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Montgomery MP, Morris SE, Rolfes MA, Kittikraisak W, Samuels AM, Biggerstaff M, Davis WW, Reed C, Olsen SJ. The role of asymptomatic infections in influenza transmission: what do we really know. THE LANCET. INFECTIOUS DISEASES 2024; 24:e394-e404. [PMID: 38128563 PMCID: PMC11127787 DOI: 10.1016/s1473-3099(23)00619-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/02/2023] [Accepted: 09/18/2023] [Indexed: 12/23/2023]
Abstract
Before the COVID-19 pandemic, the role of asymptomatic influenza virus infections in influenza transmission was uncertain. However, the importance of asymptomatic infection with SARS-CoV-2 for onward transmission of COVID-19 has led experts to question whether the role of asymptomatic influenza virus infections in transmission had been underappreciated. We discuss the existing evidence on the frequency of asymptomatic influenza virus infections, the extent to which they contribute to infection transmission, and remaining knowledge gaps. We propose priority areas for further evaluation, study designs, and case definitions to address existing knowledge gaps.
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Affiliation(s)
- Martha P Montgomery
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA; Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand.
| | - Sinead E Morris
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Melissa A Rolfes
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wanitchaya Kittikraisak
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA; Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand
| | - Aaron M Samuels
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Matthew Biggerstaff
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - William W Davis
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA; Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand
| | - Carrie Reed
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sonja J Olsen
- Influenza Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA
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Sreedevi A, Mohammad A, Satheesh M, Ushakumari A, Kumar A, Raveendran G, Narayankutty S, Gopakumar S, Rahman A, David S, Mathew MM, Nair P. Transmissibility of severe acute respiratory syndrome coronavirus 2 among household contacts of coronavirus disease 2019-positive patients: A community-based study in India. Influenza Other Respir Viruses 2023; 17:e13196. [PMID: 38019705 PMCID: PMC10655783 DOI: 10.1111/irv.13196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND This study identified the risk factors for severe acute respiratory syndrome coronavirus 2 infection among household contacts of index patients and determined the incubation period (IP), serial interval, and estimates of secondary infection rate in Kerala, India. METHODS We conducted a cohort study in three districts of Kerala among the inhabitants of households of reverse transcriptase polymerase chain reaction-positive coronavirus disease 2019 patients between January and July 2021. About 147 index patients and 362 household contacts were followed up for 28 days to determine reverse transcriptase polymerase chain reaction positivity and the presence of total antibodies against SARS-CoV-2 on days 1, 7, 14, and 28. RESULTS The mean IP, serial interval, and generation time were 1.6, 3, and 3.9 days, respectively. The secondary infection rate at 14 days was 43.0%. According to multivariable regression analysis persons who worked outside the home were protected (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.24-0.85), whereas those who had kissed the coronavirus disease 2019-positive patients during illness were more than twice at risk of infection (aOR, 2.23; 95% CI, 1.01-5.2) than those who had not kissed the patients. Sharing a toilet with the index patient increased the risk by more than twice (aOR, 2.5; 95% CI, 1.42-4.64) than not sharing a toilet. However, the contacts who reported using masks (aOR, 2.5; 95% CI, 1.4-4.4) were at a higher risk of infection in household settings. CONCLUSIONS Household settings have a high secondary infection rate and the changing transmissibility dynamics such as IP, serial interval should be considered in the prevention and control of SARS-CoV-2.
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Affiliation(s)
| | | | | | | | - Anil Kumar
- Amrita Institute of Medical SciencesKochiIndia
| | | | | | | | | | | | | | - Prem Nair
- Amrita Institute of Medical SciencesKochiIndia
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Murphy C, Wong JY, Cowling BJ. Nonpharmaceutical interventions for managing SARS-CoV-2. Curr Opin Pulm Med 2023; 29:184-190. [PMID: 36856551 PMCID: PMC10090342 DOI: 10.1097/mcp.0000000000000949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
PURPOSE OF REVIEW Initial response strategies to the COVID-19 pandemic were heavily reliant on nonpharmaceutical interventions (NPIs), a set of measures implemented to slow or even stop the spread of infection. Here, we reviewed key measures used during the COVID-19 pandemic. RECENT FINDINGS Some NPIs were successful in reducing the transmission of SARS-CoV-2. Personal protective measures such as face masks were widely used, and likely had some effect on transmission. The development and production of rapid antigen tests allowed self-diagnosis in the community, informing isolation and quarantine measures. Community-wide measures such as school closures, workplace closures and complete stay-at-home orders were able to reduce contacts and prevent transmission. They were widely used in the pandemic and contributed to reduce transmission in the community; however, there were also negative unintended consequences in the society and economy. SUMMARY NPIs slowed the spread of SARS-CoV-2 and are essential for pandemic preparedness and response. Understanding which measures are more effective at reducing transmission with lower costs is imperative.
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Affiliation(s)
- Caitriona Murphy
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam
| | - Jessica Y. Wong
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam
| | - Benjamin J. Cowling
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam
- Laboratory of Data Discovery for Health Limited, Hong Kong Science and Technology Park, New Territories, Hong Kong Special Administrative Region, China
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Kisielinski K, Wagner S, Hirsch O, Klosterhalfen B, Prescher A. Possible toxicity of chronic carbon dioxide exposure associated with face mask use, particularly in pregnant women, children and adolescents - A scoping review. Heliyon 2023; 9:e14117. [PMID: 37057051 PMCID: PMC9981272 DOI: 10.1016/j.heliyon.2023.e14117] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 02/14/2023] [Accepted: 02/21/2023] [Indexed: 03/06/2023] Open
Abstract
Introduction During the SARS-CoV-2-pandemic, face masks have become one of the most important ubiquitous factors affecting human breathing. It increases the resistance and dead space volume leading to a re-breathing of CO2. So far, this phenomenon and possible implications on early life has not been evaluated in depth. Method As part of a scoping review, literature was systematically reviewed regarding CO2 exposure and facemask use. Results Fresh air has around 0.04% CO2, while wearing masks more than 5 min bears a possible chronic exposure to carbon dioxide of 1.41% to 3.2% of the inhaled air. Although the buildup is usually within the short-term exposure limits, long-term exceedances and consequences must be considered due to experimental data. US Navy toxicity experts set the exposure limits for submarines carrying a female crew to 0.8% CO2 based on animal studies which indicated an increased risk for stillbirths. Additionally, mammals who were chronically exposed to 0.3% CO2 the experimental data demonstrate a teratogenicity with irreversible neuron damage in the offspring, reduced spatial learning caused by brainstem neuron apoptosis and reduced circulating levels of the insulin-like growth factor-1. With significant impact on three readout parameters (morphological, functional, marker) this chronic 0.3% CO2 exposure has to be defined as being toxic. Additional data exists on the exposure of chronic 0.3% CO2 in adolescent mammals causing neuron destruction, which includes less activity, increased anxiety and impaired learning and memory. There is also data indicating testicular toxicity in adolescents at CO2 inhalation concentrations above 0.5%. Discussion There is a possible negative impact risk by imposing extended mask mandates especially for vulnerable subgroups. Circumstantial evidence exists that extended mask use may be related to current observations of stillbirths and to reduced verbal motor and overall cognitive performance in children born during the pandemic. A need exists to reconsider mask mandates.
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Affiliation(s)
- Kai Kisielinski
- Independent Researcher, Surgeon, Private Practice, 40212 Düsseldorf, Germany
| | - Susanne Wagner
- Non Clinical Expert, Veterinarian, Wagner MSL Management, 15831 Mahlow, Germany
| | - Oliver Hirsch
- Department of Psychology, FOM University of Applied Sciences, 57078 Siegen, Germany
| | | | - Andreas Prescher
- Institute of Molecular and Cellular Anatomy (MOCA), 52074 Aachen, Germany
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Thiel CL, Sreedhar P, Silva GS, Greene HC, Seetharaman M, Durr M, Roberts T, Vedanthan R, Lee PH, Andrade G, El-Shahawy O, Hochman SE. Conservation Practices for Personal Protective Equipment: A Systematic Review with Focus on Lower-Income Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2575. [PMID: 36767940 PMCID: PMC9915410 DOI: 10.3390/ijerph20032575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 06/18/2023]
Abstract
During the start of the COVID-19 pandemic, shortages of personal protective equipment (PPE) necessitated unprecedented and non-validated approaches to conserve PPE at healthcare facilities, especially in high income countries where single-use disposable PPE was ubiquitous. Our team conducted a systematic literature review to evaluate historic approaches for conserving single-use PPE, expecting that lower-income countries or developing contexts may already be uniquely conserving PPE. However, of the 50 included studies, only 3 originated from middle-income countries and none originated from low-income countries. Data from the included studies suggest PPE remained effective with extended use and with multiple or repeated use in clinical settings, as long as donning and doffing were performed in a standard manner. Multiple decontamination techniques were effective in disinfecting single use PPE for repeated use. These findings can inform healthcare facilities and providers in establishing protocols for safe conservation of PPE supplies and updating existing protocols to improve sustainability and overall resilience. Future studies should evaluate conservation practices in low-resource settings during non-pandemic times to develop strategies for more sustainable and resilient healthcare worldwide.
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Affiliation(s)
- Cassandra L. Thiel
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA
| | | | - Genevieve S. Silva
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Hannah C. Greene
- Social Science Division, New York University Abu Dhabi, Abu Dhabi P.O. Box 129188, United Arab Emirates
| | - Meenakshi Seetharaman
- College of Literature, Science, and Arts, University of Michigan, Ann Arbor, MI 48109, USA
| | - Meghan Durr
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Timothy Roberts
- Health Sciences Library, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Rajesh Vedanthan
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Paul H. Lee
- Department of Oral and Maxillofacial Surgery, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Gizely Andrade
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA
| | - Omar El-Shahawy
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Sarah E. Hochman
- Department of Medicine, Division of Infectious Diseases and Immunology, NYU Grossman School of Medicine, New York, NY 10016, USA
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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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Butzin-Dozier Z, Athni TS, Benjamin-Chung J. A Review of the Ring Trial Design for Evaluating Ring Interventions for Infectious Diseases. Epidemiol Rev 2022; 44:29-54. [PMID: 35593400 PMCID: PMC10362935 DOI: 10.1093/epirev/mxac003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 03/25/2022] [Accepted: 05/12/2022] [Indexed: 12/29/2022] Open
Abstract
In trials of infectious disease interventions, rare outcomes and unpredictable spatiotemporal variation can introduce bias, reduce statistical power, and prevent conclusive inferences. Spillover effects can complicate inference if individual randomization is used to gain efficiency. Ring trials are a type of cluster-randomized trial that may increase efficiency and minimize bias, particularly in emergency and elimination settings with strong clustering of infection. They can be used to evaluate ring interventions, which are delivered to individuals in proximity to or contact with index cases. We conducted a systematic review of ring trials, compare them with other trial designs for evaluating ring interventions, and describe strengths and weaknesses of each design. Of 849 articles and 322 protocols screened, we identified 26 ring trials, 15 cluster-randomized trials, 5 trials that randomized households or individuals within rings, and 1 individually randomized trial. The most common interventions were postexposure prophylaxis (n = 23) and focal mass drug administration and screening and treatment (n = 7). Ring trials require robust surveillance systems and contact tracing for directly transmitted diseases. For rare diseases with strong spatiotemporal clustering, they may have higher efficiency and internal validity than cluster-randomized designs, in part because they ensure that no clusters are excluded from analysis due to zero cluster incidence. Though more research is needed to compare them with other types of trials, ring trials hold promise as a design that can increase trial speed and efficiency while reducing bias.
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Face masks to prevent transmission of respiratory infections: Systematic review and meta-analysis of randomized controlled trials on face mask use. PLoS One 2022; 17:e0271517. [PMID: 36454947 PMCID: PMC9714953 DOI: 10.1371/journal.pone.0271517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 07/04/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To examine the use of face mask intervention in mitigating the risk of spreading respiratory infections and whether the effect of face mask intervention differs in different exposure settings and age groups. DESIGN Systematic review and meta-analysis. We evaluated the risk of bias using the Cochrane Risk of Bias 2 tool (ROB2). DATA SOURCES We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were searched for randomized controlled trials investigating the effect of face masks on respiratory infections published between 1981 and February 9, 2022. We followed the PRISMA 2020 guidelines. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included randomized controlled trials investigating the use of face mask intervention in mitigating the risk of spreading respiratory infections across different exposure settings. RESULTS We identified 2,400 articles for screening. 18 articles passed the inclusion criteria for both evidence synthesis and meta-analysis. There were N = 189,145 individuals in the face mask intervention arm and N = 173,536 in the control arm, and the follow-up times ranged from 4 days to 19 months. Our results showed between-study heterogeneity (p < 0.0001). While there was no statistically significant association over all studies when the covariate unadjusted intervention effect estimates were used (RR = 0.977 [0.858-1.113], p = 0.728), our subgroup analyses revealed that a face mask intervention reduced respiratory infections in the adult subgroup (RR = 0.8795 [0.7861-0.9839], p = 0.0249) and in a community setting (RR = 0.890 [0.812-0.975], p = 0.0125). Furthermore, our leave-one-out analysis found that one study biased the results towards a null effect. Consequently, when using covariate adjusted odds ratio estimates to have a more precise effect estimates of the intervention effect to account for differences at the baseline, the results showed that a face mask intervention did reduce respiratory infections when the biasing study was excluded from the analysis (OR = 0.8892 [0.8061-0.9810], p = 0.0192). CONCLUSION Our findings support the use of face masks particularly in a community setting and for adults. We also observed substantial between-study heterogeneity and varying adherence to protocol. Notably, many studies were subject to contamination bias thus affecting the efficacy of the intervention, that is when also some controls used masks or when the intervention group did not comply with mask use leading to a downward biased effect of treatment receipt and efficacy. TRIAL REGISTRATION PROSPERO registration number CRD42020205523.
