13
views
0
recommends
+1 Recommend
1 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: not found

      Response to ‘MacIntyre et al., 2020: A rapid systematic review of the efficacy of face masks and respirators against coronaviruses and other respiratory transmissible viruses for the community, healthcare workers and sick patient’

      letter
      , PhD
      International Journal of Nursing Studies
      Published by Elsevier Ltd.

      Read this article at

      ScienceOpenPublisherPMC
      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          With the rapid emergence of COVID-19, public health officials, companies, and individuals in the public have scrambled to find solutions to prevent and treating this fast-spreading virus, but because of the novelty of the virus, few data are available on the effectiveness of possible solutions. Consequently, we have sometimes had to rely on studies done on the prevention and treatment of other upper respiratory infections, such as influenza. One popular practice for reducing the transmission of COVID-19, which has been widely recommended, is for people to wear face masks in public places and other venues where they will be in close proximity to other people. The equipoise about the effectiveness of face masks in these circumstances is in contrast to the well-established role of face masks to prevent the spread of viruses in hospital settings, especially with the use of N-95 face masks. MacIntyre and Chughtai (MacIntyre and Chughtai, 2020) present their findings of a systematic review of randomized controlled trials assessing the effect of face masks in the community to prevent the transmission of influence and other influenza-like illnesses. They concluded that face masks could be effective at preventing COVID-19 transmission, based on the results of eight randomized studies. However, upon closer inspection, their conclusion might be a bit optimistic. Here, we review issues of concern regarding the information they used to support their conclusion. These issues of concern fall primarily into several categories: favoring the results of a (possibly biased or spurious) sub-analysis over the null results of the primary/overall randomized analysis; relying on results of multiple testing with the possibility of experiment-wise error; and failure to separate the effects of hand hygiene from the effects of face masks. In the MacIntyre et al., (2009) study, there was no beneficial effect of wearing face masks in the intention-to-treat population. The review reports that in the subgroup of people who were adherent, face masks were beneficial, but adherence was low (<30% by day five), resulting in a biased sample. Any difference seen may be because people who wore the face masks were notably different in other ways than those who did not wear them. The two studies by Cowling et al., (2008/2009) (Cowling et al., 2009, Cowling et al., 2008) are actually preliminary and final results of the same study, which did not find any difference between masks plus hand hygiene and any of the other groups (hand hygiene or control group) in the primary analysis. They did do a sub-analysis, and they did find that both the hand hygiene group and the masks plus hand hygiene had less influenza (confirmed by PCR) than doing nothing (no difference between the two intervention groups), but when considering clinical symptoms, there was more influenza-like illness in the face mask group than in the hand hygiene only group. This suggests that face masks could actually increase virus transmission. In another study by Aiello et al., (2010) (Aiello et al., 2010) there was no difference in rates of influenza-like illness between the face mask only group and the control group. However, there was a trend towards lower influenza-like illness with the addition of handwashing (in addition to masks), suggesting that it is the handwashing and not the masks that are lowering influenza rates. In the study by Aiello et al., (2012) (Aiello et al., 2012) the use of face masks plus hand hygiene was no better at reducing rates of influenza-like illness than hand hygiene alone in the cumulative analysis. If looking at individual weeks, only the face mask plus hand hygiene group had significantly lower rates of illness in the later weeks, not the face mask only group, suggesting that it is the handwashing and not the masks that are lowering influenza rates. Larson et al., (2010) (Larson et al., 2010) did not find a significant benefit among the face mask and hand hygiene groups (there was no face mask only group) in incident rates of influenza. They did find a benefit in reducing the secondary attack rate, but they also reported that the hand hygiene group (not the face mask group) had fewer people in the household with influenza symptoms. Simmerman et al., (2011) (Simmerman et al., 2011) likewise, did not find any reduction in influenza from the use of face masks or handwashing. In fact, they found a higher rate of influenza-like illness among both the handwashing group and the handwashing group plus face masks than in the control group. Sues et al., (2012) (Suess et al., 2012) did not find any differences in incident influenza or secondary attack rates in the overall analysis. They did do many sub-analyses, but caution should be practiced when interpreting the results, considering the experiment-wise error, which can lead to spurious results when multiplicity of testing is being done. The Sues et al., study is a good example of this when some of the sub-analyses indicate that face masks are beneficial in reducing incident influenza, but in other sub-analyses, it is the hand hygiene and not face masks that appear to reduce incident influenza. Of the seven separate randomized studies MacIntyre and Chughtai include in their review, none of them show a benefit of face mask use in the community to prevent the incidence of respiratory viruses, and the results of the sub-analyses are equivocal, sometimes suggesting that masks prevent virus transmission but other times increase transmission. Based upon these studies, there is little evidence to show that face masks prevent influenza and influenza-like illnesses. It may be that face masks for COVID-19 will have different outcomes, but we cannot know for sure until an adequately powered, well-conducted randomized trial is performed, one of which is set to be completed in July 2020 (https://clinicaltrials.gov/ct2/show/NCT04337541). In evaluating whether face masks work in the community in reducing respiratory viruses, there is biologic plausibility, which has led to wide-spread popularity. However, this enthusiasm does not justify incorrect/biased summaries of published articles.

