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Research Findings from Nonpharmaceutical Intervention Studies for Pandemic Influenza And&Nbsp

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Research Findings from Nonpharmaceutical Intervention Studies for Pandemic Influenza And&Nbsp Research findings from nonpharmaceutical intervention studies for pandemic influenza and current gaps in the research Allison E. Aiello, PhD, MS,a Rebecca M. Coulborn, MPH,a Tomas J. Aragon, DrPH,b Michael G. Baker, MBChB, DPH, FAFPHM,c Barri B. Burrus, PhD,d Benjamin J. Cowling, PhD,e Alasdair Duncan, MPH,c Wayne Enanoria, PhD, MPH,b M. Patricia Fabian, ScD, MS,f,g Yu-hui Ferng, MPA,h Elaine L. Larson, PhD, RN, FAAN, CIC,h,i Gabriel M. Leung, MD, MPH, CCFP, FFPH, FHKCCM, FHKAM,e Howard Markel, MD, PhD,j Donald K. Milton, MD, DrPH,k Arnold S. Monto, MD,a Stephen S. Morse, PhD,i J. Alexander Navarro, PhD,j Sarah Y. Park, MD, FAAP,l Patricia Priest, DPhil, MBChB, MPH, FAFPHM,c Samuel Stebbins, MD, MPH,m Alexandra M. Stern, PhD,j Monica Uddin, PhD,a Scott F. Wetterhall, MD, MPH,d and Charles J. Vukotich Jr, MSm Ann Arbor, Michigan; Berkeley, California; Otago, New Zealand; Research Triangle Park, North Carolina; Hong Kong, People’s Republic of China; Lowell, Massachusetts; Boston, Massachusetts; New York, New York; College Park, Maryland; Honolulu, Hawaii; and Pittsburgh, Pennsylvania In June 2006, the Centers for Disease Control and Prevention released a request for applications to identify, improve, and evaluate the effectiveness of nonpharmaceutical interventions (NPIs)—strategies other than vaccines and antiviral medications—to mitigate the spread of pandemic influenza within communities and across international borders (RFA-CI06-010). These studies have provided major contributions to seasonal and pandemic influenza knowledge. Nonetheless, key concerns were identified related to the accept- ability and protective efficacy of NPIs. Large-scale intervention studies conducted over multiple influenza epidemics, as well as smaller studies in controlled laboratory settings, are needed to address the gaps in the research on transmission and mitigation of influenza in the community setting. The current novel influenza A (H1N1) pandemic underscores the importance of influenza research. Key Words: Hand hygiene; masks; transmission; infection control. Copyright ª 2010 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. (Am J Infect Control 2010;38:251-8.) Community mitigation is a collective term for a interventions for individuals, institutions (eg, schools), group of strategies other than vaccines and antiviral and entire communities.2 Community mitigation re- medications (ie, nonpharmaceutical interventions) de- search may include studies of the feasibility of effec- signed to slow or limit the transmission of a pandemic tiveness of, and compliance with protective devices, virus.1 It includes personal protection strategies and such as face masks. Research also may include the From the Center for Social Epidemiology and Population Health, Depart- Center for Public Health Preparedness, Department of Epidemiology, ment of Epidemiology, School of Public Health, University of Michigan, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Ann Arbor, MIa; Center for Infectious Diseases & Emergency Readiness, PA.m Division of Epidemiology, School of Public Health, University of California, Berkeley, CAb; Pandemic Influenza Research Group, University of Otago, Address correspondence to Allison E. Aiello, PhD, MS, Center for Social New Zealandc; Public Health and Social Policy Division, RTI International, Epidemiology and Population Health, 1415 Washington Heights, Ann Ar- Research Triangle Park, NCd; Department of Community Medicine and bor, MI 48109. E-mail: [email protected]. School of Public Health, University of Hong Kong, Hong Kong, People’s Charles J. Vukotich, Jr, MS, Center for Public Health Practice, Graduate Republic of Chinae; Work Environment Department, School of Health f School of Public Health, University of Pittsburgh, A711 Crabtree, 130 & Environment, University of Massachusetts, Lowell, MA ; Department DeSoto St, Pittsburgh PA 15261. E-mail: [email protected]. of Environmental Health, School of Public Health, Harvard University, Boston, MAg; School of Nursingh and Department of Epidemiology,i Conflicts of interest: None to report. Mailman School of Public Health, Columbia University, New York, NY; 0196-6553/$36.00 Center for History of Medicine, University of Michigan Medical School, Ann Arbor, MIj; Maryland Institute for Applied Environmental Health, Copyright ª 2010 by the Association for Professionals in Infection Department of Epidemiology and Biostatistics, School of Public Control and Epidemiology, Inc. Published by Elsevier Inc. All rights Health, University of Maryland, College Park, MDk; Disease Outbreak reserved. Control Division, Hawaii Department