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Shobako N. Lessons from the health policies for children during the pandemic in Japan. Front Public Health 2022; 10:1015955. [PMID: 36339184 PMCID: PMC9628751 DOI: 10.3389/fpubh.2022.1015955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/21/2022] [Indexed: 01/28/2023] Open
Abstract
It is everyone's desire to seek the sound growth of children through food education and there is a critical need for fostering an environment for this purpose. Health policies are important for this support. To the present, the Japanese society has been greatly disrupted by COVID-19 pandemic. "Stay at home", "mokusyoku (silent eating)", and mask wearing were encouraged in nationwide campaigns as public health measures to combat COVID-19. There are some papers reporting negative effects of "stay at home" and lockdowns such as weight gain, decrease in physical activities and change in eating habits. In Japan, while benefits and advantages of food education during mealtime were previously well studied, the "mokusyoku" rule may directly run counter to this food education. Moreover, there are several reports showing that nutrients might contribute to prevention of infectious diseases. Japanese children were also encouraged to wear masks all day long. The results of the clinical research, especially randomized control trials, show limited protective effect of masks. On the other hand, negative outcomes of the masks were reported in various scenes. This review focuses on these topics and arousing reconsideration for a better environment for children.
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Hilton J, Riley H, Pellis L, Aziza R, Brand SPC, K. Kombe I, Ojal J, Parisi A, Keeling MJ, Nokes DJ, Manson-Sawko R, House T. A computational framework for modelling infectious disease policy based on age and household structure with applications to the COVID-19 pandemic. PLoS Comput Biol 2022; 18:e1010390. [PMID: 36067212 PMCID: PMC9481179 DOI: 10.1371/journal.pcbi.1010390] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 09/16/2022] [Accepted: 07/14/2022] [Indexed: 11/18/2022] Open
Abstract
The widespread, and in many countries unprecedented, use of non-pharmaceutical interventions (NPIs) during the COVID-19 pandemic has highlighted the need for mathematical models which can estimate the impact of these measures while accounting for the highly heterogeneous risk profile of COVID-19. Models accounting either for age structure or the household structure necessary to explicitly model many NPIs are commonly used in infectious disease modelling, but models incorporating both levels of structure present substantial computational and mathematical challenges due to their high dimensionality. Here we present a modelling framework for the spread of an epidemic that includes explicit representation of age structure and household structure. Our model is formulated in terms of tractable systems of ordinary differential equations for which we provide an open-source Python implementation. Such tractability leads to significant benefits for model calibration, exhaustive evaluation of possible parameter values, and interpretability of results. We demonstrate the flexibility of our model through four policy case studies, where we quantify the likely benefits of the following measures which were either considered or implemented in the UK during the current COVID-19 pandemic: control of within- and between-household mixing through NPIs; formation of support bubbles during lockdown periods; out-of-household isolation (OOHI); and temporary relaxation of NPIs during holiday periods. Our ordinary differential equation formulation and associated analysis demonstrate that multiple dimensions of risk stratification and social structure can be incorporated into infectious disease models without sacrificing mathematical tractability. This model and its software implementation expand the range of tools available to infectious disease policy analysts.
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Affiliation(s)
- Joe Hilton
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
- Zeeman Institue (SBIDER), University of Warwick, Coventry, United Kingdom
- * E-mail:
| | - Heather Riley
- Department of Mathematics, University of Manchester, Manchester, United Kingdom
| | - Lorenzo Pellis
- Department of Mathematics, University of Manchester, Manchester, United Kingdom
- The Alan Turing Institute for Data Science and Artificial Intelligence, London, United Kingdom
| | - Rabia Aziza
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
- Zeeman Institue (SBIDER), University of Warwick, Coventry, United Kingdom
| | - Samuel P. C. Brand
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
- Zeeman Institue (SBIDER), University of Warwick, Coventry, United Kingdom
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ivy K. Kombe
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
| | - John Ojal
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Andrea Parisi
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
- Zeeman Institue (SBIDER), University of Warwick, Coventry, United Kingdom
| | - Matt J. Keeling
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
- Zeeman Institue (SBIDER), University of Warwick, Coventry, United Kingdom
- Mathematics Institute, University of Warwick, Coventry, United Kingdom
| | - D. James Nokes
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
- Zeeman Institue (SBIDER), University of Warwick, Coventry, United Kingdom
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Thomas House
- Department of Mathematics, University of Manchester, Manchester, United Kingdom
- The Alan Turing Institute for Data Science and Artificial Intelligence, London, United Kingdom
- IBM Research Europe, Hartree Centre, Daresbury, United Kingdom
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11
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Chen Y, Wang Y, Quan N, Yang J, Wu Y. Associations Between Wearing Masks and Respiratory Viral Infections: A Meta-Analysis and Systematic Review. Front Public Health 2022; 10:874693. [PMID: 35570912 PMCID: PMC9092448 DOI: 10.3389/fpubh.2022.874693] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background Respiratory viral infections (RVIs) are a major health concern, and some previous studies have shown that wearing masks was effective in preventing RVIs, while others failed to show such effect. Therefore, a systematic review and meta-analysis was conducted to investigate the effectiveness of wearing masks. Methods PubMed, ScienceDirect, Web of Science, the Cochrane Library, EMBASE, MEDLINE, China National Knowledge Infrastructure (CNKI), and Chinese Scientific Journal Database (VIP database) were searched for studies evaluating the effectiveness of wearing masks. The risk ratio (RR) was used to measure the effectiveness of wearing masks in preventing RVIs for randomized controlled trials (RCTs) and cohort studies, and the odds ratio (OR) was used for case-control studies. Forest plots were used to visually assess pooled estimates and corresponding 95% CIs. The I2 test was used to examine the heterogeneity, and subgroup analysis was used to explore the possible explanations for heterogeneity or compare the results between subgroups. Sensitivity analysis was conducted to assess robustness of the synthesized results. Begg's test and Egger's test were used to assess the publications bias. Results Thirty-one studies (13,329 participants) were eligible for meta-analyses. Overall, the results showed that wearing masks was effective in preventing RVIs. The sensitivity analysis showed that the results of those meta-analyses were robust and reliable. There was no significant publication bias in meta-analysis of case-control studies and most subgroup analyses. Conclusions Wearing masks might be effective in preventing RVIs. To reduce their RVI risk, people should wear masks when they go out in public. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021296092.
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Affiliation(s)
- Yiming Chen
- Department of Epidemiology and Health Statistics, School of Public Health, Faculty of Medicine, Hangzhou Normal University, Hangzhou, China
| | - Yuelin Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Faculty of Medicine, Hangzhou Normal University, Hangzhou, China
| | - Ningbin Quan
- Department of Epidemiology and Health Statistics, School of Public Health, Faculty of Medicine, Hangzhou Normal University, Hangzhou, China
| | - Jun Yang
- Department of Nutrition and Toxicology, School of Public Health, Faculty of Medicine, Hangzhou Normal University, Hangzhou, China
- National Key Laboratory for the Diagnosis and Treatment for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yinyin Wu
- Department of Epidemiology and Health Statistics, School of Public Health, Faculty of Medicine, Hangzhou Normal University, Hangzhou, China
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12
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Zhao H, Jatana S, Bartoszko J, Loeb M. Nonpharmaceutical interventions to prevent viral respiratory infection in community settings: an umbrella review. ERJ Open Res 2022; 8:00650-2021. [PMID: 35651370 PMCID: PMC9149389 DOI: 10.1183/23120541.00650-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/29/2022] [Indexed: 01/08/2023] Open
Abstract
BackgroundRespiratory viruses pose an important public health threat to most communities. Nonpharmaceutical interventions (NPIs) such as masks, hand hygiene or physical distancing, among others, are believed to play an important role in reducing transmission of respiratory viruses. In this umbrella review, we summarise the evidence of the effectiveness of NPIs for the prevention of respiratory virus transmission in the community setting.ObservationsA systematic search of PubMed, Embase, Medline and Cochrane reviews resulted in a total of 24 studies consisting of 11 systematic reviews and meta-analyses, 12 systematic reviews without meta-analyses and one standalone meta-analysis. The current evidence from these data suggests that hand hygiene is protective against respiratory viral infection. The use of hand hygiene and facemasks, facemasks alone and physical distancing were interventions with inconsistent evidence. Interventions such as school closures, oral hygiene or nasal saline rinses were shown to be effective in reducing the risk of influenza; however, the evidence is sparse and mostly of low and critically low quality.ConclusionsStudies on the effectiveness of NPIs for the prevention of respiratory viral transmission in the community vary in study design, quality and reported effectiveness. Evidence for the use of hand hygiene or facemasks is the strongest; therefore, the most reasonable suggestion is to use hand hygiene and facemasks in the community setting.
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13
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Fountoulakis KN, Breda J, Arletou MP, Charalampakis AI, Karypidou MG, Kotorli KS, Koutsoudi CG, Ladia ES, Mitkani CA, Mpouri VN, Samara AC, Stravoravdi AS, Tsiamis IG, Tzortzi A, Vamvaka MA, Zacharopoulou CN, Prezerakos PE, Koupidis SA, K Fountoulakis N, Tsapakis EM, Konsta A, Theodorakis PN. Adherence to facemask use in public places during the autumn-winter 2020 COVID-19 lockdown in Greece: observational data. Ann Gen Psychiatry 2022; 21:9. [PMID: 35264198 PMCID: PMC8905561 DOI: 10.1186/s12991-022-00386-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/22/2022] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Wearing facemasks is of proven efficacy as a public health protective measure against COVID-19. Currently there are no observational data concerning the wearing of facemasks and the adherence to guidelines concerning their handling. METHODS Registration of the way passers-by were wearing facemasks at 26 different locations of five major cities in Greece. The results were correlated with the rate of COVID-19 deaths in the region. RESULTS In total, 119,433 passers-by were registered, 57,043 females (47.8%) and 62,390 males (52.2%). From the total sample, 81.1% were wearing the mask properly, 10.8% had their nose out, 6.2% were wearing it under the jaw, and 1.9% had no mask at all . There was a significant difference between males and females concerning any use of mask. Inappropriate use of was correlated with COVID-19 death rate in the studied region. CONCLUSION Our findings suggest that under conditions of mandatory wearing and in central locations of major cities, during walking, proper use of masks is suboptimal, but still contributes with some protection. Fear and risk perception seem to be strong factors contributing to adherence to proper mask wearing.
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Affiliation(s)
- Konstantinos N Fountoulakis
- Department of Psychiatry, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 6, Odysseos str, 55535, Thessaloniki, Greece
| | - Joao Breda
- WHO Athens Quality of Care Office, WHO Regional Office for Europe, Athens, Greece
| | - Marianna P Arletou
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasios I Charalampakis
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria G Karypidou
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantina S Kotorli
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christina G Koutsoudi
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleftheria S Ladia
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Calypso A Mitkani
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki N Mpouri
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasia C Samara
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aikaterini S Stravoravdi
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis G Tsiamis
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aphrodite Tzortzi
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria A Vamvaka
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Charikleia N Zacharopoulou
- School of Medicine, Faculty of Health Sciences, Clinical Mental Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis E Prezerakos
- Department of Nursing, Laboratory of Integrated Health Care, University of Peloponnese, Tripoli, Greece
| | - Sotirios A Koupidis
- Occupational & Environmental Health Sector, Public Health Policy Department, School of Public Health, University of West Attica, Athens, Greece
| | | | | | - Anastasia Konsta
- Department of Psychiatry, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 6, Odysseos str, 55535, Thessaloniki, Greece
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14
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Li H, Yuan K, Sun YK, Zheng YB, Xu YY, Su SZ, Zhang YX, Zhong Y, Wang YJ, Tian SS, Gong YM, Fan TT, Lin X, Gobat N, Wong SYS, Chan EYY, Yan W, Sun SW, Ran MS, Bao YP, Shi J, Lu L. Efficacy and practice of facemask use in general population: a systematic review and meta-analysis. Transl Psychiatry 2022; 12:49. [PMID: 35105851 PMCID: PMC8804079 DOI: 10.1038/s41398-022-01814-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 12/14/2021] [Accepted: 01/18/2022] [Indexed: 11/17/2022] Open
Abstract
In recent decades, respiratory infections, including SARS, HINI and the currently spreading COVID-19, caused by various viruses such as influenza and coronavirus have seriously threatened human health. It has generated inconsistent recommendations on the mandatory use of facemasks across countries on a population level due to insufficient evidence on the efficacy of facemask use among the general population. This meta-analysis aimed to explore (1) the efficacy of facemask use on preventing respiratory infections, and (2) the perceptions, intentions, and practice about facemask use among the general population worldwide. We searched PubMed, MEDLINE, Web of Science, Cochrane, bioRxiv, and medRxiv databases since inception to August 17, 2020. From 21,341 records identified, eight RCTs on facemask in preventing infections and 78 studies on perception, intention, and practice of facemask use among the general population were included in the analysis. The meta-analysis of RCTs found a significant protective effect of facemask intervention (OR = 0.84; 95% CI = 0.71-0.99; I2 = 0%). This protective effect was even more pronounced when the intervention duration was more than two weeks (OR = 0.76; 95% CI = 0.66-0.88; I2 = 0%). The meta-analysis of observational studies on perception, intention, and practice on facemask use showed that 71% of respondents perceived facemasks to be effective for infection prevention, 68% of respondents would wear facemasks, and 54% of respondents wore facemasks for preventing respiratory infections. Differences in perception, intention, and practice behavior of facemask use in different regions may be related to the impact of respiratory infections, regional culture, and policies. The governments and relevant organizations should make effort to reduce the barriers in the use of facemasks.
