17/2016] [Accepted: 06/22/2016] [Indexed: 05/25/2023]
Abstract
BACKGROUND We assessed the effectiveness of a handwashing program using hand sanitizer to prevent school absenteeism due to upper respiratory infections (URIs). METHODS This was a randomized, controlled, and open study on a sample of 1341 children 4-12 years old, attending 5 state schools in Almería (Spain), with an 8-month follow-up. The experimental group (EG) washed their hands with soap and water, together with using hand sanitizer, and the control group followed their usual handwashing procedures. Absenteeism rates due to URIs were compared between the 2 groups through a multivariate Poisson regression analysis. The percent of days missed in both groups were compared with a z test. RESULTS Overall, 1271 cases of school absenteeism due to URIs were registered. Schoolchildren from the EG had a 38% lower risk of absenteeism due to URIs, incidence rate ratio: 0.62, 95% confidence interval: 0.55-0.70, and a decrease in absenteeism of 0.45 episodes/child/academic year, p < .001. Pupils missed 2734 school days due to URIs and the percentage of days absent was significantly lower in the EG, p < .001. CONCLUSIONS Use of hand sanitizer plus handwashing with soap accompanied by educational support is an effective measure to reduce absenteeism due to URIs.
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Affiliation(s)
- Ernestina Azor-Martinez
- Distrito Sanitario, Atención Primaria Almería, España, C) Haza de Acosta S/N 04009, Almería, Spain
| | - Elena Cobos-Carrascosa
- Servicio de Pediatría, Hospital Torrecárdenas, Almería, España, C) Ramon y Cajal N° 11 Villanueva Mesia 18369, Granada, Spain
| | | | - Carmen Fernández-Sánchez
- Servicio de Farmacia Hospital Torrecardenas, C) Hermandad de Donantes de Sangre S/N, CP 04009, Almería, Spain
| | - Jenna M Strizzi
- Roger Williams University, 1 Old Ferry Rd, Bristol, RI 02809
| | - Pilar Torres-Alegre
- Unidad de Formación, e Investigación Distrito Almería España, C) Pablo Neruda 2, portal 12, 6° 1, 04009, Almería, Spain
| | | | - Francisco Gimenez-Sanchez
- Servicio de Pediatría, Hospital Torrecárdenas, Almería, España, C) Pepe Isbert 55, 04007, Almería. Spain
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Foddai ACG, Grant IR, Dean M. Efficacy of Instant Hand Sanitizers against Foodborne Pathogens Compared with Hand Washing with Soap and Water in Food Preparation Settings: A Systematic Review. J Food Prot 2016; 79:1040-54. [PMID: 27296611 DOI: 10.4315/0362-028x.jfp-15-492] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hands can be a vector for transmitting pathogenic microorganisms to foodstuffs and drinks, and to the mouths of susceptible hosts. Hand washing is the primary barrier to prevent transmission of enteric pathogens via cross-contamination from infected persons. Conventional hand washing involves the use of water, soap, and friction to remove dirt and microorganisms. The availability of hand sanitizing products for use when water and soap are unavailable has increased in recent years. The aim of this systematic review was to collate scientific information on the efficacy of hand sanitizers compared with washing hands with soap and water for the removal of foodborne pathogens from the hands of food handlers. An extensive literature search was carried out using three electronic databases: Web of Science, Scopus, and PubMed. Twenty-eight scientific publications were ultimately included in the review. Analysis of this literature revealed various limitations in the scientific information owing to the absence of a standardized protocol for evaluating the efficacy of hand products and variation in experimental conditions. However, despite conflicting results, scientific evidence seems to support the historical skepticism about the use of waterless hand sanitizers in food preparation settings. Water and soap appear to be more effective than waterless products for removal of soil and microorganisms from hands. Alcohol-based products achieve rapid and effective inactivation of various bacteria, but their efficacy is generally lower against nonenveloped viruses. The presence of food debris significantly affects the microbial inactivation rate of hand sanitizers.
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Affiliation(s)
- Antonio C G Foddai
- Department of Life Sciences, School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, Scotland, UK
| | - Irene R Grant
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, Belfast BT9 5BN, Northern Ireland, UK
| | - Moira Dean
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, Belfast BT9 5BN, Northern Ireland, UK.
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Ionidis G, Hübscher J, Jack T, Becker B, Bischoff B, Todt D, Hodasa V, Brill FHH, Steinmann E, Steinmann J. Development and virucidal activity of a novel alcohol-based hand disinfectant supplemented with urea and citric acid. BMC Infect Dis 2016; 16:77. [PMID: 26864562 PMCID: PMC4750209 DOI: 10.1186/s12879-016-1410-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/02/2016] [Indexed: 11/16/2022] Open
Abstract
Background Hand disinfectants are important for the prevention of virus transmission in the health care system and environment. The development of broad antiviral spectrum hand disinfectants with activity against enveloped and non-enveloped viruses is limited due to a small number of permissible active ingredients able to inactivate viruses. Methods A new hand disinfectant was developed based upon 69.39 % w/w ethanol and 3.69 % w/w 2-propanol. Different amounts of citric acid and urea were added in order to create a virucidal claim against poliovirus (PV), adenovirus type 5 (AdV) and polyomavirus SV40 (SV40) as non-enveloped test viruses in the presence of fetal calf serum (FCS) as soil load. The exposure time was fixed to 60 s. Results With the addition of 2.0 % citric acid and 2.0 % urea an activity against the three test viruses was achieved demonstrating a four log10 reduction of viral titers. Furthermore, this formulation was able to inactivate PV, AdV, SV40 and murine norovirus (MNV) in quantitative suspension assays according to German and European Guidelines within 60 s creating a virucidal claim. For inactivation of vaccinia virus and bovine viral diarrhea virus 15 s exposure time were needed to demonstrate a 4 log10 reduction resulting in a claim against enveloped viruses. Additionally, it is the first hand disinfectant passing a carrier test with AdV and MNV. Conclusions In conclusion, this new formulation with a low alcohol content, citric acid and urea is capable of inactivating all enveloped and non-enveloped viruses as indicated in current guidelines and thereby contributing as valuable addition to the hand disinfection portfolio.
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Affiliation(s)
- Georgios Ionidis
- Oro Clean Chemie AG, Allmendstrasse 21, 8320, Fehraltorf, Switzerland.
| | - Judith Hübscher
- Oro Clean Chemie AG, Allmendstrasse 21, 8320, Fehraltorf, Switzerland.
| | - Thomas Jack
- Oro Clean Chemie AG, Allmendstrasse 21, 8320, Fehraltorf, Switzerland.
| | - Britta Becker
- Dr. Brill + Partner GmbH, Institute for Hygiene and Microbiology, Norderoog 2, 28259, Bremen, Germany.
| | - Birte Bischoff
- Dr. Brill + Partner GmbH, Institute for Hygiene and Microbiology, Norderoog 2, 28259, Bremen, Germany.
| | - Daniel Todt
- Institute for Experimental Virology, TWINCORE Centre for Experimental and Clinical Infection Research; a joint venture between the Medical School Hannover (MHH) and the Helmholtz Centre for Infection Research (HZI), Feodor-Lynen-Str. 7, 30625, Hannover, Germany.
| | - Veronika Hodasa
- Dr. Brill + Partner GmbH, Institute for Hygiene and Microbiology, Norderoog 2, 28259, Bremen, Germany.
| | - Florian H H Brill
- Dr. Brill + Partner GmbH, Institute for Hygiene and Microbiology, Norderoog 2, 28259, Bremen, Germany.
| | - Eike Steinmann
- Institute for Experimental Virology, TWINCORE Centre for Experimental and Clinical Infection Research; a joint venture between the Medical School Hannover (MHH) and the Helmholtz Centre for Infection Research (HZI), Feodor-Lynen-Str. 7, 30625, Hannover, Germany.
| | - Jochen Steinmann
- Dr. Brill + Partner GmbH, Institute for Hygiene and Microbiology, Norderoog 2, 28259, Bremen, Germany.
