The role of facemasks and hand hygiene in the prevention of influenza transmission in households: results from a cluster randomised trial; Berlin, Germany, 2009-2011
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BACKGROUND: Previous controlled studies on the effect of non-pharmaceutical interventions (NPI) - namely the use of facemasks and intensified hand hygiene - in preventing household transmission of influenza have not produced definitive results. We aimed to investigate efficacy, acceptability, and tolerability of NPI in households with influenza index patients. METHODS: We conducted a cluster randomized controlled trial during the pandemic season 2009/10 and the ensuing influenza season 2010/11. We included households with an influenza positive index case in the absence of further respiratory illness within the preceding 14 days. Study arms were wearing a facemask and practicing intensified hand hygiene (MH group), wearing facemasks only (M group) and none of the two (control group). Main outcome measure was laboratory confirmed influenza infection in a household contact. We used daily questionnaires to examine adherence and tolerability of the interventions. RESULTS: We recruited 84 households (30 control, 26 M and 28 MH households) with 82, 69 and 67 household contacts, respectively. In 2009/10 all 41 index cases had a influenza A (H1N1) pdm09 infection, in 2010/11 24 had an A (H1N1) pdm09 and 20 had a B infection. The total secondary attack rate was 16% (35/218). In intention-to-treat analysis there was no statistically significant effect of the M and MH interventions on secondary infections. When analysing only households where intervention was implemented within 36 h after symptom onset of the index case, secondary infection in the pooled M and MH groups was significantly lower compared to the control group (adjusted odds ratio 0.16, 95% CI, 0.03-0.92). In a per-protocol analysis odds ratios were significantly reduced among participants of the M group (adjusted odds ratio, 0.30, 95% CI, 0.10-0.94). With the exception of MH index cases in 2010/11 adherence was good for adults and children, contacts and index cases. CONCLUSIONS: Results suggest that household transmission of influenza can be reduced by the use of NPI, such as facemasks and intensified hand hygiene, when implemented early and used diligently. Concerns about acceptability and tolerability of the interventions should not be a reason against their recommendation. TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov (Identifier NCT00833885).
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The Saunders-Hastings 2017 review identified two RCTs which reported a significant effect of hand hygiene.
“The Saunders‐Hastings 2017 review of studies evaluating the effectiveness of personal protective measures in interrupting pandemic influenza transmission only identified two RCTs (Azor‐Martinez 2014; Suess 2012), which reported a significant effect of hand hygiene.”
From Physical interventions to interrupt or reduce the spread of respiratory viruses (2023) · cites this paper as Suess 2012
Suess 2012 is a randomized trial that tested masks plus hand hygiene, and the Results (Multivariable and other analyses; page unavailable) report a significant finding for that combined arm in an A(H1N1)pdm09 subgroup. But the Discussion says the trial cannot determine whether intensified hand hygiene adds protection; it does not establish a significant effect of hand hygiene itself. A 2012 paper also cannot substantiate what the Saunders-Hastings 2017 review identified. (LLM, conf=0.88)
Experimental — accuracy not yet measuredFour cluster-RCTs were judged to have a low risk of detection bias because the outcome was laboratory-confirmed influenza (Alfelali 2020; Barasheed 2014; Suess 2012), or physician-confirmed ILI, Pandejpong 2012.
“We judged four cluster‐RCTs to have a low risk of detection bias because the outcome was laboratory‐confirmed influenza (Alfelali 2020; Barasheed 2014; Suess 2012), or physician‐confirmed ILI, Pandejpong 2012.”
From Physical interventions to interrupt or reduce the spread of respiratory viruses (2023) · cites this paper as Suess 2012
Suess 2012 reported that the majority of participants (107/172; 62%) did not report any problems with mask-wearing.
“Suess 2012 reported that the majority of participants (107/172; 62%) did not report any problems with mask‐wearing.”
From Physical interventions to interrupt or reduce the spread of respiratory viruses (2023) · cites this paper as Suess 2012
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- Authors
- Suess, T., Remschmidt, C., Schink, S. B., Schweiger, B., Nitsche, A., Schroeder, K., Doellinger, J., Milde, J., Haas, W., Koehler, I., Krause, G., & Buchholz, U.
- Affiliations
- Robert Koch Institute (DE)
- Corresponding author
- Suess, Thorsten
- ORCID
- Venue
- BMC Infectious Diseases
- Published
- 2012-01-26
- Volume
- 12
- Issue
- 1
- Pages
- 26-26
- ISSN
- 1471-2334 (ISSN-L)
- PMC
- PMC3285078
- OpenAlex
- W2044998594
- Cited by
- 209
- References
- 33
- Citations by year
- 2026: 4 · 2025: 4 · 2024: 16 · 2023: 8 · 2022: 32 · 2021: 45 · 2020: 56 · 2019: 1 · 2018: 2 · 2017: 6 · 2016: 9 · 2015: 7 · 2014: 7 · 2013: 5 · 2012: 6
- FWCI
- 5.99
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Infectious Diseases (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Publication server of the Robert Koch Institute (Robert Kock Institute) (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Robert-Koch-Institut (RKI)
- Funders
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology
- Bundesministerium für Gesundheit
- Robert Koch Institut
- Topics
- Health Sciences › Medicine › Epidemiology › Influenza Virus Research Studies
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Infection Control and Ventilation
- Health Sciences › Medicine › Infectious Diseases › Infection Control in Healthcare
- Keywords
- influenza transmission, household transmission, face masks, hand hygiene, non-pharmaceutical interventions, secondary attack rate, influenza A(H1N1)pdm09, influenza B, index case, household contacts, intervention adherence, acceptability, pandemic influenza, Germany
- MeSH terms
- Adolescent, Adult, Aged, Aged, 80 and over, Berlin, Child, Child, Preschool, Family Characteristics, Family Health, Female, Hand Disinfection, Humans, Influenza, Human, Male, Masks, Middle Aged, Patient Compliance, Surveys and Questionnaires, Treatment Outcome, Young Adult
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