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Affiliation(s)
- Hui Li
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
| | - Kai Yuan
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
| | - Yan-Kun Sun
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
| | - Yong-Bo Zheng
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
| | - Ying-Ying Xu
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, 100191, Beijing, China
- School of Public Health, Peking University, 100191, Beijing, China
| | - Si-Zhen Su
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
| | - Yu-Xin Zhang
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
- School of Public Health, Peking University, 100191, Beijing, China
| | - Yi Zhong
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
- Peking-Tsinghua Centre for Life Sciences and PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, China
| | - Yi-Jie Wang
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
- Peking-Tsinghua Centre for Life Sciences and PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, China
| | - Shan-Shan Tian
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
| | - Yi-Miao Gong
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
- Peking-Tsinghua Centre for Life Sciences and PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, China
| | - Teng-Teng Fan
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
| | - Xiao Lin
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
- Peking-Tsinghua Centre for Life Sciences and PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, China
| | - Nina Gobat
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Samuel Yeung Shan Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Emily Ying Yang Chan
- Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response, School of Public Health and Primary Care, Prince of Wales Hospital, Sha tin, Hong Kong
| | - Wei Yan
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
| | - Si-Wei Sun
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China
| | - Mao-Sheng Ran
- Department of Social Work and Social Administration, University of Hong Kong, Hong Kong, China
| | - Yan-Ping Bao
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, 100191, Beijing, China.
- School of Public Health, Peking University, 100191, Beijing, China.
| | - Jie Shi
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, 100191, Beijing, China.
| | - Lin Lu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Chinese Academy of Medical Sciences Research Unit (No.2018RU006), Peking University, 100191, Beijing, China.
- Peking-Tsinghua Centre for Life Sciences and PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, China.
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15
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Wadud Z, Rahman SM, Enam A. Face mask mandates and risk compensation: an analysis of mobility data during the COVID-19 pandemic in Bangladesh. BMJ Glob Health 2022; 7:bmjgh-2021-006803. [PMID: 35012968 PMCID: PMC8753097 DOI: 10.1136/bmjgh-2021-006803] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 12/09/2021] [Indexed: 01/24/2023] Open
Abstract
Introduction Concerns have been raised about the potential for risk compensation in the context of mask mandates for mitigating the spread of COVID-19. However, the debate about the presence or absence of risk compensation for universal mandatory mask-wearing rules—especially in the context of COVID-19—is not settled yet. Methods Mobility is used as a proxy for risky behaviour before and after the mask mandates. Two sets of regressions are estimated to decipher (any) risk-compensating effect of mask mandate in Bangladesh. These include: (1) intervention regression analysis of daily activities at six types of locations, using pre-mask-mandate and post-mandate data; and (2) multiple regression analysis of daily new COVID-19 cases on daily mobility (lagged) to establish mobility as a valid proxy. Results (1) Statistically, mobility increased at all five non-residential locations, while home stays decreased after the mask mandate was issued; (2) daily mobility had a statistically significant association on daily new cases (with around 10 days of lag). Both significances were calculated at 95% confidence level. Conclusion Community mobility had increased (and stay at home decreased) after the mandatory mask-wearing rule, and given mobility is associated with increases in new COVID-19 cases, there is evidence of risk compensation effect of the mask mandate—at least partially—in Bangladesh.
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Affiliation(s)
- Zia Wadud
- Institute for Transport Studies & School of Chemical and Process Engineering, University of Leeds, Leeds, UK
| | - Sheikh Mokhlesur Rahman
- Department of Civil Engineering, Bangladesh University of Engineering and Technology, Dhaka, Bangladesh
| | - Annesha Enam
- Department of Civil Engineering, Bangladesh University of Engineering and Technology, Dhaka, Bangladesh
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16
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El Hassan M, Assoum H, Bukharin N, Al Otaibi H, Mofijur M, Sakout A. A review on the transmission of COVID-19 based on cough/sneeze/breath flows. EUROPEAN PHYSICAL JOURNAL PLUS 2022; 137:1. [PMID: 34909366 PMCID: PMC8660964 DOI: 10.1140/epjp/s13360-021-02162-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 11/08/2021] [Indexed: 05/17/2023]
Abstract
COVID-19 pandemic has recently had a dramatic impact on society. The understanding of the disease transmission is of high importance to limit its spread between humans. The spread of the virus in air strongly depends on the flow dynamics of the human airflows. It is, however, known that predicting the flow dynamics of the human airflows can be challenging due to different particles sizes and the turbulent aspect of the flow regime. It is thus recommended to present a deep analysis of different human airflows based on the existing experimental investigations. A validation of the existing numerical predictions of such flows would be of high interest to further develop the existing numerical model for different flow configurations. This paper presents a literature review of the experimental and numerical studies on human airflows, including sneezing, coughing and breathing. The dynamics of these airflows for different droplet sizes is discussed. The influence of other parameters, such as the viscosity and relative humidity, on the germs transmission is also presented. Finally, the efficacy of using a facemask in limiting the transmission of COVID-19 is investigated.
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Affiliation(s)
- Mouhammad El Hassan
- Mechanical Engineering Department, Prince Mohammad Bin Fahd University, Al Khobar, Kingdom of Saudi Arabia
| | - Hassan Assoum
- Mechanical Engineering Department, Beirut Arab University, Tripoli, Lebanon
| | - Nikolay Bukharin
- School of Manufacturing and Automation, Southern Alberta Institute of Technology, Calgary, Canada
| | - Huda Al Otaibi
- Mechanical Engineering Department, Prince Mohammad Bin Fahd University, Al Khobar, Kingdom of Saudi Arabia
| | - Md Mofijur
- Mechanical Engineering Department, Prince Mohammad Bin Fahd University, Al Khobar, Kingdom of Saudi Arabia
- Faculty of Engineering and Information Technology, University of Technology Sydney, Sydney, NSW 2007 Australia
| | - Anas Sakout
- LASIE, University of La Rochelle, La Rochelle, France
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17
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Dahlgren FS, Foppa IM, Stockwell MS, Vargas CY, LaRussa P, Reed C. Household transmission of influenza A and B within a prospective cohort during the 2013-2014 and 2014-2015 seasons. Stat Med 2021; 40:6260-6276. [PMID: 34580901 PMCID: PMC9293304 DOI: 10.1002/sim.9181] [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: 05/17/2021] [Revised: 07/22/2021] [Accepted: 08/15/2021] [Indexed: 01/01/2023]
Abstract
People living within the same household as someone ill with influenza are at increased risk of infection. Here, we use Markov chain Monte Carlo methods to partition the hazard of influenza illness within a cohort into the hazard from the community and the hazard from the household. During the 2013‐2014 influenza season, 49 (4.7%) of the 1044 people enrolled in a community surveillance cohort had an acute respiratory illness (ARI) attributable to influenza. During the 2014‐2015 influenza season, 50 (4.7%) of the 1063 people in the cohort had an ARI attributable to influenza. The secondary attack rate from a household member was 2.3% for influenza A (H1) during 2013‐2014, 5.3% for influenza B during 2013‐2014, and 7.6% for influenza A (H3) during 2014‐2015. Living in a household with a person ill with influenza increased the risk of an ARI attributable to influenza up to 350%, depending on the season and the influenza virus circulating within the household.
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Affiliation(s)
- F Scott Dahlgren
- Influenza Division, Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ivo M Foppa
- Influenza Division, Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Battelle Memorial Institute, Atlanta, Georgia, USA
| | - Melissa S Stockwell
- Division of Child and Adolescent Health, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, New York, USA.,Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Celibell Y Vargas
- Division of Child and Adolescent Health, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Philip LaRussa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Carrie Reed
- Influenza Division, Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Veys K, Dockx K, Van Remoortel H, Vandekerckhove P, De Buck E. The effect of hand hygiene promotion programs during epidemics and pandemics of respiratory droplet-transmissible infections on health outcomes: a rapid systematic review. BMC Public Health 2021; 21:1745. [PMID: 34563144 PMCID: PMC8467175 DOI: 10.1186/s12889-021-11815-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 09/14/2021] [Indexed: 01/03/2023] Open
Abstract
Background Public health strategies in the context of respiratory droplet-transmissible diseases (such as influenza or COVID-19) include intensified hand hygiene promotion, but a review on the effectiveness of different ways of promoting hand hygiene in the community, specifically for this type of infections, has not been performed. This rapid systematic review aims to summarize the effectiveness of community-based hand hygiene promotion programs on infection transmission, health outcomes and behavioral outcomes during epidemic periods in the context of respiratory droplet-transmissible diseases. We also included laboratory-confirmed health outcomes for epidemic-prone disease during interepidemic periods. Methods We searched for controlled experimental studies. A rapid systematic review was performed in three databases and a COVID-19 resource. Following study selection (in which studies performed in the (pre-)hospital/health care setting were excluded), study characteristics and effect measures were synthesized, using meta-analyses of cluster-RCTs where possible. Risk of bias of each study was assessed and the certainty of evidence was appraised according to the GRADE methodology. Results Out of 2050 unique references, 12 cluster-RCTs, all in the context of influenza, were selected. There were no controlled experimental studies evaluating the effectiveness of hand hygiene promotion programs in the context of COVID-19 that met the in−/exclusion criteria. There was evidence that preventive hand hygiene promotion interventions in interepidemic periods significantly decreased influenza positive cases in the school setting. However, no improvement could be demonstrated for programs implemented in households to prevent secondary influenza transmission from previously identified cases (epidemic and interepidemic periods). Conclusions The data suggest that proactive hand hygiene promotion interventions, i.e. regardless of the identification of infected cases, can improve health outcomes upon implementation of such a program, in contrast to reactive interventions in which the program is implemented after (household) index cases are identified. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11815-4.
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Affiliation(s)
- Koen Veys
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, Mechelen, Belgium
| | - Kim Dockx
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, Mechelen, Belgium
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, Mechelen, Belgium
| | - Philippe Vandekerckhove
- Belgian Red Cross, Mechelen, Belgium.,Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Emmy De Buck
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, Mechelen, Belgium. .,Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.
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19
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Tran TQ, Mostafa EM, Tawfik GM, Soliman M, Mahabir S, Mahabir R, Dong V, Ravikulan R, Alhijazeen S, Farrag DA, Dumre SP, Huy NT, Hirayama K. Efficacy of face masks against respiratory infectious diseases: a systematic review and network analysis of randomized-controlled trials. J Breath Res 2021; 15. [PMID: 34407516 DOI: 10.1088/1752-7163/ac1ea5] [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: 02/11/2021] [Accepted: 08/18/2021] [Indexed: 11/12/2022]
Abstract
During the ongoing COVID-19 pandemic, face masks are among the most common and practical control measures used globally in reducing the risk of infection and disease transmission. Although several studies have investigated the efficacy of various face masks and respirators in preventing infection, the results have been inconsistent. Therefore, we performed a systematic review and network meta-analysis (NMA) of the randomized-controlled trials (RCTs) to assess the actual efficacy of face masks in preventing respiratory infections. We searched nine electronic databases up to July 2020 to find potential articles. We accepted trials reporting the protective efficacy of face masks against respiratory infections, of which the primary endpoint was the presence of respiratory infections. We used the ROB-2 Cochrane tool to grade the trial quality. We initially registered the protocol for this study in PROSPERO (CRD42020178516). Sixteen RCTs involving 17 048 individuals were included for NMA. Overall, evidence was weak, lacking statistical power due to the small number of participants, and there was substantial inconsistency in our findings. In comparison to those without face masks, participants with fit-tested N95 respirators were likely to have lesser infection risk (RR 0.67, 95% CI 0.38-1.19,P-score 0.80), followed by those with non-fit-tested N95 and non-fit-tested FFP2 respirators that shared the similar risk, (RR 0.73, 95% CI 0.12-4.36,P-score 0.63) and (RR 0.80, 95% CI 0.38-1.71,P-score 0.63), respectively. Next, participants who donned face masks with and without hand hygiene practices showed modest risk improvement alike (RR 0.89, 95% CI 0.67-1.17,P-score 0.55) and (RR 0.92, 95% CI 0.70-1.22,P-score 0.51). Otherwise, participants donning double-layered cloth masks were prone to infection (RR 4.80, 95% CI 1.42-16.27,P-score 0.01). Eleven out of 16 RCTs that underwent a pairwise meta-analysis revealed a substantially lower infection risk in those donning medical face masks (MFMs) than those without face masks (RR 0.83 95% CI 0.71-0.96). Given the body of evidence through a systematic review and meta-analyses, our findings supported the protective benefits of MFMs in reducing respiratory transmissions, and the universal mask-wearing should be applied-especially during the COVID-19 pandemic. More clinical data is required to conclude the efficiency of cloth masks; in the short term, users should not use cloth face masks in the outbreak hot spots and places where social distancing is impossible.