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Abstract
BACKGROUND Medical professionals routinely carry out surgical hand antisepsis before undertaking invasive procedures to destroy transient micro-organisms and inhibit the growth of resident micro-organisms. Antisepsis may reduce the risk of surgical site infections (SSIs) in patients. OBJECTIVES To assess the effects of surgical hand antisepsis on preventing surgical site infections (SSIs) in patients treated in any setting. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony-forming units (CFUs) of bacteria on the hands of the surgical team. SEARCH METHODS In June 2015 for this update, we searched: The Cochrane Wounds Group Specialized Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations) and EBSCO CINAHL. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA Randomised controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions. DATA COLLECTION AND ANALYSIS Three authors independently assessed studies for inclusion and trial quality and extracted data. MAIN RESULTS Fourteen trials were included in the updated review. Four trials reported the primary outcome, rates of SSIs, while 10 trials reported number of CFUs but not SSI rates. In general studies were small, and some did not present data or analyses that could be easily interpreted or related to clinical outcomes. These factors reduced the quality of the evidence. SSIsOne study randomised 3317 participants to basic hand hygiene (soap and water) versus an alcohol rub plus additional hydrogen peroxide. There was no clear evidence of a difference in the risk of SSI (risk ratio (RR) 0.97, 95% CI 0.77 to 1.23, moderate quality evidence downgraded for imprecision).One study (500 participants) compared alcohol-only rub versus an aqueous scrub and found no clear evidence of a difference in the risk of SSI (RR 0.56, 95% CI 0.23 to 1.34, very low quality evidence downgraded for imprecision and risk of bias).One study (4387 participants) compared alcohol rubs with additional active ingredients versus aqueous scrubs and found no clear evidence of a difference in SSI (RR 1.02, 95% CI 0.70 to 1.48, low quality evidence downgraded for imprecision and risk of bias).One study (100 participants) compared an alcohol rub with an additional ingredient versus an aqueous scrub with a brush and found no evidence of a difference in SSI (RR 0.50, 95% CI 0.05 to 5.34, low quality evidence downgraded for imprecision). CFUsThe review presents results for a number of comparisons; key findings include the following.Four studies compared different aqueous scrubs in reducing CFUs on hands.Three studies found chlorhexidine gluconate scrubs resulted in fewer CFUs than povidone iodine scrubs immediately after scrubbing, 2 hours after the initial scrub and 2 hours after subsequent scrubbing. All evidence was low or very low quality, with downgrading typically for imprecision and indirectness of outcome. One trial comparing a chlorhexidine gluconate scrub versus a povidone iodine plus triclosan scrub found no clear evidence of a difference-this was very low quality evidence (downgraded for risk of bias, imprecision and indirectness of outcome).Four studies compared aqueous scrubs versus alcohol rubs containing additional active ingredients and reported CFUs. In three comparisons there was evidence of fewer CFUs after using alcohol rubs with additional active ingredients (moderate or very low quality evidence downgraded for imprecision and indirectness of outcome). Evidence from one study suggested that an aqueous scrub was more effective in reducing CFUs than an alcohol rub containing additional ingredients, but this was very low quality evidence downgraded for imprecision and indirectness of outcome.Evidence for the effectiveness of different scrub durations varied. Four studies compared the effect of different durations of scrubs and rubs on the number of CFUs on hands. There was evidence that a 3 minute scrub reduced the number of CFUs compared with a 2 minute scrub (very low quality evidence downgraded for imprecision and indirectness of outcome). Data on other comparisons were not consistent, and interpretation was difficult. All further evidence was low or very low quality (typically downgraded for imprecision and indirectness).One study compared the effectiveness of using nail brushes and nail picks under running water prior to a chlorhexidine scrub on the number of CFUs on hands. It was unclear whether there was a difference in the effectiveness of these different techniques in terms of the number of CFUs remaining on hands (very low quality evidence downgraded due to imprecision and indirectness). AUTHORS' CONCLUSIONS There is no firm evidence that one type of hand antisepsis is better than another in reducing SSIs. Chlorhexidine gluconate scrubs may reduce the number of CFUs on hands compared with povidone iodine scrubs; however, the clinical relevance of this surrogate outcome is unclear. Alcohol rubs with additional antiseptic ingredients may reduce CFUs compared with aqueous scrubs. With regard to duration of hand antisepsis, a 3 minute initial scrub reduced CFUs on the hand compared with a 2 minute scrub, but this was very low quality evidence, and findings about a longer initial scrub and subsequent scrub durations are not consistent. It is unclear whether nail picks and brushes have a differential impact on the number of CFUs remaining on the hand. Generally, almost all evidence available to inform decisions about hand antisepsis approaches that were explored here were informed by low or very low quality evidence.
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Affiliation(s)
- Judith Tanner
- University of NottinghamSchool of Health SciencesQueens Medical CentreNottinghamUKNG7 2HA
| | - Jo C Dumville
- University of ManchesterSchool of Nursing, Midwifery and Social WorkManchesterUKM13 9PL
| | - Gill Norman
- University of ManchesterSchool of Nursing, Midwifery and Social WorkManchesterUKM13 9PL
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TAMIMI AH, MAXWELL S, EDMONDS SL, GERBA CP. Impact of the use of an alcohol-based hand sanitizer in the home on reduction in probability of infection by respiratory and enteric viruses. Epidemiol Infect 2015; 143:3335-41. [PMID: 25825988 PMCID: PMC9150976 DOI: 10.1017/s0950268815000035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 12/08/2014] [Accepted: 01/07/2015] [Indexed: 11/06/2022] Open
Abstract
The goal of this study was to determine the reduction in risk of infection by viruses with the use of an alcohol-based hand sanitizer, used in addition to routine hand washing, in family members in households. A quantitative microbial risk model was used to determine the probability of infection from the concentration of virus on the hands. The model incorporated variation in hand size, frequency of touching orifices (nose, mouth, eyes), and percent transfer to the site of infection, as well as, dose-response for each virus. Data on the occurrence of virus on household members' hands from an intervention study using MS-2 coliphage was used to determine the reduction of viruses on the hands pre- and post-intervention. It was found that the risk of rhinovirus, rotavirus or norovirus infection after the intervention was reduced by 47-98% depending upon the initial concentration of virus on the hands.
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Affiliation(s)
- A. H. TAMIMI
- Department of Soil, Water and Environmental Science, University of Arizona, Tucson, AZ, USA
| | - S. MAXWELL
- Department of Soil, Water and Environmental Science, University of Arizona, Tucson, AZ, USA
| | - S. L. EDMONDS
- Research and Development, GOJO Industries, Akron, OH, USA
| | - C. P. GERBA
- Department of Soil, Water and Environmental Science, University of Arizona, Tucson, AZ, USA
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15
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Gerba CP, Pepper IL. Domestic and Indoor Microbiology. Environ Microbiol 2015. [DOI: 10.1016/b978-0-12-394626-3.00030-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Does the use of alcohol-based hand gel sanitizer reduce travellers' diarrhea and gastrointestinal upset? : A preliminary survey. Travel Med Infect Dis 2014; 12:494-8. [DOI: 10.1016/j.tmaid.2014.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/03/2014] [Accepted: 07/08/2014] [Indexed: 11/20/2022]
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17
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Azor-Martínez E, Gonzalez-Jimenez Y, Seijas-Vazquez ML, Cobos-Carrascosa E, Santisteban-Martínez J, Martínez-López JM, Jimenez-Noguera E, Galan-Requena MDM, Garrido-Fernández P, Strizzi JM, Gimenez-Sanchez F. The impact of common infections on school absenteeism during an academic year. Am J Infect Control 2014; 42:632-7. [PMID: 24837113 DOI: 10.1016/j.ajic.2014.02.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 02/18/2014] [Accepted: 02/18/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND School absenteeism because of infections is one of the most important problems facing both public and private primary schools. The aim of the study was to assess the impact of infections on school absenteeism and their reduction with a handwashing program using hand sanitizer. METHODS The study was an 8-month-long, randomized, controlled open study (N = 1,609 children, aged 4-12 years old) at 5 state schools in Almeria (Spain). The experimental group (EG) washed their hands with soap and water, complemented with the use of hand sanitizer, and the control group (CG) followed the usual handwashing procedure. The total number of episodes and days missed as well as those because of upper respiratory infections and gastrointestinal infections were compared in both groups with a Z-test. RESULTS The students were absent 12,386 days in 7,945 episodes. The incidence of total absent episodes and percent of missed days, including those because of upper respiratory infections and gastrointestinal infections, were significantly lower in the EG than the CG (P < .001), and this was maintained through the flu pandemic period. CONCLUSION School absenteeism because of infections in schools is reduced when a hand hygiene program utilizing sanitizing gels is properly carried out, especially during the flu season.