of Health, Honolulu, HIl; and doi:10.1016/j.ajic.2009.12.007 251 252 Aiello et al. American Journal of Infection Control May 2010 generation of data to inform mathematical models to compliance with face mask use was low in most stud- estimate influenza attacks rates, along with the devel- ies. These findings mirror predictions from an earlier opment and evaluation of interventions to delay the study of acceptability of NPI interventions led by spread of pandemic influenza by travelers crossing in- Stebbins.5 ternational air, land, and sea borders. Studies also support the need for consistent and In June 2006, the Centers for Disease Control and coordinated NPI response during pandemics. For Prevention (CDC) released a request for applications example, research conducted by RTI International (B) to identify, improve, and evaluate the effectiveness of identified that the acceptability of NPIs depends largely nonpharmaceutical interventions (NPIs) to mitigate on early planning, consistent and targeted communica- the spread of pandemic influenza within communities tion during implementation, and clear delineation of and across international borders (RFA-CI06-010).3 responsibilities and lines of authority. Acceptability Eleven studies were funded to identify optimal, dis- also requires communication from both traditional crete, or combined NPIs for implementation during (eg, emergency response organizations, public health an influenza pandemic. The results of these studies departments, media) and nontraditional (eg, churches, have provided valuable contributions to the knowledge child care centers, businesses) sources. of seasonal and pandemic influenza, identified addi- tional gaps in data, and offered important insights Laboratory assessment of face mask efficacy into future research on mitigating the current pan- The efficacy of face masks for preventing transmis- demic of novel A (H1N1) influenza. Here we describe sion of influenza viruses has yet to be fully determined. the studies, summarize the results, present a synthesis In a laboratory study conducted by researchers at Uni- of the research gaps, and define future research needs. versity of Massachusetts, Lowell (C), influenza virus nu- cleic acid was present in fine-particle aerosols from DESCRIPTION OF STUDIES AND FINDINGS influenza patients in both tidal breathing (14%-33%) 6 The studies include research using seasonal influ- and coughing (64%). Preliminary results demon- enza outbreaks as a model for testing preventive mea- strated that surgical ear-loop face masks limit the gen- sures for future influenza pandemics, as well as eration of droplets $5.0 mm in diameter containing historical research of past pandemics (Table 1). What influenza virus RNA; investigation of fine droplet follows is a summary of the published, accepted, and virus-containing particles is ongoing. in-preparation work across all projects. Examination of the efficacy of NPIs for reducing Assessment of NPI acceptability transmission of influenza in the community setting Community mitigation of pandemic influenza might be achieved through the use of NPIs, specifically per- The studies assessed the effectiveness of multilay- sonal protective measures. These measures must gain ered NPIs (ie, the use of multiple NPIs in conjunction community acceptance to be effective, however. Stud- with one another) based on CDC’s hypothesis that this ies assessing the acceptability of NPIs have demon- approach could create multiple barriers to stop the strated that NPI behaviors can be successfully taught transmission of influenza.1 Several studies have shown to and adopted by a variety of individuals through the that NPIs can be efficacious for reducing rates of influ- use of community health education, interactive class- enza and influenza-like illness (ILI). Results from the room teaching, or Internet-based instruction. For ex- University of Hong Kong (D) suggested substantial re- ample, a study of urban Hispanic households ductions in household secondary attack ratios when conducted by Columbia University (A) showed that all household members practice frequent handwashing although household members had misunderstandings and wear face masks within 36 hours of symptom onset regarding influenza, their knowledge, attitudes, and of the index case.7 Aiello et al,8 at the University of Mich- practices improved through a community education igan (E), reported that hand hygiene with alcohol-based program.4 (Note: Here the studies are identified by let- hand sanitizers and mask use among university stu- ter, as listed in Table 1.) In all mask and hand hygiene dents was associated with a 50%-65% reduction in intervention studies, hand hygiene interventions that the rate of ILI over a 6-week intervention period. Com- generally were perceived as typical daily behavior pared with other projects, rates
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