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Affiliation(s)
- Thach Quang Tran
- Department of Immunogenetics, Nagasaki University, Nagasaki, Japan
| | | | | | | | | | | | - Vinh Dong
- AU/UGA Medical Partnership, Athens, Georgia, United States of America
| | | | | | | | | | - Nguyen Tien Huy
- School of Tropical Medicine and Global Health (TMGH), Nagasaki University, Nagasaki 852-8523, Japan
| | - Kenji Hirayama
- School of Tropical Medicine and Global Health (TMGH), Nagasaki University, Nagasaki 852-8523, Japan
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20
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Hoffmann T, Bakhit M, Krzyzaniak N, Del Mar C, Scott AM, Glasziou P. Soap versus sanitiser for preventing the transmission of acute respiratory infections in the community: a systematic review with meta-analysis and dose-response analysis. BMJ Open 2021; 11:e046175. [PMID: 34408031 PMCID: PMC8375726 DOI: 10.1136/bmjopen-2020-046175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To compare the effectiveness of hand hygiene using alcohol-based hand sanitiser to soap and water for preventing the transmission of acute respiratory infections (ARIs) and to assess the relationship between the dose of hand hygiene and the number of ARI, influenza-like illness (ILI) or influenza events. DESIGN Systematic review and meta-analysis. DATA SOURCES Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and trial registries were searched in April 2020. INCLUSION CRITERIA We included randomised controlled trials that compared a community-based hand hygiene intervention (soap and water, or sanitiser) with a control, or trials that compared sanitiser with soap and water, and measured outcomes of ARI, ILI or laboratory-confirmed influenza or related consequences. DATA EXTRACTION AND ANALYSIS Two review authors independently screened the titles and abstracts for inclusion and extracted data. RESULTS Eighteen trials were included. When meta-analysed, three trials of soap and water versus control found a non-significant increase in ARI events (risk ratio (RR) 1.23, 95% CI 0.78 to 1.93); six trials of sanitiser versus control found a significant reduction in ARI events (RR 0.80, 95% CI 0.71 to 0.89). When hand hygiene dose was plotted against ARI relative risk, no clear dose-response relationship was observable. Four trials were head-to-head comparisons of sanitiser and soap and water but too heterogeneous to pool: two found a significantly greater reduction in the sanitiser group compared with the soap group and two found no significant difference between the intervention arms. CONCLUSIONS Adequately performed hand hygiene, with either soap or sanitiser, reduces the risk of ARI virus transmission; however, direct and indirect evidence suggest sanitiser might be more effective in practice.
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Affiliation(s)
- Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Natalia Krzyzaniak
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Chris Del Mar
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Anna Mae Scott
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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21
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Perski O, Szinay D, Corker E, Shahab L, West R, Michie S. Interventions to increase personal protective behaviours to limit the spread of respiratory viruses: A rapid evidence review and meta-analysis. Br J Health Psychol 2021; 27:215-264. [PMID: 34173697 DOI: 10.1111/bjhp.12542] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/04/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE Increasing personal protective behaviours is critical for stopping the spread of respiratory viruses, including SARS-CoV-2: We need evidence to inform how to achieve this. We aimed to synthesize evidence on interventions to increase six personal protective behaviours (e.g., hand hygiene, face mask use, maintaining physical distancing) to limit the spread of respiratory viruses. METHODS We used best practice for rapid evidence reviews. We searched Ovid MEDLINE and Scopus. Studies conducted in adults or children with active or passive comparators were included. We extracted data on study design, intervention content, mode of delivery, population, setting, mechanism(s) of action, acceptability, practicability, effectiveness, affordability, spill-over effects, and equity impact. Study quality was assessed with Cochrane's risk-of-bias tool. A narrative synthesis and random-effects meta-analyses were conducted. RESULTS We identified 39 studies conducted across 15 countries. Interventions targeted hand hygiene (n = 30) and/or face mask use (n = 12) and used two- or three-arm study designs with passive comparators. Interventions were typically delivered face-to-face and included a median of three behaviour change techniques. The quality of included studies was low. Interventions to increase hand hygiene (k = 6) had a medium, positive effect (d = .62, 95% CI = 0.43-0.80, p < .001, I2 = 81.2%). Interventions targeting face mask use (k = 4) had mixed results, with an imprecise pooled estimate (OR = 4.14, 95% CI = 1.24-13.79, p < .001, I2 = 89.67%). Between-study heterogeneity was high. CONCLUSIONS We found low-quality evidence for positive effects of interventions targeting hand hygiene, with unclear results for interventions targeting face mask use. There was a lack of evidence for most behaviours of interest within this review.
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Affiliation(s)
- Olga Perski
- Department of Behavioural Science and Health, University College London, UK
| | - Dorothy Szinay
- Behavioural and Implementation Science Group, School of Health Sciences, University of East Anglia, Norwich, UK
| | - Elizabeth Corker
- Department of Clinical, Educational and Health Psychology, University College London, UK
| | - Lion Shahab
- Department of Behavioural Science and Health, University College London, UK
| | - Robert West
- Department of Behavioural Science and Health, University College London, UK
| | - Susan Michie
- Department of Clinical, Educational and Health Psychology, University College London, UK
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22
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Li Y, Wei Z, Zhang J, Li R, Li H, Cao L, Hou L, Zhang W, Chen N, Guo K, Li X, Yang K. Wearing masks to reduce the spread of respiratory viruses: a systematic evidence mapping. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:811. [PMID: 34268424 PMCID: PMC8246209 DOI: 10.21037/atm-20-6745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 02/28/2021] [Indexed: 01/08/2023]
Abstract
Since the outbreak of coronavirus disease in 2019, the controversy over the effectiveness, safety, and enforceability of masks used by the public has been prominent. This study aims to identify, describe, and organize the currently available high-quality design evidence concerning mask use during the spread of respiratory viruses and find evidence gaps. Databases including PubMed, Cochrane Library, Web of Science, EMBASE, WHO International Clinical Trials Registry Platform (ICTRP), clinical trial registry, gray literature database, and reference lists of articles were searched for relevant randomized controlled trials (RCTs) and systematic reviews (SRs) in April 2020. The quality of the studies was assessed using the risk of bias tool recommended by the Cochrane Handbook Version 5.1.0 and the Assessment of Multiple Systematic Reviews (AMSTAR 2) tool. A bubble plot was designed to display information in four dimensions. Finally, twenty-one RCTs and nine SRs met our inclusion criteria. Most studies were of “Low quality” and focused on healthcare workers. Six RCTs reported adverse effects, with one implying that the cloth masks reuse may increase the infection risk. When comparing masks with usual practice, over 70% RCTs and also SRs showed that masks were “beneficial” or “probably beneficial”; however, when comparing N95 respirators with medical masks, 75% of SRs showed “no effect”, whereas 50% of RCTs showed “beneficial effect”. Overall, the current evidence provided by high-quality designs may be insufficient to deal with a second impact of the pandemic. Masks may be effective in interrupting or reducing the spread of respiratory viruses; however, the effect of an N95 respirator or cloth masks versus medical masks is unclear. Additional high-quality studies determining the impact of prolonged mask use on vulnerable populations (such as children and pregnant women), the possible adverse effects (such as skin allergies and shortness of breath) and optimal settings and exposure circumstances for populations to use masks are needed.
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Affiliation(s)
- Yanfei Li
- Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China.,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.,Chinese GRADE Center, Lanzhou University, Lanzhou, China
| | - Zhipeng Wei
- Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China.,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.,Chinese GRADE Center, Lanzhou University, Lanzhou, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Jingyun Zhang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Rui Li
- Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China.,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.,Chinese GRADE Center, Lanzhou University, Lanzhou, China
| | - Huijuan Li
- Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China.,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.,Chinese GRADE Center, Lanzhou University, Lanzhou, China
| | - Liujiao Cao
- Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China.,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.,Chinese GRADE Center, Lanzhou University, Lanzhou, China
| | - Liangying Hou
- Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China.,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.,Chinese GRADE Center, Lanzhou University, Lanzhou, China
| | - Weiyi Zhang
- Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China.,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.,Chinese GRADE Center, Lanzhou University, Lanzhou, China
| | - Nan Chen
- Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China.,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.,Chinese GRADE Center, Lanzhou University, Lanzhou, China
| | - Kangle Guo
- Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China.,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.,Chinese GRADE Center, Lanzhou University, Lanzhou, China
| | - Xiuxia Li
- Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China.,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.,Chinese GRADE Center, Lanzhou University, Lanzhou, China
| | - Kehu Yang
- Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China.,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.,Chinese GRADE Center, Lanzhou University, Lanzhou, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
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23
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Yeung AY, Roewer-Despres F, Rosella L, Rudzicz F. Machine Learning-Based Prediction of Growth in Confirmed COVID-19 Infection Cases in 114 Countries Using Metrics of Nonpharmaceutical Interventions and Cultural Dimensions: Model Development and Validation. J Med Internet Res 2021; 23:e26628. [PMID: 33844636 PMCID: PMC8074952 DOI: 10.2196/26628] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/05/2021] [Accepted: 03/23/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND National governments worldwide have implemented nonpharmaceutical interventions to control the COVID-19 pandemic and mitigate its effects. OBJECTIVE The aim of this study was to investigate the prediction of future daily national confirmed COVID-19 infection growth-the percentage change in total cumulative cases-across 14 days for 114 countries using nonpharmaceutical intervention metrics and cultural dimension metrics, which are indicative of specific national sociocultural norms. METHODS We combined the Oxford COVID-19 Government Response Tracker data set, Hofstede cultural dimensions, and daily reported COVID-19 infection case numbers to train and evaluate five non-time series machine learning models in predicting confirmed infection growth. We used three validation methods-in-distribution, out-of-distribution, and country-based cross-validation-for the evaluation, each of which was applicable to a different use case of the models. RESULTS Our results demonstrate high R2 values between the labels and predictions for the in-distribution method (0.959) and moderate R2 values for the out-of-distribution and country-based cross-validation methods (0.513 and 0.574, respectively) using random forest and adaptive boosting (AdaBoost) regression. Although these models may be used to predict confirmed infection growth, the differing accuracies obtained from the three tasks suggest a strong influence of the use case. CONCLUSIONS This work provides new considerations in using machine learning techniques with nonpharmaceutical interventions and cultural dimensions as metrics to predict the national growth of confirmed COVID-19 infections.
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Affiliation(s)
- Arnold Ys Yeung
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada
| | - Francois Roewer-Despres
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada
| | - Laura Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Frank Rudzicz
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada
- Unity Health Toronto, Toronto, ON, Canada
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24
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Yuen E, Fried J, Salvador C, Gudis DA, Schlosser RJ, Nguyen SA, Brennan EA, Rowan NR. Nonpharmacological interventions to reduce respiratory viral transmission: an evidence-based review with recommendations. Rhinology 2021; 59:114-132. [PMID: 33760909 DOI: 10.4193/rhin20.563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Viral respiratory infections are a leading cause of worldwide mortality and exert the potential to cause global socioeconomic crises. However, inexpensive, efficacious, and rapidly deployable strategies to reduce viral transmission are increasingly important in the setting of an ongoing pandemic, though not entirely understood. This article provides a comprehensive review of commonly employed nonpharmacological interventions to interrupt viral spread and provides evidence-based recommendations for their use. METHODOLOGY A systematic review of three databases was performed. Studies with defined endpoints of subjects receiving one of five interventions (nasal washing, gargling, personal protective equipment (PPE), social distancing, and hand hygiene) were included. An evidence-based review of the highest level of evidence, with recommendations, was created in accordance with a previously described, rigorous, iterative process. RESULTS Fifty-four primary studies were included. The most commonly studied intervention was hand hygiene, followed by PPE, gargling, saline nasal washing, and social distancing. CONCLUSIONS Mask use and hand hygiene are strong recommendations for prevention of viral transmission. Donning gloves, gowns, and eye protection are a recommendation in healthcare settings. Saline nasal washing and gargling are options in selected populations. Although an aggregate level of evidence is not provided, the authors recommend social distancing.