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Effectiveness of a multifactorial handwashing program to reduce school absenteeism due to acute gastroenteritis. Pediatr Infect Dis J 2014; 33:e34-9. [PMID: 24096730 DOI: 10.1097/inf.0000000000000040] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute gastroenteritis (AGE) is one of the most common diseases among children and an important cause of school absenteeism. The aim of this study was to assess the effectiveness of a handwashing program using hand sanitizers for the prevention of school absenteeism due to AGE. METHODS A randomized, controlled and open study of a sample of 1341 children between 4 and 12 years of age, attending 5 state schools in Almería (Spain), with an 8-month follow up (academic year). The experimental group (EG) washed their hands with soap and water, complementing this with the use of a hand sanitizer, and the control group (CG) followed the usual handwashing procedure. Absenteeism rates due GI were compared between the 2 groups through the multivariate Poisson regression analysis. Percent days absent in both groups were compared with a Z-test. RESULTS 446 cases of school absenteeism due to AGE were registered. The school children from the EG had a 36% lower risk of absenteeism due to AGE (IRR: 0.64, 95% confidence interval: 0.52-0.78) and a decrease in absenteeism of 0.13 episodes/child/academic year (0.27 of EG vs 0.40 CG/episodes/child/academic year, P < 0.001). Pupils missed 725 school days due to AGE and absent days was significantly lower in the EG (EG: 0.31%, 95% confidence interval: 0.28-0.35 vs. CG: 0.44%, 95% confidence interval: 0.40-0.48, P < 0.001). CONCLUSIONS The use of hand sanitizer as a complement to handwashing with soap is an efficient measure to reduce absent days and the number of school absenteeism cases due to AGE.
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A risk assessment approach to use of antimicrobials in the home to prevent spread of infection. Am J Infect Control 2013; 41:S87-93. [PMID: 23622757 DOI: 10.1016/j.ajic.2013.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 12/19/2012] [Accepted: 01/04/2013] [Indexed: 12/31/2022]
Abstract
Home and everyday life hygiene is a key part of the public health strategy to reduce infectious disease, but an effective code of practice is required. This short review summarizes the basic scientific principles of a risk-based approach to home hygiene where hygiene procedures are applied at critical points at appropriate times. It suggests that, although detergent-based cleaning can be used to break the chain of infection, in some cases an antimicrobial agent is required.
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Klick B, Nishiura H, Cowling BJ. Optimal design of intervention studies to prevent influenza in healthy cohorts. PLoS One 2012; 7:e35166. [PMID: 22514718 PMCID: PMC3325991 DOI: 10.1371/journal.pone.0035166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 03/13/2012] [Indexed: 11/19/2022] Open
Abstract
Background Influenza cohort studies, in which participants are monitored for infection over an epidemic period, are invaluable in assessing the effectiveness of control measures such as vaccination, antiviral prophylaxis and non-pharmaceutical interventions (NPIs). Influenza infections and illnesses can be identified through a number of approaches with different costs and logistical requirements. Methodology and Principal Findings In the context of a randomized controlled trial of an NPI with a constrained budget, we used a simulation approach to examine which approaches to measuring outcomes could provide greater statistical power to identify an effective intervention against confirmed influenza. We found that for a short epidemic season, the optimal design was to collect respiratory specimens at biweekly intervals, as well as following report of acute respiratory illness (ARI), for virologic testing by reverse transcription polymerase chain reaction (RT-PCR). Collection of respiratory specimens only from individuals reporting ARI was also an efficient design particularly for studies in settings with longer periods of influenza activity. Collection of specimens only from individuals reporting a febrile ARI was less efficient. Collection and testing of sera before and after influenza activity appeared to be inferior to collection of respiratory specimens for RT-PCR confirmation of acute infections. The performance of RT-PCR was robust to uncertainty in the costs and diagnostic performance of RT-PCR and serological tests. Conclusions and Significance Our results suggest that unless the sensitivity or specificity of serology can be increased RT-PCR will remain as the preferable outcome measure in NPI studies. Routine collection of specimens for RT-PCR testing even when study participants do not report acute respiratory illness appears to be the most cost efficient design under most scenarios.
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Affiliation(s)
- Brendan Klick
- Infectious Disease Epidemiology Group, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People's Republic of China
| | - Hiroshi Nishiura
- Infectious Disease Epidemiology Group, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People's Republic of China
- PRESTO, Japan Science and Technology Agency, Saitama, Japan
| | - Benjamin J. Cowling
- Infectious Disease Epidemiology Group, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People's Republic of China
- * E-mail:
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Kinnula S, Buettcher M, Tapiainen T, Renko M, Vepsäläinen K, Lantto R, Heininger U, Uhari M. Hospital-associated infections in children: a prospective post-discharge follow-up survey in three different paediatric hospitals. J Hosp Infect 2012; 80:17-24. [DOI: 10.1016/j.jhin.2011.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 09/25/2011] [Indexed: 10/15/2022]
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Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al‐Ansary LA, Bawazeer GA, van Driel ML, Nair NS, Jones MA, Thorning S, Conly JM. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev 2011; 2011:CD006207. [PMID: 21735402 PMCID: PMC6993921 DOI: 10.1002/14651858.cd006207.pub4] [Citation(s) in RCA: 242] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a global threat. Antiviral drugs and vaccinations may be insufficient to prevent their spread. OBJECTIVES To review the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses. SEARCH STRATEGY We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2010, Issue 3), which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to October 2010), OLDMEDLINE (1950 to 1965), EMBASE (1990 to October 2010), CINAHL (1982 to October 2010), LILACS (2008 to October 2010), Indian MEDLARS (2008 to October 2010) and IMSEAR (2008 to October 2010). SELECTION CRITERIA In this update, two review authors independently applied the inclusion criteria to all identified and retrieved articles and extracted data. We scanned 3775 titles, excluded 3560 and retrieved full papers of 215 studies, to include 66 papers of 67 studies. We included physical interventions (screening at entry ports, isolation, quarantine, social distancing, barriers, personal protection, hand hygiene) to prevent respiratory virus transmission. We included randomised controlled trials (RCTs), cohorts, case-controls, before-after and time series studies. DATA COLLECTION AND ANALYSIS We used a standardised form to assess trial eligibility. We assessed RCTs by randomisation method, allocation generation, concealment, blinding and follow up. We assessed non-RCTs for potential confounders and classified them as low, medium and high risk of bias. MAIN RESULTS We included 67 studies including randomised controlled trials and observational studies with a mixed risk of bias. A total number of participants is not included as the total would be made up of a heterogenous set of observations (participant people, observations on participants and countries (object of some studies)). The risk of bias for five RCTs and most cluster-RCTs was high. Observational studies were of mixed quality. Only case-control data were sufficiently homogeneous to allow meta-analysis. The highest quality cluster-RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children. Benefit from reduced transmission from children to household members is broadly supported also in other study designs where the potential for confounding is greater. Nine case-control studies suggested implementing transmission barriers, isolation and hygienic measures are effective at containing respiratory virus epidemics. Surgical masks or N95 respirators were the most consistent and comprehensive supportive measures. N95 respirators were non-inferior to simple surgical masks but more expensive, uncomfortable and irritating to skin. Adding virucidals or antiseptics to normal handwashing to decrease respiratory disease transmission remains uncertain. Global measures, such as screening at entry ports, led to a non-significant marginal delay in spread. There was limited evidence that social distancing was effective, especially if related to the risk of exposure. AUTHORS' CONCLUSIONS Simple and low-cost interventions would be useful for reducing transmission of epidemic respiratory viruses. Routine long-term implementation of some measures assessed might be difficult without the threat of an epidemic.
