Physical interventions to interrupt or reduce the spread of respiratory viruses
Open accessAbstract
BACKGROUND: Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a global threat. Antiviral drugs and vaccinations may be insufficient to prevent their spread. OBJECTIVES: To review the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses. SEARCH STRATEGY: We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2010, Issue 3), which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to October 2010), OLDMEDLINE (1950 to 1965), EMBASE (1990 to October 2010), CINAHL (1982 to October 2010), LILACS (2008 to October 2010), Indian MEDLARS (2008 to October 2010) and IMSEAR (2008 to October 2010). SELECTION CRITERIA: In this update, two review authors independently applied the inclusion criteria to all identified and retrieved articles and extracted data. We scanned 3775 titles, excluded 3560 and retrieved full papers of 215 studies, to include 66 papers of 67 studies. We included physical interventions (screening at entry ports, isolation, quarantine, social distancing, barriers, personal protection, hand hygiene) to prevent respiratory virus transmission. We included randomised controlled trials (RCTs), cohorts, case-controls, before-after and time series studies. DATA COLLECTION AND ANALYSIS: We used a standardised form to assess trial eligibility. We assessed RCTs by randomisation method, allocation generation, concealment, blinding and follow up. We assessed non-RCTs for potential confounders and classified them as low, medium and high risk of bias. MAIN RESULTS: We included 67 studies including randomised controlled trials and observational studies with a mixed risk of bias. A total number of participants is not included as the total would be made up of a heterogenous set of observations (participant people, observations on participants and countries (object of some studies)). The risk of bias for five RCTs and most cluster-RCTs was high. Observational studies were of mixed quality. Only case-control data were sufficiently homogeneous to allow meta-analysis. The highest quality cluster-RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children. Benefit from reduced transmission from children to household members is broadly supported also in other study designs where the potential for confounding is greater. Nine case-control studies suggested implementing transmission barriers, isolation and hygienic measures are effective at containing respiratory virus epidemics. Surgical masks or N95 respirators were the most consistent and comprehensive supportive measures. N95 respirators were non-inferior to simple surgical masks but more expensive, uncomfortable and irritating to skin. Adding virucidals or antiseptics to normal handwashing to decrease respiratory disease transmission remains uncertain. Global measures, such as screening at entry ports, led to a non-significant marginal delay in spread. There was limited evidence that social distancing was effective, especially if related to the risk of exposure. AUTHORS' CONCLUSIONS: Simple and low-cost interventions would be useful for reducing transmission of epidemic respiratory viruses. Routine long-term implementation of some measures assessed might be difficult without the threat of an epidemic.
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No RCTs of nose disinfection or disinfection of living quarters were found.
“We found no RCTs of nose disinfection, or disinfection of living quarters, as described in observational studies reported in Jefferson 2011.”
From Physical interventions to interrupt or reduce the spread of respiratory viruses (2023) · cites this paper as Jefferson 2011
The RCT summary table (page unavailable) lists disinfection of living quarters only under case-control studies, and the case-control results describe a study of that measure. Our copy does not identify an observational study of nose disinfection or state that no RCTs of it were found (searched: nose disinfection, nasal disinfection). (LLM, conf=0.82)
Experimental — accuracy not yet measuredJefferson 2011 found a protective effect of wearing surgical masks with hygienic measures compared to not wearing masks in the SARS 2003 outbreak (OR 0.32, 95% CI 0.26 to 0.39).
“Also based on observational studies, Jefferson 2011 found a protective effect of wearing surgical masks with hygienic measures compared to not wearing masks in the SARS 2003 outbreak (OR 0.32, 95% CI 0.26 to 0.39).”
From Physical interventions to interrupt or reduce the spread of respiratory viruses (2023) · cites this paper as Jefferson 2011
The review’s case-control analysis of SARS studies reports a protective association for simple mask wearing (OR 0.32, 95% CI 0.25–0.40). It does not give the claimed CI of 0.26–0.39 or describe that estimate as specifically for surgical masks worn with hygienic measures; it reports combined protective measures separately. Page numbers are unavailable in our copy. (LLM, conf=0.90)
Experimental — accuracy not yet measuredTwo reports (three trials) identified in Jefferson 2011 studied the effect of virucidal tissues compared to placebo or no tissues.
