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Meta-Analysis
. 2011 Jul 6;2011(7):CD006207.
doi: 10.1002/14651858.CD006207.pub4.

Physical interventions to interrupt or reduce the spread of respiratory viruses

Tom Jefferson  1 , Chris B Del Mar, Liz Dooley, Eliana Ferroni, Lubna A Al-Ansary, Ghada A Bawazeer, Mieke L van Driel, Sreekumaran Nair, Mark A Jones, Sarah Thorning, John M Conly
Affiliations
Meta-Analysis

Physical interventions to interrupt or reduce the spread of respiratory viruses

Tom Jefferson et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a global threat. Antiviral drugs and vaccinations may be insufficient to prevent their spread.

Objectives: To review the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses.

Search strategy: We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2010, Issue 3), which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to October 2010), OLDMEDLINE (1950 to 1965), EMBASE (1990 to October 2010), CINAHL (1982 to October 2010), LILACS (2008 to October 2010), Indian MEDLARS (2008 to October 2010) and IMSEAR (2008 to October 2010).

Selection criteria: In this update, two review authors independently applied the inclusion criteria to all identified and retrieved articles and extracted data. We scanned 3775 titles, excluded 3560 and retrieved full papers of 215 studies, to include 66 papers of 67 studies. We included physical interventions (screening at entry ports, isolation, quarantine, social distancing, barriers, personal protection, hand hygiene) to prevent respiratory virus transmission. We included randomised controlled trials (RCTs), cohorts, case-controls, before-after and time series studies.

Data collection and analysis: We used a standardised form to assess trial eligibility. We assessed RCTs by randomisation method, allocation generation, concealment, blinding and follow up. We assessed non-RCTs for potential confounders and classified them as low, medium and high risk of bias.

Main results: We included 67 studies including randomised controlled trials and observational studies with a mixed risk of bias. A total number of participants is not included as the total would be made up of a heterogenous set of observations (participant people, observations on participants and countries (object of some studies)). The risk of bias for five RCTs and most cluster-RCTs was high. Observational studies were of mixed quality. Only case-control data were sufficiently homogeneous to allow meta-analysis. The highest quality cluster-RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children. Benefit from reduced transmission from children to household members is broadly supported also in other study designs where the potential for confounding is greater. Nine case-control studies suggested implementing transmission barriers, isolation and hygienic measures are effective at containing respiratory virus epidemics. Surgical masks or N95 respirators were the most consistent and comprehensive supportive measures. N95 respirators were non-inferior to simple surgical masks but more expensive, uncomfortable and irritating to skin. Adding virucidals or antiseptics to normal handwashing to decrease respiratory disease transmission remains uncertain. Global measures, such as screening at entry ports, led to a non-significant marginal delay in spread. There was limited evidence that social distancing was effective, especially if related to the risk of exposure.

Authors' conclusions: Simple and low-cost interventions would be useful for reducing transmission of epidemic respiratory viruses. Routine long-term implementation of some measures assessed might be difficult without the threat of an epidemic.

PubMed Disclaimer

Conflict of interest statement

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

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included RCTs.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included RCT.
1.1
1.1. Analysis
Comparison 1 Case‐control studies, Outcome 1 Thorough disinfection of living quarters.
1.2
1.2. Analysis
Comparison 1 Case‐control studies, Outcome 2 Frequent handwashing.
1.3
1.3. Analysis
Comparison 1 Case‐control studies, Outcome 3 Wearing mask.
1.4
1.4. Analysis
Comparison 1 Case‐control studies, Outcome 4 Wearing N95 respirator.
1.5
1.5. Analysis
Comparison 1 Case‐control studies, Outcome 5 Wearing gloves.
1.6
1.6. Analysis
Comparison 1 Case‐control studies, Outcome 6 Wearing gowns.
1.7
1.7. Analysis
Comparison 1 Case‐control studies, Outcome 7 All interventions.
1.8
1.8. Analysis
Comparison 1 Case‐control studies, Outcome 8 Use of eye protection (mask/goggles).
1.9
1.9. Analysis
Comparison 1 Case‐control studies, Outcome 9 Nose wash.
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References

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References to studies awaiting assessment

Aiello 2010b {published data only}
    1. Aiello AE, Coulborn RM, Perez V, Davis BM, Uddin M, Murray GF, et al. A randomized intervention trial of mask use and hand hygiene to reduce seasonal influenza‐like illness and influenza infections among young adults in a university setting. International Journal of Infectious Diseases 2010;14:e320. - PubMed
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References to other published versions of this review

Jefferson 2007
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