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Affiliation(s)
- Tom Jefferson
- University of OxfordCentre for Evidence Based MedicineOxfordUKOX2 6GG
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)University DriveGold CoastQueenslandAustralia4229
| | - Liz Dooley
- Bond UniversityFaculty of Health Sciences and MedicineGold CoastQueenslandAustralia4229
| | - Eliana Ferroni
- Regional Center for Epidemiology, Veneto RegionEpidemiological System of the Veneto RegionPassaggio Gaudenzio 1PadovaItaly35131
| | - Lubna A Al‐Ansary
- World Health OrganizationDepartment of Health Metrics and MeasurementGenevaSwitzerland
| | - Ghada A Bawazeer
- King Saud UniversityDepartment of Clinical Pharmacy, College of PharmacyP.O. Box 22452RiyadhSaudi Arabia11495
| | - Mieke L van Driel
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineBrisbaneQueenslandAustralia4029
- Ghent UniversityDepartment of Public Health and Primary CareCampus UZ 6K3, Corneel Heymanslaan 10GhentBelgium9000
| | - N Sreekumaran Nair
- Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) (Institution of National Importance Under Ministry of Health and Family Welfare, Government of India)Department of Medical Biometrics & Informatics (Biostatistics)4th Floor, Administrative BlockDhanvantri NagarPuducherryIndia605006
| | - Mark A Jones
- Bond UniversityInstitute for Evidence‐Based Healthcare11 University DriveRobinaGold CoastQueenslandAustralia4226
| | - Sarah Thorning
- Gold Coast Hospital and Health ServiceGCUH LibraryLevel 1, Block E, GCUHSouthportQueenslandAustralia4215
| | - John M Conly
- Foothills Medical Centre, Room 930, North Tower1403‐29th St NWCalgaryABCanadaT2N 2T9
- WHO. Infection Prevention and Control in Health CareDepartment of Global Alert and Response ‐ Health Security and EnvironmentOffice L420, 20, Avenue AppiaGenevaSwitzerlandCH‐1211
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Liu P, Macinga DR, Fernandez ML, Zapka C, Hsiao HM, Berger B, Arbogast JW, Moe CL. Comparison of the Activity of Alcohol-Based Handrubs Against Human Noroviruses Using the Fingerpad Method and Quantitative Real-Time PCR. FOOD AND ENVIRONMENTAL VIROLOGY 2011; 3:35-42. [PMID: 35255643 DOI: 10.1007/s12560-011-9053-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Accepted: 02/01/2011] [Indexed: 06/14/2023]
Abstract
Noroviruses (NoV) are the most common cause of acute nonbacterial gastroenteritis in the United States, and human hands play an important role in their transmission. Little is known about the efficacy of hand hygiene agents against these highly infectious pathogens. We investigated the activity of seven commercially available hand hygiene products against human noroviruses by in vivo fingerpad tests. The in vivo activity of alcohol-based handrubs ranged from 0.10 to 3.74 log reduction and was not solely dependent on alcohol concentration. A handrub (VF481) based on 70% ethanol and a blend of other skin care ingredients reduced Norwalk virus (NV) by 3.74 log in 15 s and provided significantly greater NV reduction than all the other products tested (P < 0.001). Furthermore, VF481 was the most effective product tested against the NoV genogroup II strains Snow Mountain virus (GII.2) and a GII.4 strain. These results demonstrate that alcohol by itself is not effective against NoV, but effective formulation of alcohol-based handrubs can achieve significant reduction of norovirus RNA on fingers.
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Affiliation(s)
- Pengbo Liu
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road, CNR 6043, Atlanta, GA, 30322, USA
| | | | - Marina L Fernandez
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road, CNR 6050, Atlanta, GA, 30322, USA
| | | | - Hui-Mien Hsiao
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road, CNR 6041, Atlanta, GA, 30322, USA
| | - Brynn Berger
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30322, USA
| | | | - Christine L Moe
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road, CNR 6041, Atlanta, GA, 30322, USA.
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Sattar SA, Ali M, Tetro JA. In vivo comparison of two human norovirus surrogates for testing ethanol-based handrubs: the mouse chasing the cat! PLoS One 2011; 6:e17340. [PMID: 21390325 PMCID: PMC3044752 DOI: 10.1371/journal.pone.0017340] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 01/29/2011] [Indexed: 11/25/2022] Open
Abstract
Human noroviruses (HuNoV), a major cause of acute gastroenteritis worldwide, cannot be readily cultured in the lab. Therefore, a feline calicivirus (FCV) is often used as its surrogate to, among other things, test alcohol-based handrubs (ABHR). The more recent laboratory culture of a mouse norovirus (MNV) provides an alternative. While MNV is closer to HuNoV in several respects, to date, no comparative testing of FCV and MNV survival and inactivation on human hands has been performed. This study was designed to address the knowledge gap. The rates of loss in viability during drying on hands were -1.91 and -1.65% per minute for FCV and MNV, respectively. When the contaminated skin was exposed for 20 s to either a commercial ABHR with 62% (v/v) ethanol or to 75% (v/v) ethanol in water, FCV infectivity was reduced by <1 log₁₀ while that of MNV by nearly 2.8 log₁₀. Extending the contact time to 30 s reduced the FCV titer by almost 2 log₁₀ by both test substances and that of MNV by >3.5 log₁₀ by the commercial ABHR while 75% ethanol did not show any noticeable improvement in activity as compared to the 20 s contact. An 80% (v/v) aqueous solution of ethanol gave only a 1.75 log₁₀ reduction in MNV activity after 20 s. The results show significant differences in the ethanol susceptibility of FCV and MNV in contact times relevant to field use of ABHR and also that 62% ethanol was a more effective virucide than either 75% or 80% ethanol. These findings indicate the need for a review of the continuing use of FCV as a surrogate for HuNoV.
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Affiliation(s)
- Syed A Sattar
- Center for Research on Environmental Microbiology (CREM), University of Ottawa, Ottawa, Ontario, Canada.
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Todd ECD, Michaels BS, Holah J, Smith D, Greig JD, Bartleson CA. Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 10. Alcohol-based antiseptics for hand disinfection and a comparison of their effectiveness with soaps. J Food Prot 2010; 73:2128-40. [PMID: 21219730 DOI: 10.4315/0362-028x-73.11.2128] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Alcohol compounds are increasingly used as a substitute for hand washing in health care environments and some public places because these compounds are easy to use and do not require water or hand drying materials. However, the effectiveness of these compounds depends on how much soil (bioburden) is present on the hands. Workers in health care environments and other public places must wash their hands before using antiseptics and/or wearing gloves. However, alcohol-based antiseptics, also called rubs and sanitizers, can be very effective for rapidly destroying some pathogens by the action of the aqueous alcohol solution without the need for water or drying with towels. Alcohol-based compounds seem to be the most effective treatment against gram-negative bacteria on lightly soiled hands, but antimicrobial soaps are as good or better when hands are more heavily contaminated. Instant sanitizers have no residual effect, unlike some antimicrobial soaps that retain antimicrobial activity after the hygienic action has been completed, e.g., after hand washing. Many alcohol-based hand rubs have antimicrobial agents added to them, but each formulation must be evaluated against the target pathogens in the environment of concern before being considered for use. Wipes also are widely used for quick cleanups of hands, other body parts, and surfaces. These wipes often contain alcohol and/or antimicrobial compounds and are used for personal hygiene where water is limited. However, antiseptics and wipes are not panaceas for every situation and are less effective in the presence of more than a light soil load and against most enteric viruses.
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Affiliation(s)
- Ewen C D Todd
- Department of Advertising, Public Relations and Retailing, Michigan State University, East Lansing, Michigan 48824, USA.
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Todd ECD, Michaels BS, Smith D, Greig JD, Bartleson CA. Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 9. Washing and drying of hands to reduce microbial contamination. J Food Prot 2010; 73:1937-55. [PMID: 21067683 DOI: 10.4315/0362-028x-73.10.1937] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
During various daily activities at home and work, hands quickly become contaminated. Some activities increase the risk of finger contamination by pathogens more than others, such as the use of toilet paper to clean up following a diarrheal episode, changing the diaper of a sick infant, blowing a nose, or touching raw food materials. Many foodborne outbreak investigation reports have identified the hands of food workers as the source of pathogens in the implicated food. The most convenient and efficient way of removing pathogens from hands is through hand washing. Important components of hand washing are potable water for rinsing and soaps to loosen microbes from the skin. Hand washing should occur after any activity that soils hands and certainly before preparing, serving, or eating food. Antimicrobial soaps are marginally more effective than plain soaps, but constant use results in a buildup of the antimicrobial compound on the skin. The time taken to wash hands and the degree of friction generated during lathering are more important than water temperature for removing soil and microorganisms. However, excessive washing and scrubbing can cause skin damage and infections. Drying hands with a towel removes pathogens first by friction during rubbing with the drying material and then by wicking away the moisture into that material. Paper rather than cloth towels should be encouraged, although single-use cloth towels are present in the washrooms of higher class hotels and restaurants. Warm air dryers remove moisture and any surface microorganisms loosened by washing from hands by evaporation while the hands are rubbed together vigorously; however, these dryers take too long for efficient use. The newer dryers with high-speed air blades can achieve dryness in 10 to 15 s without hand rubbing.
