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Non-Pharmaceutical Measures to Prevent Influenza Transmission

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Non-Pharmaceutical Measures to Prevent Influenza Transmission September 2011 Non-Pharmaceutical Measures to Prevent Influenza Transmission: The Evidence for Individual Protective Measures Alexis Crabtree, MPH, 1 and Bonnie Henry,MD, MPH, FRCP(C)1,2 1University of British Columbia; 2British Columbia Centre for Disease Control Key Points Introduction • Mask use by cases and/or household contacts may be efficacious A wealth of knowledge has become in reducing the transmission of influenza, but that effectiveness available concerning influenza is likely reduced by poor compliance. Mask use in the community prevention and control in the wake of setting is of dubious benefit, as is the use of N95 respirators rather the 2009 H1N1 pandemic. The purpose than surgical masks outside of health care settings. of this review is to summarize the recent • Isolation and quarantine are effective and acceptable interventions literature on several non-pharmaceutical to reduce the spread of influenza, particularly pandemic influ- interventions: masks; quarantine, enza. Social distancing measures (excluding school closures and isolation, and social distancing; and prohibitions on mass gatherings, which are covered in another hand hygiene, respiratory hygiene, and paper in this series (Roth, 2011)), however, are of unproven value cleaning of fomites. and associated with low uptake. Special attention should be paid to providing tools and supports to those in quarantine or isolation, particularly to vulnerable groups. Masks A recently updated Cochrane review • Moderate evidence exists to support recommendations for hand concluded that mask use can interrupt and respiratory hygiene, especially in children. Further research is the transmission of influenza (1). While needed to show benefits from cleaning and disinfection of surfac- es in household and public spaces. the review found evidence for the efficacy of this approach, the study did not examine the real-world effectiveness of public spaces. Recommendations for mask-wearing, given the inconvenience Mask Use by Symptomatic mask use among health care personnel and costs of the strategy. Individuals and Their Household are summarized elsewhere (e.g. see Contacts Mask use to prevent influenza Carlson et al, 2010 (2)). Here, we review transmission can be divided into four recent literature on mask use for ill and A systematic review (3) found some categories of users: health care personnel, healthy individuals in the community evidence to support the use of masks by symptomatic individuals, well individuals and summarize recent recommendations symptomatic individuals. Most of the exposed to household contacts with regarding the utility of N95 respirators studies reviewed had both index cases influenza, and well individuals in versus surgical masks. and household contacts instructed to knowledge that’s contagious! Des saviors qui se transmettent! wear masks, thereby creating difficulty recommendations for household contacts weekly ILI attack rate during some weeks identifying where an interruption in only to wear them. Although there was no of the trial, but found no difference in the influenza transmission occurred. They significant difference in the transmission cumulative attack rate (10). do, however, cite an experimental study risk of ILI between the three study arms As with mask use by cases and household of infectious volunteers with influenza, in an intention-to-treat analysis, adherent contacts, poor compliance could decrease supporting the conclusion that surgical use of either surgical masks or N95- the effectiveness of mask use in public masks provide outward protection (i.e. equivialent masks was the only variable settings. Observed rates of mask wearing mask-wearing by a case reduces the that was significantly associated with on Mexico City public transportation early likelihood that the case will infect others) a reduced risk of ILI infection among in the 2009 H1N1 pandemic were above (4). The review finds less evidence to household contacts of cases (7). 60%, but declined to below 40% within a support the use of masks in household Among possible interventions to reduce week (11), although only a slight decrease contacts of cases and suggests that such the spread of influenza, mask-wearing was reported in Hong Kong (12). Two interventions would result in difficulties by students was rated the lowest median Australian surveys, conducted before and with compliance (3). acceptability in a survey of teachers, and after the pandemic, found a significant Several recent randomized controlled mask-wearing while caring for ill children decrease in subjects’ willingness to wear trials (RCTs) have attempted to a mask in public (13, 14). A pandemic determine the effectiveness of masks and model, however, suggests that even if hand hygiene in preventing primary and/ Debate over the utility masks were only 20% effective and only or secondary transmission of influenza of N95 respirators versus 10% of the population wore them during compared to hand hygiene alone and surgical masks for the a pandemic, cases of influenza would be to a usual practice control group. One prevention of influenza reduced by 20%; masks that were 6% study found no decrease in overall effective worn by 50% of the population rates of upper respiratory infections in transmission is based would reduce cumulative cases by only those houses using masks, but did find to a large extent on 6% (15). mask wearing associated with reduced uncertainty about the secondary transmission (despite poor relative importance adherence) (5). Another trial also found Mask Type no significant difference in influenza of various modes of Debate over the utility of N95 respirators infection between the three arms of their transmission. versus surgical masks for the prevention study (where households with a member of influenza transmission is based to a presenting to clinic with influenza-like large extent on uncertainty about the illness [ILI] were assigned to the control was the least acceptable of interventions relative importance of various modes of group, the soap/hand sanitizer supplies proposed to parents (8). Similarly, transmission. Supporters of the key role and education group, or the third group surveyed university students were more of aerosol transmission, such as in a recent which received soap/hand sanitizer resistant to wearing a mask in public if expert-led review (16) and mathematical supplies and education plus surgical experiencing influenza-like symptoms model (17), encourage the use of N95 mask provision and education), but did than to any other proposed strategy respirators because they provide better see a reduction in influenza transmission (including isolation and vaccination) (9). filtration of small particles under ideal in the mask plus hand hygiene group conditions. Critics can point to a recent when the intervention was implemented model citing contact between virus- within 36 hours of symptom onset (6). Mask Use in Public Spaces laden hands and facial membranes as In these studies both index cases and Mask use in the general public is predicated the key transmission route (18), which is household contacts were instructed on the assumption that a significant supported by reviews finding no difference to wear masks, making it difficult to proportion of transmission events will in attack rates for influenza between isolate the effectiveness of mask-wearing occur in public spaces. Evidence for this masks and respirators (1, 19). Given that by index cases versus contacts. A final assumption is limited. Among recent the RCT comparing the two types of RCT recruited households of children literature on the subject, a RCT found masks in households was underpowered presenting to clinics with ILI and assigned mask-wearing plus hand hygiene in to detect a difference (7), resolution of them to the control intervention, surgical university dormitories decreased the this debate is still forthcoming. masks, or N95-equivalent masks, with 2 National Collaborating Centre for Infectious Diseases Overall, these results suggest mask use by strategies, according to a systematic given interventions. Two models from the cases and/or household contacts may be review of pandemic models (20). School UK found that the expected impact of a efficacious in reducing transmission of closures, social distancing of adults and pandemic was small (0.5%-2% of GDP) influenza, but that effectiveness is likely children, and targeted antivirals were and that the bulk of the economic impact reduced by poor compliance. Mask use associated with lowering the attack rate would come from quarantine and school in the community setting is of dubious from 35% to 10% when the reproduction closures (27, 28). benefit, as is the use of N95 respirators number (R0) was greater than 2.1 in rather than surgical masks outside of one model; the preferred strategy for an Focus Groups, Interviews, and Surveys health care settings. R0 below 1.6 was social distancing and antivirals alone (21). Another study found Even if efficacious under ideal that, for an R0 of 1.5, a combination of circumstances, quarantine, isolation, Quarantine, Isolation, and Social school closures, in-household isolation, and social distancing will be ineffective Distancing workplace non-attendance, and reduction at controlling pandemic influenza if Measures to reduce interactions between of community contacts implemented adherence to these measures is low. ill and healthy individuals are some of the 6 weeks after identification of the first A variety of studies have
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