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Affiliation(s)
- E Yuen
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Charleston, SC, USA
| | - J Fried
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Charleston, SC, USA
| | - C Salvador
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Charleston, SC, USA
| | - D A Gudis
- Columbia University Irving Medical Centre, Department of Otolaryngology-Head and Neck Surgery, New York, NY, USA
| | - R J Schlosser
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Charleston, SC, USA
| | - S A Nguyen
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Charleston, SC, USA
| | - E A Brennan
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Charleston, SC, USA
| | - N R Rowan
- The Johns Hopkins University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, MD, USA
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25
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Chaabna K, Doraiswamy S, Mamtani R, Cheema S. Facemask use in community settings to prevent respiratory infection transmission: A rapid review and meta-analysis. Int J Infect Dis 2021; 104:198-206. [PMID: 32987183 PMCID: PMC7518963 DOI: 10.1016/j.ijid.2020.09.1434] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Synthesis of the available evidence on the effectiveness of medical and cloth facemask use by the general public in community settings is required to learn lessons for future respiratory epidemics/pandemics. METHOD Search terms relating to facemasks, infection and community settings were used for PubMed, the Cochrane Library Database and Google Scholar. A meta-analysis was conducted using a random-effects model. RESULTS The review included 12 primary studies on the effectiveness of medical facemask use to prevent influenza, influenza-like illness, SARS-CoV, and SARS-CoV-2 transmission. The meta-analysis demonstrated that facemask use significantly reduces the risk of transmitting these respiratory infections (pooled OR = 0.66, 95% CI 0.54-0.81). Of the 12 studies, 10 clinical trials suggested that respiratory infection incidence is lower with high medical facemask compliance, early use and use in combination with intensive hand hygiene. One cohort study conducted during the SARS-CoV-2 pandemic demonstrated that facemasks are effective in reducing SARS-CoV-2 transmission when used before those who are infected develop symptoms. One case-control study reported that controls used medical facemasks more often than cases infected with SARS-CoV (p < 0.05). No primary study on cloth facemask effectiveness to prevent respiratory infection transmission was found. CONCLUSION Based on the available evidence, medical facemask use by healthy and sick individuals is recommended for preventing respiratory infection transmission in community settings. Medical facemask effectiveness is dependent on compliance and utilization in combination with preventive measures such as intensive hand hygiene. No direct evidence is currently available in humans supporting the recommendation of cloth facemask use to prevent respiratory infection transmission.
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Affiliation(s)
- Karima Chaabna
- Institute for Population Health, Weill Cornell Medicine, Doha, Qatar.
| | | | - Ravinder Mamtani
- Institute for Population Health, Weill Cornell Medicine, Doha, Qatar
| | - Sohaila Cheema
- Institute for Population Health, Weill Cornell Medicine, Doha, Qatar
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26
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Bakhit M, Krzyzaniak N, Scott AM, Clark J, Glasziou P, Del Mar C. Downsides of face masks and possible mitigation strategies: a systematic review and meta-analysis. BMJ Open 2021; 11:e044364. [PMID: 33619199 PMCID: PMC7903088 DOI: 10.1136/bmjopen-2020-044364] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To identify, appraise and synthesise studies evaluating the downsides of wearing face masks in any setting. We also discuss potential strategies to mitigate these downsides. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Embase, CENTRAL and EuropePMC were searched (inception-18 May 2020), and clinical registries were searched via CENTRAL. We also did a forward-backward citation search of the included studies. INCLUSION CRITERIA We included randomised controlled trials and observational studies comparing face mask use to any active intervention or to control. DATA EXTRACTION AND ANALYSIS Two author pairs independently screened articles for inclusion, extracted data and assessed the quality of included studies. The primary outcomes were compliance, discomforts, harms and adverse events of wearing face masks. RESULTS We screened 5471 articles, including 37 (40 references); 11 were meta-analysed. For mask wear adherence, 47% (95% CI 25% to 68%, p<0.0001), more people wore face masks in the face mask group compared with control; adherence was significantly higher (26%, 95% CI 8% to 46%, p<0.01) in the surgical/medical mask group than in N95/P2 group. The largest number of studies reported on the discomfort and irritation outcome (20 studies); fewest reported on the misuse of masks, and none reported on mask contamination or risk compensation behaviour. Risk of bias was generally high for blinding of participants and personnel and low for attrition and reporting biases. CONCLUSIONS There are insufficient data to quantify all of the adverse effects that might reduce the acceptability, adherence and effectiveness of face masks. New research on face masks should assess and report the harms and downsides. Urgent research is also needed on methods and designs to mitigate the downsides of face mask wearing, particularly the assessment of possible alternatives. SYSTEMATIC REVIEW REGISTRATION Open Science Framework website https://osf.io/sa6kf/ (timestamp 20-05-2020).
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Affiliation(s)
- Mina Bakhit
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Natalia Krzyzaniak
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Anna Mae Scott
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Chris Del Mar
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
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27
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Wang Y, Deng Z, Shi D. How effective is a mask in preventing COVID-19 infection? ACTA ACUST UNITED AC 2021; 4:e10163. [PMID: 33615150 PMCID: PMC7883189 DOI: 10.1002/mds3.10163] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/04/2020] [Accepted: 12/04/2020] [Indexed: 12/27/2022]
Abstract
The main clinical characteristics of COVID‐19 are respiratory symptoms that can lead to serious cardiovascular damages and severe worsening of other medical conditions. One of the major strategies in preparedness and response to COVID 19 is effective utilization of personal protective equipment (PPE) among which the masks of different kinds are on the top of the list especially for activities in the public places. However, the underlying mechanisms of masks in preventing virus transmission have not been well identified and the current experimental data still show inconsistent outcomes that may mislead the public. For instance, the early understanding of the mask functions was limited especially in the escalating phase of the COVID 19 pandemic, resulting in quite controversial remarks on masks. Although extensive studies in mask functions have been carried out ever since the COVID‐19 outbreaks, most of the investigations appear to have focused on exhalation isolation of individuals who may have been infected with the disease. Less emphasis was laid on inhalation protection from virus transmission, an important aspect that undergirds the public health policies and protective strategies. This review provides the most up‐to‐date information on the transmission modes of COVID‐19 virus in terms of droplets and aerosols. The roles of masks in disease prevention and transmission reduction are evaluated on various types, structures and functions. More important, both aspects of exhalation isolation and inhalation protection are discussed based on virus transmission modes and the effectiveness of different types of masks under varied environmental conditions.
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Affiliation(s)
- Yuxin Wang
- The Materials Science and Engineering Program College of Engineering and Applied Science University of Cincinnati Cincinnati OH USA
| | - Zicheng Deng
- The Materials Science and Engineering Program College of Engineering and Applied Science University of Cincinnati Cincinnati OH USA.,Center for Lung Regenerative Medicine Cincinnati Children's Hospital Medical Center Cincinnati OH USA.,Division of Pulmonary Biology Cincinnati Children's Hospital Medical Center Cincinnati OH USA
| | - Donglu Shi
- The Materials Science and Engineering Program College of Engineering and Applied Science University of Cincinnati Cincinnati OH USA
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Brainard J, Jones NR, Lake IR, Hooper L, Hunter PR. Community use of face masks and similar barriers to prevent respiratory illness such as COVID-19: a rapid scoping review. ACTA ACUST UNITED AC 2021; 25. [PMID: 33303066 PMCID: PMC7730486 DOI: 10.2807/1560-7917.es.2020.25.49.2000725] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BackgroundEvidence for face-mask wearing in the community to protect against respiratory disease is unclear.AimTo assess effectiveness of wearing face masks in the community to prevent respiratory disease, and recommend improvements to this evidence base.MethodsWe systematically searched Scopus, Embase and MEDLINE for studies evaluating respiratory disease incidence after face-mask wearing (or not). Narrative synthesis and random-effects meta-analysis of attack rates for primary and secondary prevention were performed, subgrouped by design, setting, face barrier type, and who wore the mask. Preferred outcome was influenza-like illness. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) quality assessment was undertaken and evidence base deficits described.Results33 studies (12 randomised control trials (RCTs)) were included. Mask wearing reduced primary infection by 6% (odds ratio (OR): 0.94; 95% CI: 0.75-1.19 for RCTs) to 61% (OR: 0.85; 95% CI: 0.32-2.27; OR: 0.39; 95% CI: 0.18-0.84 and OR: 0.61; 95% CI: 0.45-0.85 for cohort, case-control and cross-sectional studies respectively). RCTs suggested lowest secondary attack rates when both well and ill household members wore masks (OR: 0.81; 95% CI: 0.48-1.37). While RCTs might underestimate effects due to poor compliance and controls wearing masks, observational studies likely overestimate effects, as mask wearing might be associated with other risk-averse behaviours. GRADE was low or very low quality.ConclusionWearing face masks may reduce primary respiratory infection risk, probably by 6-15%. It is important to balance evidence from RCTs and observational studies when their conclusions widely differ and both are at risk of significant bias. COVID-19-specific studies are required.
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Affiliation(s)
- Julii Brainard
- The Norwich School of Medicine, University of East Anglia, Norwich, Norfolk, United Kingdom
| | - Natalia R Jones
- School of Environmental Sciences, University of East Anglia, Norwich, Norfolk, United Kingdom
| | - Iain R Lake
- School of Environmental Sciences, University of East Anglia, Norwich, Norfolk, United Kingdom
| | - Lee Hooper
- The Norwich School of Medicine, University of East Anglia, Norwich, Norfolk, United Kingdom
| | - Paul R Hunter
- The Norwich School of Medicine, University of East Anglia, Norwich, Norfolk, United Kingdom
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29
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Boretti A. Efficacy of Generalized Face Masking Mandates. Health Serv Res Manag Epidemiol 2021; 8:23333928211058023. [PMID: 34778494 PMCID: PMC8586184 DOI: 10.1177/23333928211058023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This commentary discusses if targeted uses of face masks may provide better results than generalized face masks mandates to limit the spread of Covid-19. The study is based on a literature review, as well as the analysis of cases and fatalities of different countries adopting different mask mandates. Before the Covid-19 emergency, the literature was consistently against generalized masking for cold and flu viruses. The latest literature for Covid-19 infection is opposite mostly supportive for generalized masking, even if contrarian works exist. The Covid-19 recommendations are not based on randomized controlled trials of healthy individuals wearing or not masks, differentiating in between closed or open spaces. Countries that did not mandate face masks have not performed worse for the number of cases and fatalities than countries that adopted generalized face masking policies during the Covid-19 emergency. Face masks help against Covid-19 infection but also have downfalls. Their benefits are overestimated, while their risks are underestimated. Masks can block the larger droplets exhaled by an infected wearer, protecting the healthy from viral exposure, but their ability to filter out viruses is variable and generally poor especially in reused cloth masks worn by the public. New surgical masks should be used in crowded spaces especially indoors, preferring distancing without masks outdoor. There are serious unintended consequences from wearing face masks improperly and for too long that must be accounted for. There could be more advantages from targeted rather than generalized uses of only surgical face masks.
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Affiliation(s)
- Alberto Boretti
- Prince Mohammad Bin Fahd University, Al Khobar, Kingdom of Saudi Arabia
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30
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Community interventions in Low-And Middle-Income Countries to inform COVID-19 control implementation decisions in Kenya: A rapid systematic review. PLoS One 2020; 15:e0242403. [PMID: 33290402 PMCID: PMC7723273 DOI: 10.1371/journal.pone.0242403] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/02/2020] [Indexed: 12/21/2022] Open
Abstract
Globally, public health measures like face masks, hand hygiene and maintaining social distancing have been implemented to delay and reduce local transmission of COVID-19. To date there is emerging evidence to provide effectiveness and compliance to intervention measures on COVID-19 due to rapid spread of the disease. We synthesized evidence of community interventions and innovative practices to mitigate COVID-19 as well as previous respiratory outbreak infections which may share some aspects of transmission dynamics with COVID-19. In the study, we systematically searched the literature on community interventions to mitigate COVID-19, SARS (severe acute respiratory syndrome), H1N1 Influenza and MERS (middle east respiratory syndrome) epidemics in PubMed, Google Scholar, World Health Organization (WHO), MEDRXIV and Google from their inception until May 30, 2020 for up-to-date published and grey resources. We screened records, extracted data, and assessed risk of bias in duplicates. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. This study is registered with PROSPERO (CRD42020183064). Of 41,138 papers found, 17 studies met the inclusion criteria in various settings in Low- and Middle-Income Countries (LMICs). One of the papers from LMICs originated from Africa (Madagascar) with the rest from Asia 9 (China 5, Bangladesh 2, Thailand 2); South America 5 (Mexico 3, Peru 2) and Europe 2 (Serbia and Romania). Following five studies on the use of face masks, the risk of contracting SARS and Influenza was reduced OR 0.78 and 95% CI = 0.36–1.67. Equally, six studies on hand hygiene practices reported a reduced risk of contracting SARS and Influenza OR 0.95 and 95% CI = 0.83–1.08. Further two studies that looked at combined use of face masks and hand hygiene interventions showed the effectiveness in controlling the transmission of influenza OR 0.94 and 95% CI = 0.58–1.54. Nine studies on social distancing intervention demonstrated the importance of physical distance through closure of learning institutions on the transmission dynamics of disease. The evidence confirms the use of face masks, good hand hygiene and social distancing as community interventions are effective to control the spread of SARS and influenza in LMICs. However, the effectiveness of community interventions in LMICs should be informed by adherence of the mitigation measures and contextual factors taking into account the best practices. The study has shown gaps in adherence/compliance of the interventions, hence a need for robust intervention studies to better inform the evidence on compliance of the interventions. Nevertheless, this rapid review of currently best available evidence might inform interim guidance on similar respiratory infectious diseases like Covid-19 in Kenya and similar LMIC context.