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Affiliation(s)
- Ewen C D Todd
- Department of Advertising Public Relations and Retailing, Michigan State University, East Lansing, Michigan 48824, USA.
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Prospective surveillance of nosocomial viral infections during and after hospitalization at a university children's hospital. Pediatr Infect Dis J 2010; 29:950-6. [PMID: 20879093 DOI: 10.1097/inf.0b013e3181e32d97] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In Switzerland 5% to 10% of hospitalized adults acquire nosocomial infections (NI) but few data are available in children. Most former studies on NI in hospitalized children analyzed specific units or pathogens and neglected the postdischarge period. We aimed to prospectively assess viral NI occurring during and shortly after hospitalization in children. METHODS Prospective surveillance was performed during a 24-month period. Electronic standardized questionnaires were completed for each patient by physicians during hospital stay. On a ward-based rotational schedule, follow-up information was obtained from a subset of patients 1 week after hospital discharge. NI were defined using CDC recommendations. RESULTS Overall, 6250 patients (34,608 patient hospitalization days, PHD) were enrolled and 1272 patients were recruited for postdischarge surveillance. Mean hospitalization duration was 5 days. Fifty-two (0.8%) patients acquired 54 viral NI during hospitalization and 12 patients (1.1%) acquired 12 viral NI after hospital discharge (NI incidence: 1.9 per 1000 PHD including follow-up period). NI rate in infants was higher compared with children >12 months old (2.0% vs. 0.8%; P 0.05) and the infant ward also had the highest incidence (4.0 NI per 1000 PHD). Most NI were gastrointestinal tract infections with 55% caused by rotavirus infection. NI rates were highest between November and March. CONCLUSIONS A significant part of NI will only be detected if surveillance includes the immediate postdischarge period. Given the strong seasonality of pediatric NI, intensifying hygiene measurements particularly on infant wards and prior to the cold season would be beneficial in reducing NI incidence.
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Jefferson T, Del Mar C, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, van Driel ML, Nair S, Foxlee R, Rivetti A. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev 2010:CD006207. [PMID: 20091588 DOI: 10.1002/14651858.cd006207.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a world-wide threat. Antiviral drugs and vaccinations may be insufficient to prevent catastrophe. OBJECTIVES To systematically review the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 2); MEDLINE (1966 to May 2009); OLDMEDLINE (1950 to 1965); EMBASE (1990 to May 2009); and CINAHL (1982 to May 2009). SELECTION CRITERIA We scanned 2958 titles, excluded 2790 and retrieved the full papers of 168 trials, to include 59 papers of 60 studies. We included any physical interventions (isolation, quarantine, social distancing, barriers, personal protection and hygiene) to prevent transmission of respiratory viruses. We included the following study designs: randomised controlled trials (RCTs), cohorts, case controls, cross-over, before-after, and time series studies. DATA COLLECTION AND ANALYSIS We used a standardised form to assess trial eligibility. RCTs were assessed by: randomisation method; allocation generation; concealment; blinding; and follow up. Non-RCTs were assessed for the presence of potential confounders, and classified into low, medium, and high risks of bias. MAIN RESULTS The risk of bias for the four RCTs, and most cluster RCTs, was high. The observational studies were of mixed quality. Only case-control data were sufficiently homogeneous to allow meta-analysis.The highest quality cluster RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children. Additional benefit from reduced transmission from children to other household members is broadly supported in results of other study designs, where the potential for confounding is greater. Six case-control studies suggested that implementing barriers to transmission, isolation, and hygienic measures are effective at containing respiratory virus epidemics. We found limited evidence that N95 respirators were superior to simple surgical masks, but were more expensive, uncomfortable, and caused skin irritation. The incremental effect of adding virucidals or antiseptics to normal handwashing to decrease respiratory disease remains uncertain. Global measures, such as screening at entry ports, were not properly evaluated. There was limited evidence that social distancing was effective especially if related to the risk of exposure. AUTHORS' CONCLUSIONS Many simple and probably low-cost interventions would be useful for reducing the transmission of epidemic respiratory viruses. Routine long-term implementation of some of the measures assessed might be difficult without the threat of a looming epidemic.
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Affiliation(s)
- Tom Jefferson
- Vaccines Field, The Cochrane Collaboration, Via Adige 28a, Anguillara Sabazia, Roma, Italy, 00061
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Effectiveness of liquid soap and hand sanitizer against Norwalk virus on contaminated hands. Appl Environ Microbiol 2009; 76:394-9. [PMID: 19933337 DOI: 10.1128/aem.01729-09] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Disinfection is an essential measure for interrupting human norovirus (HuNoV) transmission, but it is difficult to evaluate the efficacy of disinfectants due to the absence of a practicable cell culture system for these viruses. The purpose of this study was to screen sodium hypochlorite and ethanol for efficacy against Norwalk virus (NV) and expand the studies to evaluate the efficacy of antibacterial liquid soap and alcohol-based hand sanitizer for the inactivation of NV on human finger pads. Samples were tested by real-time reverse transcription-quantitative PCR (RT-qPCR) both with and without a prior RNase treatment. In suspension assay, sodium hypochlorite concentrations of >or=160 ppm effectively eliminated RT-qPCR detection signal, while ethanol, regardless of concentration, was relatively ineffective, giving at most a 0.5 log(10) reduction in genomic copies of NV cDNA. Using the American Society for Testing and Materials (ASTM) standard finger pad method and a modification thereof (with rubbing), we observed the greatest reduction in genomic copies of NV cDNA with the antibacterial liquid soap treatment (0.67 to 1.20 log(10) reduction) and water rinse only (0.58 to 1.58 log(10) reduction). The alcohol-based hand sanitizer was relatively ineffective, reducing the genomic copies of NV cDNA by only 0.14 to 0.34 log(10) compared to baseline. Although the concentrations of genomic copies of NV cDNA were consistently lower on finger pad eluates pretreated with RNase compared to those without prior RNase treatment, these differences were not statistically significant. Despite the promise of alcohol-based sanitizers for the control of pathogen transmission, they may be relatively ineffective against the HuNoV, reinforcing the need to develop and evaluate new products against this important group of viruses.
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Tomblyn M, Chiller T, Einsele H, Gress R, Sepkowitz K, Storek J, Wingard JR, Young JAH, Boeckh MJ, Boeckh MA. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant 2009; 15:1143-238. [PMID: 19747629 PMCID: PMC3103296 DOI: 10.1016/j.bbmt.2009.06.019] [Citation(s) in RCA: 1138] [Impact Index Per Article: 75.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 06/23/2009] [Indexed: 02/07/2023]
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Rotter M, Sattar S, Dharan S, Allegranzi B, Mathai E, Pittet D. Methods to evaluate the microbicidal activities of hand-rub and hand-wash agents. J Hosp Infect 2009; 73:191-9. [PMID: 19729223 DOI: 10.1016/j.jhin.2009.06.024] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 06/16/2009] [Indexed: 11/16/2022]
Abstract
In vitro carrier tests, suspension tests, time-kill curves, and determinations of minimum inhibitory concentrations to evaluate the microbicidal activities of hand antiseptics provide only a preliminary indication of the antimicrobial spectrum and speed of action of a given formulation. Ex vivo testing with human or animal skin at human skin temperature and at contact times reflecting field conditions may give a better indication of a formulation's ability to tackle hand-transmitted pathogens. Field testing of hands for levels of skin microbiota before and after antisepsis may be easier to perform, but it is subject to many uncontrollable factors. Whereas randomised clinical trials may be the ultimate approach to assess the effectiveness of hand hygiene protocols and products in preventing microbial cross-transmission and, ultimately, infections, they can be prohibitively expensive, time-consuming, difficult to design, and therefore impractical. Hence, the primary emphasis should be on in vivo testing on human hands, using a well-designed protocol that closely simulates the recommended field use of the formulation, and possibly followed by clinical studies. The use of these method is the most likely to yield useful data on the potential of a formulation to interrupt the spread of pathogens transmitted by hands in healthcare settings. This review provides a critical assessment of the methods currently used to meet regulatory requirements for hand antiseptics in Europe and North America.