“Two reports (three trials) identified in Jefferson 2011 studied the effect of virucidal tissues compared to placebo or no tissues (Farr 1988a; Farr 1988b; Longini 1988).”
From Physical interventions to interrupt or reduce the spread of respiratory viruses (2023) · cites this paper as Jefferson 2011
This 2022 update focused on RCTs and cluster-RCTs, providing a higher level of evidence compared with the previous version of the review, which also meta-analysed observational studies when appropriate.
“In this 2022 update, we again focused on RCTs and cluster‐RCTs, providing a higher level of evidence compared with the previous version of the review, which also meta‐analysed observational studies when appropriate (Jefferson 2011).”
From Physical interventions to interrupt or reduce the spread of respiratory viruses (2023) · cites this paper as Jefferson 2011
There was some additional but very limited supportive evidence from the cohort studies in Jefferson 2011.
“There was some additional but very limited supportive evidence from the cohort studies in Jefferson 2011.”
From Physical interventions to interrupt or reduce the spread of respiratory viruses (2023) · cites this paper as Jefferson 2011
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- Authors
- Jefferson, T., Del Mar, C. B., Dooley, L., Ferroni, E., Al-Ansary, L. A., Bawazeer, G. A., van Driel, M. L., Nair, N. S., Jones, M. A., Thorning, S., & Conly, J. M.
- Affiliations
- University of Oxford (GB)
- Bond University; Centre for Research in Evidence-Based Practice (CREBP); University Drive Gold Coast Queensland Australia 4229
- Bond University (AU)
- Regione del Veneto (IT)
- World Health Organization; Department of Health Metrics and Measurement; Geneva Switzerland
- King Saud University (SA)
- The University of Queensland; Primary Care Clinical Unit, Faculty of Medicine; Brisbane Queensland Australia 4029
- Government of India (IN)
- Gold Coast Hospital (AU)
- Foothills Medical Centre (CA)
- ORCID
- Venue
- Cochrane Database of Systematic Reviews
- Publisher
- Wiley
- Published
- 2011-07-06
- Volume
- 11
- Issue
- 7
- Pages
- CD006207-CD006207
- ISSN
- 1361-6137 (ISSN-L)
- 1465-1858
- PMC
- PMC8094623
- OpenAlex
- W1534533078
- Cited by
- 805
- References
- 292
- Citations by year
- 2026: 5 · 2025: 19 · 2024: 54 · 2023: 81 · 2022: 95 · 2021: 135 · 2020: 191 · 2019: 20 · 2018: 20 · 2017: 16 · 2016: 26 · 2015: 41 · 2014: 31 · 2013: 33 · 2012: 20
- FWCI
- 4.98
- Type
- journal article
- Language
- en
- Update notices
- new_version (2020-11-20)
- Open access
- bronze
- doi.org
- Locations
- Cochrane Database of Systematic Reviews (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Ghent University Academic Bibliography (Ghent University) (submittedVersion)
- Bond University Research Portal (Bond University) (submittedVersion, other-oa)
- Topics
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Infection Control and Ventilation
- Health Sciences › Medicine › Epidemiology › Respiratory viral infections research
- Health Sciences › Medicine › Infectious Diseases › Infection Control in Healthcare
- Keywords
- physical interventions, respiratory virus transmission, acute respiratory infections, face masks, hand hygiene, social distancing, quarantine, isolation, personal protection, gargling, influenza, SARS, COVID-19 pandemic, pandemic preparedness, infection control, non-pharmaceutical interventions, harms of interventions, randomized controlled trials
- MeSH terms
- Humans, Influenza, Human, Respiratory Tract Infections, Virus Diseases, Case-Control Studies, Randomized Controlled Trials as Topic, Virus Shedding
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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