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31
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Abboah-Offei M, Salifu Y, Adewale B, Bayuo J, Ofosu-Poku R, Opare-Lokko EBA. A rapid review of the use of face mask in preventing the spread of COVID-19. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2020; 3:100013. [PMID: 33313575 PMCID: PMC7718106 DOI: 10.1016/j.ijnsa.2020.100013] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/21/2020] [Accepted: 11/19/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction The original use of face masks was to help protect surgical wounds from staff-generated nasal and oral bacteria. Currently governments across the world have instituted the mandatory use of masks and other face coverings so that face masks now find much broader usage in situations where close contact of people is frequent and inevitable, particularly inside public transport facilities, shopping malls and workplaces in response to the COVID-19. Objective We conducted a rapid review to investigate the impact face mask use has had in controlling transmission of respiratory viral infections. Method A rapid review was conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. Five electronic databases (CINAHL, Embase, Medline, PsycINFO and Global Health) were searched from database inception to date, using pre-defined search terms. We included all studies of any design and used descriptive analysis to report summary statistics of search results. Data were extracted including sample characteristics, study design, respiratory virus being controlled, type of face masks used and their effectiveness. Results 58 out of 84 studies met the inclusion criteria, of which 13 were classified as systematic reviews and 45 were quantitative studies (comprising randomised controlled trials, retrospective cohort studies, case control, cross-sectional, surveys, observational and descriptive studies). N = 27 studies were conducted amongst healthcare workers wearing face masks, n = 19 studies among the general population, n = 9 studies among healthcare workers the general population and patients wearing masks, and n = 3 among only patients. Face masks use have shown a great potential for preventing respiratory virus transmission including COVID-19. Conclusion Regardless of the type, setting, or who wears the face mask, it serves primarily a dual preventive purpose; protecting oneself from getting viral infection and protecting others. Therefore, if everyone wears a face mask in public, it offers a double barrier against COVID-19 transmission.
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Affiliation(s)
- Mary Abboah-Offei
- Department of Health Sciences, University of York, Heslington York Y10 5DD, United Kingdom
| | - Yakubu Salifu
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | - Bisi Adewale
- Faculty of Nursing, University of Alberta, Canada
| | - Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong Special Administrative Region
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Brainard J, Jones NR, Lake IR, Hooper L, Hunter PR. Community use of face masks and similar barriers to prevent respiratory illness such as COVID-19: a rapid scoping review. Euro Surveill 2020; 25. [PMID: 33303066 DOI: 10.1101/2020.04.01.20049528] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023] Open
Abstract
BackgroundEvidence for face-mask wearing in the community to protect against respiratory disease is unclear.AimTo assess effectiveness of wearing face masks in the community to prevent respiratory disease, and recommend improvements to this evidence base.MethodsWe systematically searched Scopus, Embase and MEDLINE for studies evaluating respiratory disease incidence after face-mask wearing (or not). Narrative synthesis and random-effects meta-analysis of attack rates for primary and secondary prevention were performed, subgrouped by design, setting, face barrier type, and who wore the mask. Preferred outcome was influenza-like illness. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) quality assessment was undertaken and evidence base deficits described.Results33 studies (12 randomised control trials (RCTs)) were included. Mask wearing reduced primary infection by 6% (odds ratio (OR): 0.94; 95% CI: 0.75-1.19 for RCTs) to 61% (OR: 0.85; 95% CI: 0.32-2.27; OR: 0.39; 95% CI: 0.18-0.84 and OR: 0.61; 95% CI: 0.45-0.85 for cohort, case-control and cross-sectional studies respectively). RCTs suggested lowest secondary attack rates when both well and ill household members wore masks (OR: 0.81; 95% CI: 0.48-1.37). While RCTs might underestimate effects due to poor compliance and controls wearing masks, observational studies likely overestimate effects, as mask wearing might be associated with other risk-averse behaviours. GRADE was low or very low quality.ConclusionWearing face masks may reduce primary respiratory infection risk, probably by 6-15%. It is important to balance evidence from RCTs and observational studies when their conclusions widely differ and both are at risk of significant bias. COVID-19-specific studies are required.
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Affiliation(s)
- Julii Brainard
- The Norwich School of Medicine, University of East Anglia, Norwich, Norfolk, United Kingdom
| | - Natalia R Jones
- School of Environmental Sciences, University of East Anglia, Norwich, Norfolk, United Kingdom
| | - Iain R Lake
- School of Environmental Sciences, University of East Anglia, Norwich, Norfolk, United Kingdom
| | - Lee Hooper
- The Norwich School of Medicine, University of East Anglia, Norwich, Norfolk, United Kingdom
| | - Paul R Hunter
- The Norwich School of Medicine, University of East Anglia, Norwich, Norfolk, United Kingdom
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33
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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 DOI: 10.1101/2020.03.30.20047217] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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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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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Bradford Smith P, Agostini G, Mitchell JC. A scoping review of surgical masks and N95 filtering facepiece respirators: Learning from the past to guide the future of dentistry. SAFETY SCIENCE 2020; 131:104920. [PMID: 32834515 PMCID: PMC7406415 DOI: 10.1016/j.ssci.2020.104920] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 05/03/2023]
Abstract
With the 2019 emergence of coronavirus disease 19 (colloquially called COVID-19) came renewed public concern about airborne and aerosolized virus transmission. Accompanying this concern were many conflicting dialogues about which forms of personal protective equipment best protect dental health care practitioners and their patients from viral exposure. In this comprehensive review we provide a thorough and critical assessment of face masks and face shields, some of the most frequently recommended personal safeguards against viral infection. We begin by describing the function and practicality of the most common mask types used in dentistry: procedural masks, surgical masks, and filtering respirator facemasks (also called N95s). This is followed by a critical assessment of mask use based on a review of published evidence in three key domains: the degree to which each mask type is shown to protect against airborne and aerosolized disease, the reported likelihood for non-compliance among mask users, and risk factors associated with both proper and improper mask use. We use this information to conclude our review with several practical, evidence-based recommendations for mask use in dental and dental educational clinics.
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Key Words
- ADA, American Dental Association
- ARI, Acute Respiratory Infections
- ASTM, American Society of Testing Materials
- CDC, Center for Disease Control
- COVID-19, Coronavirus Disease, first detected in 2019
- CRI, Confirmed respiratory infection
- DHCP, Dental Health Care Practitioner
- ER, Emergency Room
- Evidence-based review
- FDA, Food and Drug Administration
- FFR, Filtering Facepiece Respirators
- H1N1, H1N1 Subtype of Influenza-A
- HCW, Healthcare Workers
- HVE, High-Volume Evacuation
- ICP, Infection Control Protocol
- ILI, Influenza-like Illness
- Infectious disease transmission
- LCI, Laboratory-confirmed Influenza
- MERS, Middle East Respiratory Syndrome (a coronavirus formally identified in 2012)
- N95 respirator
- N95, Non-oil-resistant, filtering facepiece respirator filtering 95% of airborne particles
- NASIOM, National Academy of Sciences’ Institute of Medicine
- NIOSH, National Institute for Occupational Safety and Health
- OSHA, Occupational Safety and Health Administration
- PPE, Personal protective equipment
- RCT, Randomized Controlled Trial
- SARS, Severe Acute Respiratory Syndrome (a coronavirus formally identified in 2003
- Surgical facemask
- WHO, World Health Organization
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Affiliation(s)
- P Bradford Smith
- Midwestern University College of Dental Medicine, AZ, United States
| | - Gina Agostini
- Midwestern University College of Dental Medicine, AZ, United States
| | - John C Mitchell
- Midwestern University College of Dental Medicine, AZ, United States
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Leffler CT, Ing E, Lykins JD, Hogan MC, McKeown CA, Grzybowski A. Association of Country-wide Coronavirus Mortality with Demographics, Testing, Lockdowns, and Public Wearing of Masks. Am J Trop Med Hyg 2020; 103:2400-2411. [PMID: 33124541 PMCID: PMC7695060 DOI: 10.4269/ajtmh.20-1015] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We studied sources of variation between countries in per-capita mortality from COVID-19 (caused by the SARS-CoV-2 virus). Potential predictors of per-capita coronavirus-related mortality in 200 countries by May 9, 2020 were examined, including age, gender, obesity prevalence, temperature, urbanization, smoking, duration of the outbreak, lockdowns, viral testing, contact-tracing policies, and public mask-wearing norms and policies. Multivariable linear regression analysis was performed. In univariate analysis, the prevalence of smoking, per-capita gross domestic product, urbanization, and colder average country temperature were positively associated with coronavirus-related mortality. In a multivariable analysis of 196 countries, the duration of the outbreak in the country, and the proportion of the population aged 60 years or older were positively associated with per-capita mortality, whereas duration of mask-wearing by the public was negatively associated with mortality (all P < 0.001). Obesity and less stringent international travel restrictions were independently associated with mortality in a model which controlled for testing policy. Viral testing policies and levels were not associated with mortality. Internal lockdown was associated with a nonsignificant 2.4% reduction in mortality each week (P = 0.83). The association of contact-tracing policy with mortality was not statistically significant (P = 0.06). In countries with cultural norms or government policies supporting public mask-wearing, per-capita coronavirus mortality increased on average by just 16.2% each week, as compared with 61.9% each week in remaining countries. Societal norms and government policies supporting the wearing of masks by the public, as well as international travel controls, are independently associated with lower per-capita mortality from COVID-19.
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Affiliation(s)
- Christopher T Leffler
- Department of Ophthalmology, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia.,Department of Ophthalmology, Virginia Commonwealth University, Richmond, Virginia
| | - Edsel Ing
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Joseph D Lykins
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia.,Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Matthew C Hogan
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Craig A McKeown
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, Florida
| | - Andrzej Grzybowski
- Institute for Research in Ophthalmology, Poznan, Poland.,Department of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland
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Qaseem A, Etxeandia-Ikobaltzeta I, Yost J, Miller MC, Abraham GM, Obley AJ, Forciea MA, Jokela JA, Humphrey LL, Centor RM, Andrews R, Bledsoe TA, Haeme R, Kansagara DL, Marcucci M. Use of N95, Surgical, and Cloth Masks to Prevent COVID-19 in Health Care and Community Settings: Living Practice Points From the American College of Physicians (Version 1). Ann Intern Med 2020; 173:642-649. [PMID: 32551813 PMCID: PMC7357230 DOI: 10.7326/m20-3234] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Controversy exists around the appropriate types of masks and the situations in which they should be used in community and health care settings for the prevention of SARS-CoV-2 infection. In this article, the American College of Physicians (ACP) provides recommendations based on the best available evidence through 14 April 2020 on the effectiveness of N95 respirators, surgical masks, and cloth masks in reducing transmission of infection. The ACP plans periodic updates of these recommendations on the basis of ongoing surveillance of the literature for 1 year from the initial search date.
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Affiliation(s)
- Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q., I.E.)
| | | | - Jennifer Yost
- American College of Physicians, Philadelphia, and Villanova University, Villanova, Pennsylvania (J.Y.)
| | | | - George M Abraham
- University of Massachusetts Medical School and Saint Vincent Hospital, Worcester, Massachusetts (G.M.A.)
| | - Adam J Obley
- Portland Veterans Affairs Medical Center and Oregon Health & Science University, Portland, Oregon (A.J.O., L.L.H.)
| | | | - Janet A Jokela
- University of Illinois College of Medicine at Urbana-Champaign, Champaign, Illinois (J.A.J.)
| | - Linda L Humphrey
- Portland Veterans Affairs Medical Center and Oregon Health & Science University, Portland, Oregon (A.J.O., L.L.H.)
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Rohde D, Ahern S, Clyne B, Comber L, Spillane S, Walsh KA, Carty PG, Drummond L, Boland T, Smith SM, Connolly MA, Harrington P, Ryan M, O'Neill M. Effectiveness of face masks worn in community settings at reducing the transmission of SARS-CoV-2: A rapid review. HRB Open Res 2020. [DOI: 10.12688/hrbopenres.13161.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: The use of face masks is part of a suite of infection prevention and control measures intended to limit the transmission of respiratory viral diseases. The use of face masks by the general public has been subject to ongoing debate, with limited direct evidence on the effectiveness of face masks in the community during the COVID-19 pandemic. The aim of this review was to synthesise direct evidence on the effectiveness of wearing face masks at reducing the transmission of SARS-CoV-2 in community settings. Methods: A rapid review was conducted. PubMed, Embase, NHS Evidence and Europe PMC were searched systematically from 1 January to 27 August 2020. Clinical trials, cohort, case control, and cross-sectional studies were included if they reported on the effectiveness of face masks in community settings at reducing the transmission of SARS-CoV-2. Studies were critically appraised and synthesised narratively. Results: Seven observational studies were identified, including one study set in households and six in community settings, that reported on the effectiveness of wearing face masks compared with not wearing face masks at reducing the transmission of SARS-CoV-2. Results suggested that face masks reduce the risk of SARS-CoV-2 infection; however, all studies were at high risk of bias and the quality of the evidence was low. Conclusions: This is to date the most comprehensive review of direct evidence on the effectiveness of wearing face masks in the community during the COVID-19 pandemic. There is limited, low certainty direct evidence that wearing face masks reduces the risk of transmission of SARS-CoV-2 in community settings. Further high quality studies are required to confirm these findings.