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Affiliation(s)
- M Rotter
- Institute of Hygiene and Medical Microbiology, Medical University of Vienna, Vienna, Austria
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Kinnula S, Tapiainen T, Renko M, Uhari M. Safety of alcohol hand gel use among children and personnel at a child day care center. Am J Infect Control 2009; 37:318-21. [PMID: 18945516 DOI: 10.1016/j.ajic.2008.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 06/06/2008] [Accepted: 06/08/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Alcohol hand gels (AHG) have been used by children in child day care centers (CDCCs) to prevent the transmission of microbes. Because parents and personnel have been concerned about the safety of AHGs, we conducted a trial to assess this. METHODS A total of 82 children age 3.5 to 7.2 years (mean, 5.7 years) at 2 CDCCs rubbed their hands with AHG. Alcohol concentrations in expiratory air were measured using an official police alcometer after 15 and 60 minutes. We also conducted a questionnaire survey asking how commonly AHGs were used in CDCCs, obtaining 128 answers from 68 CDCCs (with more than 1 person responding in 6 CDCCs). RESULTS All of the alcometer readings were < 0.01 per thousand, although up to 30 contacts with the mucous membranes (mean, 2.4) occurred during the first 15 minutes. An AHG was used in all 68 CDCCs, but only by adults at 11 of them. The most common occasions for using an AHG were before serving food and after cleaning secretions. One case of fire occurred when a worker lit a fire while his hands were covered with AHG. Personnel were most concerned about situations in which children put their fingers into their mouth or eyes after using an AHG. CONCLUSION The use of an AHG in CDCCs is safe. Even though children tend to put their hands into their mouth after disinfection, no significant amount of alcohol is absorbed.
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Jefferson T, Foxlee R, Del Mar C, Dooley L, Ferroni E, Hewak B, Prabhala A, Nair S, Rivetti A. Cochrane Review: Interventions for the interruption or reduction of the spread of respiratory viruses. ACTA ACUST UNITED AC 2008; 3:951-1013. [PMID: 32313518 PMCID: PMC7163512 DOI: 10.1002/ebch.291] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Viral epidemics or pandemics such as of influenza or severe acute respiratory syndrome (SARS) pose a significant threat. Antiviral drugs and vaccination may not be adequate to prevent catastrophe in such an event. Objectives To systematically review the evidence of effectiveness of interventions to interrupt or reduce the spread of respiratory viruses (excluding vaccines and antiviral drugs, which have been previously reviewed). Search strategy 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). Selection criteria We scanned 2300 titles, excluded 2162 and retrieved the full papers of 138 trials, including 49 papers of 51 studies. The quality of three randomised controlled trials (RCTs) was poor; as were most cluster RCTs. The observational studies were of mixed quality. We were only able to meta‐analyse case‐control data. We searched for any interventions to prevent viral transmission of respiratory viruses (isolation, quarantine, social distancing, barriers, personal protection and hygiene). Study design included RCTs, cohort studies, case‐control studies, cross‐over studies, before‐after, and time series studies. Data collection and analysis We scanned the titles, abstracts and full text articles using a standardised form to assess eligibility. RCTs were assessed according to randomisation method, allocation generation, concealment, blinding, and follow up. Non‐RCTs were assessed for the presence of potential confounders and classified as low, medium, and high risk of bias. Main results The highest quality cluster RCTs suggest respiratory virus spread can be prevented by hygienic measures around younger children. Additional benefit from reduced transmission from children to other household members is broadly supported in results of other study designs, where the potential for confounding is greater. The six case‐control studies suggested that implementing barriers to transmission, isolation, and hygienic measures are effective at containing respiratory virus epidemics. We found limited evidence that the more uncomfortable and expensive N95 masks were superior to simple surgical masks. The incremental effect of adding virucidals or antiseptics to normal handwashing to decrease respiratory disease remains uncertain. The lack of proper evaluation of global measures such as screening at entry ports and social distancing prevent firm conclusions about these measures. Authors' conclusions Many simple and probably low‐cost interventions would be useful for reducing the transmission of epidemic respiratory viruses. Routine long‐term implementation of some of the measures assessed might be difficult without the threat of a looming epidemic. Plain language summary Interventions to interrupt or reduce the spread of respiratory viruses Although respiratory viruses usually only cause minor disease, they can cause epidemics. Approximately 10% to 15% of people worldwide contract influenza annually, with attack rates as high as 50% during major epidemics. Global pandemic viral infections have been devastating because of their wide spread. In 2003 the severe acute respiratory syndrome (SARS) epidemic affected ˜8,000 people, killed 780, and caused an enormous social and economic crisis. A new avian influenza pandemic caused by the H5N1 strain might be more catastrophic. Single measures (particularly the use of vaccines or antiviral drugs) may be insufficient to interrupt the spread. We found 51 studies including randomised controlled trials (RCTs) and observational studies with a mixed risk of bias. Respiratory virus spread might be prevented by hygienic measures around younger children. These might also reduce transmission from children to other household members. Implementing barriers to transmission, isolation, and hygienic measures may be effective at containing respiratory virus epidemics. There was limited evidence that (more uncomfortable and expensive) N95 masks were superior to simple ones. Adding virucidals or antiseptics to normal handwashing is of uncertain benefit. There is insufficient evaluation of global measures such as screening at entry ports and social distancing.
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Affiliation(s)
- Tom Jefferson
- Vaccines Field, The Cochrane Collaboration, Roma, Italy
| | - Ruth Foxlee
- Cochrane Wounds Group, Health Sciences, University of York, York, UK
| | - Chris Del Mar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Liz Dooley
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Eliana Ferroni
- Institute of Hygiene, Catholic University of The Sacred Heart, Rome, Italy
| | | | - Adi Prabhala
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Sreekumaran Nair
- Department of Statistics, Manipal Academy of Higher Education, Manipal, India
| | - Alessandro Rivetti
- Servizio Regionale di Riferimento per l'Epidemiologia, SSEpi-SeREMI - Cochrane Vaccines Field, Azienda Sanitaria Locale ASL AL, Alessandria, Italy
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Improved inactivation of nonenveloped enteric viruses and their surrogates by a novel alcohol-based hand sanitizer. Appl Environ Microbiol 2008; 74:5047-52. [PMID: 18586970 DOI: 10.1128/aem.00487-08] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Norovirus is the leading cause of food-related illness in the United States, and contamination of ready-to-eat items by food handlers poses a high risk for disease. This study reports the in vitro (suspension test) and in vivo (fingerpad protocol) assessments of a new ethanol-based hand sanitizer containing a synergistic blend of polyquaternium polymer and organic acid, which is active against viruses of public health importance, including norovirus. When tested in suspension, the test product reduced the infectivity of the nonenveloped viruses human rotavirus (HRV), poliovirus type 1 (PV-1), and the human norovirus (HNV) surrogates feline calicivirus (FCV) F-9 and murine norovirus type 1 (MNV-1) by greater than 3 log(10) after a 30-s exposure. In contrast, a benchmark alcohol-based hand sanitizer reduced only HRV by greater than 3 log(10) and none of the additional viruses by greater than 1.2 log(10) after the same exposure. In fingerpad experiments, the test product produced a 2.48 log(10) reduction of MNV-1 after a 30-s exposure, whereas a 75% ethanol control produced a 0.91 log(10) reduction. Additionally, the test product reduced the infectivity titers of adenovirus type 5 (ADV-5) and HRV by > or =3.16 log(10) and > or =4.32 log(10), respectively, by the fingerpad assay within 15 s; and PV-1 was reduced by 2.98 log(10) in 30 s by the same method. Based on these results, we conclude that this new ethanol-based hand sanitizer is a promising option for reducing the transmission of enteric viruses, including norovirus, by food handlers and care providers.
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Kinnula S, Renko M, Tapiainen T, Knuutinen M, Uhari M. Hospital-associated infections during and after care in a paediatric infectious disease ward. J Hosp Infect 2008; 68:334-40. [DOI: 10.1016/j.jhin.2008.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Accepted: 02/04/2008] [Indexed: 10/22/2022]
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Abstract
BACKGROUND Surgical hand antisepsis, to destroy transient micro-organisms and inhibit the growth of resident micro-organisms, is routinely carried out before undertaking invasive procedures. Antisepsis may reduce the risk of surgical site infections in patients. OBJECTIVES To determine the effects of surgical hand antisepsis on the number of surgical site infections (SSIs) in patients. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony forming units (CFUs) of bacteria on the hands of the surgical team. SEARCH STRATEGY We searched the Cochrane Wounds Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials (Issue 2, 2007), MEDLINE (Week 5, 2007), CINAHL (June 2007), EMBASE (Week 23, 2007) and ZETOC (2005). SELECTION CRITERIA Randomised controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions. DATA COLLECTION AND ANALYSIS Three authors independently assessed studies for selection, trial quality and extracted data. MAIN RESULTS Ten trials were included in this review. Only one trial reported the primary outcome, rates of SSIs, and nine trials measured numbers of CFUs. One trial involving 4387 patients found alcohol rubs with additional active ingredients were as effective as aqueous scrubs in reducing SSIs. Four trials compared different alcohol rubs containing additional active ingredients with aqueous scrubs for numbers of CFUs on hands. One trial found N-duopropenide more effective than chlorhexidine and povidone iodine aqueous scrubs. One trial found 45% propanol-2, 30% propanol-1 with 0.2% ethylhexadecyldimethyl ammonium ethylsulfate more effective than chlorhexidine scrubs. One trial found no difference between 1% chlorhexidine gluconate in 61% ethyl alcohol or zinc pyrithione in 70% ethyl alcohol against aqueous povidone iodine. A fourth trial found 4% chlorhexidine gluconate scrubs more effective than chlorhexidine in 70% alcohol rubs. Four trials compared the relative effects of different aqueous scrubs in reducing CFUs on hands. Three trials found chlorhexidine gluconate scrubs were significantly more effective than povidone iodine scrubs. One trial found no difference between chlorhexidine gluconate scrubs and povidone iodine plus triclosan scrubs. Two trials found no evidence of a difference between alternative alcohol rubs in terms of the number of CFUs. Four trials compared the effect of different durations of scrubs and rubs on the numbers of CFUs on hands. One trial found no difference after the initial scrub but found subsequent three minute scrubs using chlorhexidine significantly more effective than subsequent scrubs lasting 30 seconds. One trial found that following a one minute hand wash, a three minute rub appears to be more effective than the five minute rub using alcohol disinfectant. The other comparisons demonstrated no difference. AUTHORS' CONCLUSIONS Alcohol rubs used in preparation for surgery by the scrub team are as effective as aqueous scrubbing in preventing SSIs however this evidence comes from only one, equivalence, cluster trial which did not appear to adjust for clustering. Four comparisons suggest that alcohol rubs are at least as, if not more, effective than aqueous scrubs though the quality of these is mixed and each study presents a different comparison, precluding meta analysis. There is no evidence to suggest that any particular alcohol rub is better than another. Evidence from 4 studies suggests that chlorhexidine gluconate based aqueous scrubs are more effective than povidone iodine based aqueous scrubs in terms of the numbers of CFUs on the hands. There is limited evidence regarding the effects on CFUs numbers of different scrub durations. There is no evidence regarding the effect of equipment such as brushes and sponges.
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Affiliation(s)
- J Tanner
- De Montfort University and University Hospitals Leicester, Charles Frears Campus, 266 London Road, Leicester, UK, LE2 1RQ.
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Bloomfield SF, Aiello AE, Cookson B, O'Boyle C, Larson EL. The effectiveness of hand hygiene procedures in reducing the risks of infections in home and community settings including handwashing and alcohol-based hand sanitizers. Am J Infect Control 2007. [PMCID: PMC7115270 DOI: 10.1016/j.ajic.2007.07.001] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jefferson T, Foxlee R, Del Mar C, Dooley L, Ferroni E, Hewak B, Prabhala A, Nair S, Rivetti A. Interventions for the interruption or reduction of the spread of respiratory viruses. Cochrane Database Syst Rev 2007:CD006207. [PMID: 17943895 DOI: 10.1002/14651858.cd006207.pub2] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Viral epidemics or pandemics such as of influenza or severe acute respiratory syndrome (SARS) pose a significant threat. Antiviral drugs and vaccination may not be adequate to prevent catastrophe in such an event. OBJECTIVES To systematically review the evidence of effectiveness of interventions to interrupt or reduce the spread of respiratory viruses (excluding vaccines and antiviral drugs, which have been previously reviewed). SEARCH STRATEGY 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). SELECTION CRITERIA We scanned 2300 titles, excluded 2162 and retrieved the full papers of 138 trials, including 49 papers of 51 studies. The quality of three randomised controlled trials (RCTs) was poor; as were most cluster RCTs. The observational studies were of mixed quality. We were only able to meta-analyse case-control data. We searched for any interventions to prevent viral transmission of respiratory viruses (isolation, quarantine, social distancing, barriers, personal protection and hygiene). Study design included RCTs, cohort studies, case-control studies, cross-over studies, before-after, and time series studies. DATA COLLECTION AND ANALYSIS We scanned the titles, abstracts and full text articles using a standardised form to assess eligibility. RCTs were assessed according to randomisation method, allocation generation, concealment, blinding, and follow up. Non-RCTs were assessed for the presence of potential confounders and classified as low, medium, and high risk of bias. MAIN RESULTS The highest quality cluster RCTs suggest respiratory virus spread can be prevented by hygienic measures around younger children. Additional benefit from reduced transmission from children to other household members is broadly supported in results of other study designs, where the potential for confounding is greater. The six case-control studies suggested that implementing barriers to transmission, isolation, and hygienic measures are effective at containing respiratory virus epidemics. We found limited evidence that the more uncomfortable and expensive N95 masks were superior to simple surgical masks. The incremental effect of adding virucidals or antiseptics to normal handwashing to decrease respiratory disease remains uncertain. The lack of proper evaluation of global measures such as screening at entry ports and social distancing prevent firm conclusions about these measures. AUTHORS' CONCLUSIONS Many simple and probably low-cost interventions would be useful for reducing the transmission of epidemic respiratory viruses. Routine long-term implementation of some of the measures assessed might be difficult without the threat of a looming epidemic.
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Abstract
Older age is an important factor in preparing travelers owing not only to physiologic changes and the increased probability of underlying medical conditions and prescription medications but also to immune status with regard to naturally acquired immunity versus immunization for vaccine-preventable diseases. Cardiovascular events (including myocardial infarctions and cerebrovascular accidents) account for most deaths abroad, followed by injuries. To plan for healthy travel, international travelers should be advised to seek care at least 4 to 6 weeks before departure. Travel medicine is a dynamic field because conditions worldwide are subject to rapid change. Clinicians must maintain a current base of knowledge if they will be regularly advising travelers or must set a threshold for referral to a travel medicine specialist.
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Affiliation(s)
- Christie M Reed
- Travelers' Health Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, 1600 Clifton Road, MS E-03, Atlanta, GA 30333, USA.
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Boone SA, Gerba CP. Significance of fomites in the spread of respiratory and enteric viral disease. Appl Environ Microbiol 2007; 73:1687-96. [PMID: 17220247 PMCID: PMC1828811 DOI: 10.1128/aem.02051-06] [Citation(s) in RCA: 400] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Stephanie A Boone
- University of Arizona, 1117 East Lowell Street Building 90, Room 415, Tucson, AZ 85721, USA.
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Houben E, De Paepe K, Rogiers V. Skin condition associated with intensive use of alcoholic gels for hand disinfection: a combination of biophysical and sensorial data. Contact Dermatitis 2006; 54:261-7. [PMID: 16689810 DOI: 10.1111/j.0105-1873.2006.00817.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Although hand hygiene is an important and inexpensive measure to prevent nosocomial infections in clinical settings, the compliance of healthcare workers remains low. In Europe, alcoholic hand disinfection is first choice, but there exists a limited user acceptability due to estimated adverse effects on skin condition. This study was designed to investigate skin tolerance to alcohol-based disinfecting gels and changes in skin condition depending on humectant concentration, alcohol grades, as well as type of alcohol used. A comparison of 6 alcohol-based gels was made based on a randomized double-blind study under in use conditions for 1 day. Skin condition was evaluated by measuring transepidermal water loss (TEWL), stratum corneum hydration, apparent skin pH, redness and degree of scaliness. With respect to user acceptability, all gels were sensorially evaluated using a questionnaire. We saw that none of the alcohol-based gels, applied under in use conditions, altered TEWL or caused irritation. All gels hydrated the skin, proportionally to their glycerine content, and decreased skin pH. Elevated ethanol concentrations resulted in increased scaliness. Sensorial assessment revealed less appreciation for isopropanol. From this study, it was concluded that gels containing an elevated glycerine concentration and 70% (v/v) ethanol are preferred.