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Alfelali M, Haworth EA, Barasheed O, Badahdah AM, Bokhary H, Tashani M, Azeem MI, Kok J, Taylor J, Barnes EH, El Bashir H, Khandaker G, Holmes EC, Dwyer DE, Heron LG, Wilson GJ, Booy R, Rashid H. Facemask against viral respiratory infections among Hajj pilgrims: A challenging cluster-randomized trial. PLoS One 2020; 15:e0240287. [PMID: 33048964 PMCID: PMC7553311 DOI: 10.1371/journal.pone.0240287] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 09/24/2020] [Indexed: 12/24/2022] Open
Abstract
Background In this large-scale cluster-randomized controlled trial (cRCT) we sought to assess the effectiveness of facemasks against viral respiratory infections. Methods and results Over three consecutive Hajj seasons (2013, 2014, 2015) pilgrims’ tents in Makkah were allocated to ‘facemask’ or ‘no facemask’ group. Fifty facemasks were offered to participants in intervention tents, to be worn over four days, and none were offered to participants in control tents. All participants recorded facemask use and respiratory symptoms in health diaries. Nasal swabs were collected from the symptomatic for virus detection by reverse transcription polymerase chain reaction. Clinical symptoms and laboratory results were analyzed by ‘intention- to-treat’ and ‘per-protocol’. A total of 7687 adult participants from 318 tents were randomized: 3864 from 149 tents to the intervention group, and 3823 from 169 tents to the control group. Participants were aged 18 to 95 (median 34, mean 37) years, with a male to female ratio of 1:1.2. Overall, respiratory viruses were detected in 277 of 650 (43%) nasal/pharyngeal swabs collected from symptomatic pilgrims. Common viruses were rhinovirus (35.1%), influenza (4.5%) and parainfluenza (1.7%). In the intervention arm, respectively 954 (24.7%) and 1842 (47.7%) participants used facemasks daily and intermittently, while in the control arm, respectively 546 (14.3%) and 1334 (34.9%) used facemasks daily and intermittently. By intention-to-treat analysis, facemask use did not seem to be effective against laboratory-confirmed viral respiratory infections (odds ratio [OR], 1.4; 95% confidence interval [CI], 0.9 to 2.1, p = 0.18) nor against clinical respiratory infection (OR, 1.1; 95% CI, 0.9 to 1.4, p = 0.40). Similarly, in a per-protocol analysis, facemask use did not seem to be effective against laboratory-confirmed viral respiratory infections (OR 1.2, 95% CI 0.9–1.7, p = 0.26) nor against clinical respiratory infection (OR 1.3, 95% CI 1.0–1.8, p = 0.06). Conclusion This trial was unable to provide conclusive evidence on facemask efficacy against viral respiratory infections most likely due to poor adherence to protocol.
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Affiliation(s)
- Mohammad Alfelali
- National Centre for Immunisation Research and Surveillance, The Children’s Hospital at Westmead and The University of Sydney, Sydney, New South Wales, Australia
- Department of Family and Community Medicine, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Osamah Barasheed
- National Centre for Immunisation Research and Surveillance, The Children’s Hospital at Westmead and The University of Sydney, Sydney, New South Wales, Australia
- Research Center, King Abdullah Medical City, Mecca, Saudi Arabia
| | - Al-Mamoon Badahdah
- National Centre for Immunisation Research and Surveillance, The Children’s Hospital at Westmead and The University of Sydney, Sydney, New South Wales, Australia
- Department of Family and Community Medicine, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Hamid Bokhary
- Marie Bashir Institute for Infectious Diseases and Biosecurity, School of Life & Environmental Sciences and School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia
- Umm Al-Qura University, Mecca, Saudi Arabia
| | - Mohamed Tashani
- Discipline of Child and Adolescent Health, The Children’s Hospital at Westmead Clinical School, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, The University of Tripoli, Ain Zara, Tripoli, Libya
| | - Mohammad I. Azeem
- National Centre for Immunisation Research and Surveillance, The Children’s Hospital at Westmead and The University of Sydney, Sydney, New South Wales, Australia
| | - Jen Kok
- Marie Bashir Institute for Infectious Diseases and Biosecurity, School of Life & Environmental Sciences and School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia
- NSW Health Pathology - Institute for Clinical Pathology and Medical Research, Westmead Hospital and The University of Sydney, Sydney, New South Wales, Australia
| | - Janette Taylor
- NSW Health Pathology - Institute for Clinical Pathology and Medical Research, Westmead Hospital and The University of Sydney, Sydney, New South Wales, Australia
| | - Elizabeth H. Barnes
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Haitham El Bashir
- Rehabilitation Department, Al Jalila Children Specialty Hospital, Dubai, United Arab Emirates
| | - Gulam Khandaker
- Discipline of Child and Adolescent Health, The Children’s Hospital at Westmead Clinical School, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Edward C. Holmes
- Marie Bashir Institute for Infectious Diseases and Biosecurity, School of Life & Environmental Sciences and School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Dominic E. Dwyer
- Marie Bashir Institute for Infectious Diseases and Biosecurity, School of Life & Environmental Sciences and School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia
- NSW Health Pathology - Institute for Clinical Pathology and Medical Research, Westmead Hospital and The University of Sydney, Sydney, New South Wales, Australia
| | - Leon G. Heron
- National Centre for Immunisation Research and Surveillance, The Children’s Hospital at Westmead and The University of Sydney, Sydney, New South Wales, Australia
| | - Godwin J. Wilson
- Department of Laboratory Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Robert Booy
- National Centre for Immunisation Research and Surveillance, The Children’s Hospital at Westmead and The University of Sydney, Sydney, New South Wales, Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, School of Life & Environmental Sciences and School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Harunor Rashid
- National Centre for Immunisation Research and Surveillance, The Children’s Hospital at Westmead and The University of Sydney, Sydney, New South Wales, Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, School of Life & Environmental Sciences and School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia
- * E-mail:
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Chou R, Dana T, Jungbauer R, Weeks C, McDonagh MS. Masks for Prevention of Respiratory Virus Infections, Including SARS-CoV-2, in Health Care and Community Settings : A Living Rapid Review. Ann Intern Med 2020; 173:542-555. [PMID: 32579379 PMCID: PMC7322812 DOI: 10.7326/m20-3213] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Recommendations on masks for preventing coronavirus disease 2019 (COVID-19) vary. PURPOSE To examine the effectiveness of N95, surgical, and cloth masks in community and health care settings for preventing respiratory virus infections, and effects of reuse or extended use of N95 masks. DATA SOURCES Multiple electronic databases, including the World Health Organization COVID-19 database and medRxiv preprint server (2003 through 14 April 2020; surveillance through 2 June 2020), and reference lists. STUDY SELECTION Randomized trials of masks and risk for respiratory virus infection, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and observational studies of mask use and coronavirus infection risk were included. New evidence will be incorporated by using living review methods. DATA EXTRACTION One reviewer abstracted data and assessed methodological limitations; a second reviewer provided verification. DATA SYNTHESIS 39 studies (18 randomized controlled trials and 21 observational studies; 33 867 participants) were included. No study evaluated reuse or extended use of N95 masks. Evidence on SARS-CoV-2 was limited to 2 observational studies with serious limitations. Community mask use was possibly associated with decreased risk for SARS-CoV-1 infection in observational studies. In high- or moderate-risk health care settings, observational studies found that risk for infection with SARS-CoV-1 and Middle East respiratory syndrome coronavirus probably decreased with mask use versus nonuse and possibly decreased with N95 versus surgical mask use. Randomized trials in community settings found possibly no difference between N95 versus surgical masks and probably no difference between surgical versus no mask in risk for influenza or influenza-like illness, but compliance was low. In health care settings, N95 and surgical masks were probably associated with similar risks for influenza-like illness and laboratory-confirmed viral infection; clinical respiratory illness had inconsistency. Bothersome symptoms were common. LIMITATIONS There were few SARS-CoV-2 studies, observational studies have methodological limitations, and the review was done by using streamlined methods. CONCLUSION Evidence on mask effectiveness for respiratory infection prevention is stronger in health care than community settings. N95 respirators might reduce SARS-CoV-1 risk versus surgical masks in health care settings, but applicability to SARS-CoV-2 is uncertain. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- Roger Chou
- Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon (R.C., T.D., R.J., C.W., M.S.M.)
| | - Tracy Dana
- Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon (R.C., T.D., R.J., C.W., M.S.M.)
| | - Rebecca Jungbauer
- Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon (R.C., T.D., R.J., C.W., M.S.M.)
| | - Chandler Weeks
- Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon (R.C., T.D., R.J., C.W., M.S.M.)
| | - Marian S McDonagh
- Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon (R.C., T.D., R.J., C.W., M.S.M.)
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Haslam A. Response to 'MacIntyre et al., 2020: A rapid systematic review of the efficacy of face masks and respirators against coronaviruses and other respiratory transmissible viruses for the community, healthcare workers and sick patient'. Int J Nurs Stud 2020; 111:103750. [PMID: 32891417 PMCID: PMC7434616 DOI: 10.1016/j.ijnurstu.2020.103750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Alyson Haslam
- Nutritional Epidemiologist, Oklahoma State University, Center for Indigenous Health Research and Policy, USA.
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Greenhalgh T. Face coverings for the public: Laying straw men to rest. J Eval Clin Pract 2020; 26:1070-1077. [PMID: 32455503 PMCID: PMC8581764 DOI: 10.1111/jep.13415] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 12/24/2022]
Abstract
Background This article responds to one by Graham Martin and colleagues, who offered a critique of my previous publications on face coverings for the lay public in the Covid-19 pandemic. Their paper reflects criticisms that have been made of face coverings policies more generally. Method Narrative rebuttal. Results I address charges that my coauthors and I had misapplied the precautionary principle; drawn conclusions that were not supported by empirical research; and failed to take account of potential harms But before that, I remind my critics that the evidence on face coverings goes beyond the contested trials and observational studies they place centre stage. I set out some key findings from basic science, epidemiology, mathematical modelling, case studies, and natural experiments, and use this rich and diverse body of evidence as the backdrop for my rebuttal of their narrowly framed objections. I challenge my critics' apparent assumption that a particular kind of systematic review should be valorised over narrative and real-world evidence, since stories are crucial to both our scientific understanding and our moral imagination. Conclusion I conclude by thanking my academic adversaries for the intellectual sparring match, but exhort them to remember our professional accountability to a society in crisis. It is time to lay straw men to rest and embrace the full range of evidence in the context of the perilous threat the world is now facing.
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Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
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Affiliation(s)
- Eleni Mantzari
- Department of Public Health and Primary Care, Behaviour and Heath Research Unit, University of Cambridge, Cambridge, UK
| | - G James Rubin
- Department of Psychological Medicine, King's College London, London, UK
| | - Theresa M Marteau
- Department of Public Health and Primary Care, Behaviour and Heath Research Unit, University of Cambridge, Cambridge, UK
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Dugré N, Ton J, Perry D, Garrison S, Falk J, McCormack J, Moe S, Korownyk CS, Lindblad AJ, Kolber MR, Thomas B, Train A, Allan GM. Masks for prevention of viral respiratory infections among health care workers and the public: PEER umbrella systematic review. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:509-517. [PMID: 32675098 PMCID: PMC7365162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To determine the effect of mask use on viral respiratory infection risk. DATA SOURCES MEDLINE and the Cochrane Library. STUDY SELECTION Randomized controlled trials (RCTs) included in at least 1 published systematic review comparing the use of masks with a control group, either in community or health care settings, on the risk of viral respiratory infections. SYNTHESIS In total, 11 systematic reviews were included and 18 RCTs of 26 444 participants were found, 12 in the community and 6 in health care workers. Included studies had limitations and were deemed at high risk of bias. Overall, the use of masks in the community did not reduce the risk of influenza, confirmed viral respiratory infection, influenzalike illness, or any clinical respiratory infection. However, in the 2 trials that most closely aligned with mask use in real-life community settings, there was a significant risk reduction in influenzalike illness (risk ratio [RR] = 0.83; 95% CI 0.69 to 0.99). The use of masks in households with a sick contact was not associated with a significant infection risk reduction in any analysis, no matter if masks were used by the sick individual, the healthy family members, or both. In health care workers, surgical masks were superior to cloth masks for preventing influenzalike illness (RR = 0.12; 95% CI 0.02 to 0.98), and N95 masks were likely superior to surgical masks for preventing influenzalike illness (RR = 0.78; 95% CI 0.61 to 1.00) and any clinical respiratory infections (RR = 0.95; 95% CI 0.90 to 1.00). CONCLUSION This systematic review found limited evidence that the use of masks might reduce the risk of viral respiratory infections. In the community setting, a possible reduced risk of influenzalike illness was found among mask users. In health care workers, the results show no difference between N95 masks and surgical masks on the risk of confirmed influenza or other confirmed viral respiratory infections, although possible benefits from N95 masks were found for preventing influenzalike illness or other clinical respiratory infections. Surgical masks might be superior to cloth masks but data are limited to 1 trial.