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Affiliation(s)
- Evi Houben
- Department of Toxicology, Dermato-Cosmetology and Pharmacognosy, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
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Chandran A, Heinzen RR, Santosham M, Siberry GK. Nosocomial rotavirus infections: a systematic review. J Pediatr 2006; 149:441-7. [PMID: 17011311 DOI: 10.1016/j.jpeds.2006.04.054] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2005] [Revised: 03/16/2006] [Accepted: 04/25/2006] [Indexed: 10/24/2022]
Affiliation(s)
- Aruna Chandran
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205, USA
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Gaonkar TA, Geraldo I, Shintre M, Modak SM. In vivo efficacy of an alcohol-based surgical hand disinfectant containing a synergistic combination of ethylhexylglycerin and preservatives. J Hosp Infect 2006; 63:412-7. [PMID: 16759740 DOI: 10.1016/j.jhin.2006.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2005] [Accepted: 03/01/2006] [Indexed: 11/30/2022]
Abstract
Alcohol-based surgical hand disinfectants are widely available in healthcare settings. Some currently marketed alcohol-based products use active concentrations of antimicrobials to achieve the required efficacy, raising the risk for exposure to potentially irritating levels of antimicrobials. This study compares the in vitro and in vivo efficacy of an alcohol-based surgical hand preparation containing 70% ethanol and preservative levels of chlorhexidine gluconate (CHG) and benzalkonium chloride (BZK) in synergistic combination with ethylhexylglycerin (Surgicept) with a surgical hand disinfectant containing 61% ethanol and 1% CHG (Avagard). The in vivo efficacy of Surgicept and Avagard was evaluated in volunteers using the Tentative Final Monograph method of the Food and Drug Administration (FDA), and their prolonged effect against transient pathogens was compared using a pig skin model. Surgicept exceeded the FDA requirements for surgical hand antiseptic with mean log(10) reductions of 2.36, 3.3 and 3.54 in resident flora 1 min after initial application, and showed a persistent effect with mean log(10) reductions of 2.23, 2.73 and 3.3, 6h post application on days 1, 2 and 5, respectively. Surgicept showed a superior prolonged effect against transient bacteria compared with Avagard. Surgicept (70% alcohol and preservative levels of CHG and BZK) may provide similar in vivo efficacy as Avagard (61% ethanol and 1% CHG).
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Affiliation(s)
- T A Gaonkar
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
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Galtelli M, Deschamp C, Rogers J. An assessment of the prevalence of pathogenic microorganisms in the rotor wing air ambulance: one program's findings. Air Med J 2006; 25:81-4. [PMID: 16516119 DOI: 10.1016/j.amj.2005.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Mark Galtelli
- University of Mississippi Medical Center, AirCare, Jackson, Mississippi, USA.
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Hicks LA, Shepard CW, Britz PH, Erdman DD, Fischer M, Flannery BL, Peck AJ, Lu X, Thacker WL, Benson RF, Tondella ML, Moll ME, Whitney CG, Anderson LJ, Feikin DR. Two outbreaks of severe respiratory disease in nursing homes associated with rhinovirus. J Am Geriatr Soc 2006; 54:284-9. [PMID: 16460380 DOI: 10.1111/j.1532-5415.2005.00529.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To characterize illness and identify the etiology for two nursing home outbreaks of respiratory illness. DESIGN Multisite outbreak investigations; cohort. SETTING Two nursing homes in Pennsylvania. PARTICIPANTS Facility A residents (n = 170), Facility B residents (n = 124), and employees (n = 91). MEASUREMENTS Medical records for Facility A and B residents were reviewed, and employees from Facility B self-administered a questionnaire to identify risk factors for illness. Serological, oropharyngeal, and nasopharyngeal specimens were collected for both outbreaks, and testing for respiratory pathogens was performed. RESULTS In Facility A, 40 (24%) of 170 residents were identified with respiratory illness; 13 (33%) case-patients had radiographically confirmed pneumonia, 15 (38%) were taken to a hospital, and two (5%) died. Of 10 specimens collected from symptomatic Facility A case-patients, four (40%) tested positive using reverse transcription polymerase chain reaction for rhinovirus. In Facility B, 77 (62%) of 124 residents had respiratory illness, and 40 (52%) had radiographically confirmed pneumonia; 12 (16%) case-patients were hospitalized, and five (6%) died. Of 19 respiratory specimens collected from symptomatic Facility B case-patients, six (32%) were positive for rhinovirus; one was from an employee. Five (50%) of 10 rhinovirus-positive cases in both outbreaks had clinical and radiographic evidence of pneumonia. CONCLUSION These investigations suggest that rhinoviruses may be an underrecognized cause of respiratory outbreaks in nursing homes, capable of causing pneumonia and perhaps death.
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Affiliation(s)
- Lauri A Hicks
- Respiratory Diseases Branch, National Center for Infectious Diseases, Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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Malik YS, Maherchandani S, Goyal SM. Comparative efficacy of ethanol and isopropanol against feline calicivirus, a norovirus surrogate. Am J Infect Control 2006; 34:31-5. [PMID: 16443090 DOI: 10.1016/j.ajic.2005.05.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2005] [Revised: 05/16/2005] [Accepted: 05/17/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND Improper disinfection of environmental surfaces contaminated by the feces or vomitus of infected patients is believed to be a major cause of the spread of noroviruses (NoV) in close institutional settings. Although several disinfectants are available, the search for safe and effective disinfectant continues. Because alcohol and alcohol-based products have been used as antiseptics and their efficacy against several enveloped viruses has been documented, we wanted to determine their efficacy against nonenveloped calicivirus. METHODS Feline calicivirus (FCV) was used as a surrogate for NoVs, using the carrier test. We evaluated the virucidal efficacy of various concentrations of ethanol and isopropanol against FCV, dried on an inanimate, nonporous contact surface for contact times of 1, 3, and 10 minutes. The virus was eluted after alcohol treatment and titrated in feline kidney cells. Percentage virus inactivation was calculated by comparing these titers with those obtained with virus eluted from controls. RESULTS Ethanol at 70% and 90% and isopropanol at 40% to 60% concentrations were found to be the most effective, killing 99% of FCV within a short contact time of 1 minute. CONCLUSION Isopropanol was more efficacious than ethanol at 40% to 60% concentrations, suggesting that the use of an appropriate concentration of isopropanol or ethanol would help in controlling the transmission of NoVs from environmental contact surfaces.
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Affiliation(s)
- Yashpal S Malik
- Department of Veterinary Medicine, College of Veterinary Medicine, University of Minnesota, St. Paul, 55108, USA
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Abstract
BACKGROUND Even among travelers who undergo evaluation in travel medicine clinics, illnesses develop despite the emphasis placed on prevention. It is possible that travel-associated disease rates may be modified by maximizing access to care and augmenting educational methods of disease prevention. Use of alternative preventive measures such as alcohol hand gel sanitizers may also alter illnesses among travelers. METHODS We assessed medical outcomes in a travel population cared for in the setting of free vaccinations, medications, and travel medicine consultation, in which personal preventive measures were presented in numerous formats by a physician specializing in infectious diseases. An initial demographic questionnaire was administered at the time of travel consultation. A post-travel telephone interview conducted 2 weeks after return from travel evaluated illness while abroad, illness upon return, and adherence to travel recommendations. An assessment was also performed regarding the utility of an alcohol hand gel sanitizer. RESULTS One hundred fifty-five travelers were evaluated (primarily older, well-educated US-born travelers, on vacation with family or coworkers). Travelers filled their prescriptions 98% of the time; 77% reported adherence to antimalarial chemoprophylaxis. Sixty-four percent of travelers developed illness abroad, and 20% developed illness upon return. The most frequent complaints were diarrhea and upper respiratory illness. Ten percent of travelers altered their itinerary owing to illness. The use of alcohol hand gel sanitizers did not appear to impact the development of diarrhea or respiratory illnesses. CONCLUSION In this small group of travelers, access to free consultation, vaccinations, and medications along with presentation of personal protective measures in various formats did not seem to influence the development of illnesses among travelers. Although not rigorously analyzed, alcohol hand gel sanitizers did not seem to alter diarrhea or respiratory tract illness rates. These data highlight the need for new or more effective methods to prevent illness among travelers.
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Affiliation(s)
- Lynn L Horvath
- Department of Clinical Investigation, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
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Rotter M, Sattar SA, Dharan S, Webber P, Voss A, Pittet D. Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses. Am J Infect Control 2005; 33:558-60. [PMID: 16260331 DOI: 10.1016/j.ajic.2005.05.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2005] [Accepted: 05/17/2005] [Indexed: 10/25/2022]
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