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Affiliation(s)
- Nicolas Dugré
- Pharmacist at the CIUSSS du Nord-de-l'Ile-de-Montréal in Quebec and Clinical Assistant Professor in the Faculty of Pharmacy at the University of Montreal.
| | - Joey Ton
- Pharmacist and Clinical Evidence Expert at the College of Family Physicians of Canada in Edmonton
| | - Danielle Perry
- Knowledge Translation Expert at the Alberta College of Family Physicians in Edmonton
| | - Scott Garrison
- Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton
| | - Jamie Falk
- Associate Professor in the College of Pharmacy at the University of Manitoba in Winnipeg
| | - James McCormack
- Professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia in Vancouver
| | - Samantha Moe
- Clinical Evidence Expert at the College of Family Physicians of Canada in Mississauga, Ont
| | - Christina S Korownyk
- Associate Professor in the Department of Family Medicine at the University of Alberta
| | - Adrienne J Lindblad
- Knowledge Translation and Evidence Coordinator at the Alberta College of Family Physicians and Associate Clinical Professor in the Department of Family Medicine at the University of Alberta
| | - Michael R Kolber
- Professor in the Department of Family Medicine at the University of Alberta
| | - Betsy Thomas
- Knowledge Translation Expert at the Alberta College of Family Physicians
| | - Anthony Train
- Assistant Professor in the Department of Family Medicine at Queen's University in Kingston, Ont
| | - G Michael Allan
- Director of Programs and Practice Support at the College of Family Physicians of Canada and Professor in the Department of Family Medicine at the University of Alberta
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Ippolito M, Vitale F, Accurso G, Iozzo P, Gregoretti C, Giarratano A, Cortegiani A. Medical masks and Respirators for the Protection of Healthcare Workers from SARS-CoV-2 and other viruses. Pulmonology 2020; 26:204-212. [PMID: 32362505 PMCID: PMC7184017 DOI: 10.1016/j.pulmoe.2020.04.009] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/09/2020] [Accepted: 04/14/2020] [Indexed: 01/19/2023] Open
Abstract
The use of medical masks and respirators as personal protective equipment is pivotal to reducing the level of biological hazard to which healthcare workers are exposed during the outbreak of highly diffusible pathogens, such as the recent novel coronavirus SARS-CoV-2. Unfortunately, during this pandemic, supplies are rapidly running out worldwide, with potential consequences for the rate of occupational infections. Also, knowledge about specific characteristics of respirators is of utmost importance to select the proper type according to the clinical setting. A wide variety of literature is available on the topic, but mostly based on Influenza viruses infection models. Clinical evidence on the use of respirators is poor and interest in the topic has not been constant over time. A better understanding of SARS-CoV-2 transmission is needed, together with high-quality clinical data on the use of respirators or alternative devices. Moreover, healthcare workers, regardless of their level of experience, should receive specific training. This review aims to summarize the available evidence on the use of medical masks and respirators in the context of viral infections, especially the current coronavirus disease 2019 (COVID-19).
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Affiliation(s)
- Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy.
| | - Filippo Vitale
- Department of Anesthesia and Intensive Care, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy.
| | - Giuseppe Accurso
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy.
| | - Pasquale Iozzo
- Department of Anesthesia and Intensive Care, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy.
| | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy.
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy.
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy.
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Wang H, Chen MB, Cui WY, Xu HL, Zheng QH. The efficacy of masks for influenza-like illness in the community: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20525. [PMID: 32502005 PMCID: PMC7306358 DOI: 10.1097/md.0000000000020525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/01/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND During the COVID-19 period, there was a huge gap in the understanding of masks between east and west. At the same time, the mechanism of the mask and the effect after use, also appeared differences. The Objective of this Meta-analysis is to systematically evaluate the efficacy of masks for influenza in the community. METHODS The Web of Science, PubMed, The Cochrane Library, EMBASE and Clinical Trials will be electronically searched to collect randomized controlled trials regarding the efficacy of masks for influenza in the community through Apr 2020. Two researchers independently screened and evaluated the obtained studies and extracted the outcome indexes. Revman 5.3 software will be used for the meta-analysis. RESULTS The outbreak is continuing, and we need to be prepared for a long fight. If masks are effective, we need to promote their use as soon as possible. If masks are ineffective, strong evidence should be given. This is an urgent task and our team will finish it as soon as possible. CONCLUSION Provide stronger evidence to solve the problem, should we wear masks or not right now.
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Affiliation(s)
| | - Mao-Bing Chen
- Department of Emergency, Wujin People's Hospital Affiliated with Jiangsu University and Wujin Clinical College of Xuzhou Medical University, Changzhou, Jiangsu, PR China
| | | | | | - Qi-Han Zheng
- Department of Emergency, Wujin People's Hospital Affiliated with Jiangsu University and Wujin Clinical College of Xuzhou Medical University, Changzhou, Jiangsu, PR China
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Liang M, Gao L, Cheng C, Zhou Q, Uy JP, Heiner K, Sun C. Efficacy of face mask in preventing respiratory virus transmission: A systematic review and meta-analysis. Travel Med Infect Dis 2020; 36:101751. [PMID: 32473312 PMCID: PMC7253999 DOI: 10.1016/j.tmaid.2020.101751] [Citation(s) in RCA: 245] [Impact Index Per Article: 61.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/16/2020] [Accepted: 05/20/2020] [Indexed: 01/11/2023]
Abstract
Background Conflicting recommendations exist related to whether masks have a protective effect on the spread of respiratory viruses. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was consulted to report this systematic review. Relevant articles were retrieved from PubMed, Web of Science, ScienceDirect, Cochrane Library, and Chinese National Knowledge Infrastructure (CNKI), VIP (Chinese) database. Results A total of 21 studies met our inclusion criteria. Meta-analyses suggest that mask use provided a significant protective effect (OR = 0.35 and 95% CI = 0.24–0.51). Use of masks by healthcare workers (HCWs) and non-healthcare workers (Non-HCWs) can reduce the risk of respiratory virus infection by 80% (OR = 0.20, 95% CI = 0.11–0.37) and 47% (OR = 0.53, 95% CI = 0.36–0.79). The protective effect of wearing masks in Asia (OR = 0.31) appeared to be higher than that of Western countries (OR = 0.45). Masks had a protective effect against influenza viruses (OR = 0.55), SARS (OR = 0.26), and SARS-CoV-2 (OR = 0.04). In the subgroups based on different study designs, protective effects of wearing mask were significant in cluster randomized trials and observational studies. Conclusions This study adds additional evidence of the enhanced protective value of masks, we stress that the use masks serve as an adjunctive method regarding the COVID-19 outbreak. At present, the epidemic of COVID-19 has caused global concern. Masks protect HCWs and other populations against respiratory viral infection. The effectiveness of masks has been proven in different settings, populations, and areas.
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Affiliation(s)
- Mingming Liang
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, PR China; Center for Evidence-Based Practice, Anhui Medical University, Hefei, 230032, Anhui, PR China
| | - Liang Gao
- Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrberger Straße Building 37-38, D-66421, Homburg, Saar, Germany
| | - Ce Cheng
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, 28304, NC, USA
| | - Qin Zhou
- Mayo Clinic, Rochester, MN, 55905, USA
| | - John Patrick Uy
- AMITA Health Saint Joseph Hospital Chicago, Chicago, 60657, Illinois, USA
| | - Kurt Heiner
- Dignity Health Mercy Hospital, Merced, 95340, CA, USA
| | - Chenyu Sun
- AMITA Health Saint Joseph Hospital Chicago, Chicago, 60657, Illinois, USA.
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Xiao J, Shiu EYC, Gao H, Wong JY, Fong MW, Ryu S, Cowling BJ. Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings-Personal Protective and Environmental Measures. Emerg Infect Dis 2020; 26:967-975. [PMID: 32027586 PMCID: PMC7181938 DOI: 10.3201/eid2605.190994] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
There were 3 influenza pandemics in the 20th century, and there has been 1 so far in the 21st century. Local, national, and international health authorities regularly update their plans for mitigating the next influenza pandemic in light of the latest available evidence on the effectiveness of various control measures in reducing transmission. Here, we review the evidence base on the effectiveness of nonpharmaceutical personal protective measures and environmental hygiene measures in nonhealthcare settings and discuss their potential inclusion in pandemic plans. Although mechanistic studies support the potential effect of hand hygiene or face masks, evidence from 14 randomized controlled trials of these measures did not support a substantial effect on transmission of laboratory-confirmed influenza. We similarly found limited evidence on the effectiveness of improved hygiene and environmental cleaning. We identified several major knowledge gaps requiring further research, most fundamentally an improved characterization of the modes of person-to-person transmission.
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Long Y, Hu T, Liu L, Chen R, Guo Q, Yang L, Cheng Y, Huang J, Du L. Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis. J Evid Based Med 2020; 13:93-101. [PMID: 32167245 PMCID: PMC7228345 DOI: 10.1111/jebm.12381] [Citation(s) in RCA: 204] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/12/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Previous meta-analyses concluded that there was insufficient evidence to determine the effect of N95 respirators. We aimed to assess the effectiveness of N95 respirators versus surgical masks for prevention of influenza by collecting randomized controlled trials (RCTs). METHODS We searched PubMed, EMbase and The Cochrane Library from the inception to January 27, 2020 to identify relevant systematic reviews. The RCTs included in systematic reviews were identified. Then we searched the latest published RCTs from the above three databases and searched ClinicalTrials.gov for unpublished RCTs. Two reviewers independently extracted the data and assessed risk of bias. Meta-analyses were conducted to calculate pooled estimates by using RevMan 5.3 software. RESULTS A total of six RCTs involving 9 171 participants were included. There were no statistically significant differences in preventing laboratory-confirmed influenza (RR = 1.09, 95% CI 0.92-1.28, P > .05), laboratory-confirmed respiratory viral infections (RR = 0.89, 95% CI 0.70-1.11), laboratory-confirmed respiratory infection (RR = 0.74, 95% CI 0.42-1.29) and influenzalike illness (RR = 0.61, 95% CI 0.33-1.14) using N95 respirators and surgical masks. Meta-analysis indicated a protective effect of N95 respirators against laboratory-confirmed bacterial colonization (RR = 0.58, 95% CI 0.43-0.78). CONCLUSION The use of N95 respirators compared with surgical masks is not associated with a lower risk of laboratory-confirmed influenza. It suggests that N95 respirators should not be recommended for general public and nonhigh-risk medical staff those are not in close contact with influenza patients or suspected patients.
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Affiliation(s)
- Youlin Long
- Chinese Evidence‐Based Medicine CenterWest China HospitalSichuan UniversityChengduP.R. China
| | - Tengyue Hu
- West China School of MedicineSichuan UniversityChengduP.R. China
| | - Liqin Liu
- West China School of MedicineSichuan UniversityChengduP.R. China
| | - Rui Chen
- School of Clinical MedicineChengdu University of Traditional Chinese MedicineChengduP.R. China
| | - Qiong Guo
- Chinese Evidence‐Based Medicine CenterWest China HospitalSichuan UniversityChengduP.R. China
| | - Liu Yang
- Chinese Evidence‐Based Medicine CenterWest China HospitalSichuan UniversityChengduP.R. China
| | - Yifan Cheng
- Chinese Evidence‐Based Medicine CenterWest China HospitalSichuan UniversityChengduP.R. China
| | - Jin Huang
- West China HospitalSichuan UniversityChengduP.R. China
| | - Liang Du
- Chinese Evidence‐Based Medicine CenterWest China HospitalSichuan UniversityChengduP.R. China
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A rapid systematic review of the efficacy of face masks and respirators against coronaviruses and other respiratory transmissible viruses for the community, healthcare workers and sick patients. Int J Nurs Stud 2020; 108:103629. [PMID: 32512240 PMCID: PMC7191274 DOI: 10.1016/j.ijnurstu.2020.103629] [Citation(s) in RCA: 175] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/18/2020] [Accepted: 04/21/2020] [Indexed: 12/15/2022]
Abstract
Background The pandemic of COVID-19 is growing, and a shortage of masks and respirators has been reported globally. Policies of health organizations for healthcare workers are inconsistent, with a change in policy in the US for universal face mask use. The aim of this study was to review the evidence around the efficacy of masks and respirators for healthcare workers, sick patients and the general public. Methods A systematic review of randomized controlled clinical trials on use of respiratory protection by healthcare workers, sick patients and community members was conducted. Articles were searched on Medline and Embase using key search terms. Results A total of 19 randomised controlled trials were included in this study – 8 in community settings, 6 in healthcare settings and 5 as source control. Most of these randomised controlled trials used different interventions and outcome measures. In the community, masks appeared to be effective with and without hand hygiene, and both together are more protective. Randomised controlled trials in health care workers showed that respirators, if worn continually during a shift, were effective but not if worn intermittently. Medical masks were not effective, and cloth masks even less effective. When used by sick patients randomised controlled trials suggested protection of well contacts. Conclusion The study suggests that community mask use by well people could be beneficial, particularly for COVID-19, where transmission may be pre-symptomatic. The studies of masks as source control also suggest a benefit, and may be important during the COVID-19 pandemic in universal community face mask use as well as in health care settings. Trials in healthcare workers support the use of respirators continuously during a shift. This may prevent health worker infections and deaths from COVID-19, as aerosolisation in the hospital setting has been documented.
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