          Related collections

          Most cited references7

          • Record: found
          • Abstract: found
          • Article: not found

          Facemasks and hand hygiene to prevent influenza transmission in households: a cluster randomized trial.

          Few data are available about the effectiveness of nonpharmaceutical interventions for preventing influenza virus transmission. To investigate whether hand hygiene and use of facemasks prevents household transmission of influenza. Cluster randomized, controlled trial. Randomization was computer generated; allocation was concealed from treating physicians and clinics and implemented by study nurses at the time of the initial household visit. Participants and personnel administering the interventions were not blinded to group assignment. (ClinicalTrials.gov registration number: NCT00425893) Households in Hong Kong. 407 people presenting to outpatient clinics with influenza-like illness who were positive for influenza A or B virus by rapid testing (index patients) and 794 household members (contacts) in 259 households. Lifestyle education (control) (134 households), hand hygiene (136 households), or surgical facemasks plus hand hygiene (137 households) for all household members. Influenza virus infection in contacts, as confirmed by reverse-transcription polymerase chain reaction (RT-PCR) or diagnosed clinically after 7 days. Sixty (8%) contacts in the 259 households had RT-PCR-confirmed influenza virus infection in the 7 days after intervention. Hand hygiene with or without facemasks seemed to reduce influenza transmission, but the differences compared with the control group were not significant. In 154 households in which interventions were implemented within 36 hours of symptom onset in the index patient, transmission of RT-PCR-confirmed infection seemed reduced, an effect attributable to fewer infections among participants using facemasks plus hand hygiene (adjusted odds ratio, 0.33 [95% CI, 0.13 to 0.87]). Adherence to interventions varied. The delay from index patient symptom onset to intervention and variable adherence may have mitigated intervention effectiveness. Hand hygiene and facemasks seemed to prevent household transmission of influenza virus when implemented within 36 hours of index patient symptom onset. These findings suggest that nonpharmaceutical interventions are important for mitigation of pandemic and interpandemic influenza. Centers for Disease Control and Prevention.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            A RAPID SYSTEMATIC REVIEW OF THE EFFICACY OF FACE MASKS AND RESPIRATORS AGAINST CORONAVIRUSES AND OTHER RESPIRATORY TRANSMISSIBLE VIRUSES FOR THE COMMUNITY, HEALTHCARE WORKERS AND SICK PATIENTS

            Background The pandemic of COVID-19 is growing, and a shortage of masks and respirators has been reported globally. Policies of health organizations for healthcare workers are inconsistent, with a change in policy in the US for universal face mask use. The aim of this study was to review the evidence around the efficacy of masks and respirators for healthcare workers, sick patients and the general public. Methods A systematic review of randomized controlled clinical trials on use of respiratory protection by healthcare workers, sick patients and community members was conducted. Articles were searched on Medline and Embase using key search terms. Results A total of 19 randomised controlled trials were included in this study – 8 in community settings, 6 in healthcare settings and 5 as source control. Most of these randomised controlled trials used different interventions and outcome measures. In the community, masks appeared to be more effective than hand hygiene alone, and both together are more protective. Randomised controlled trials in health care workers showed that respirators, if worn continually during a shift, were effective but not if worn intermittently. Medical masks were not effective, and cloth masks even less effective. When used by sick patients randomised controlled trials suggested protection of well contacts. Conclusion The study suggests that community mask use by well people could be beneficial, particularly for COVID-19, where transmission may be pre-symptomatic. The studies of masks as source control also suggest a benefit, and may be important during the COVID-19 pandemic in universal community face mask use as well as in health care settings. Trials in healthcare workers support the use of respirators continuously during a shift. This may prevent health worker infections and deaths from COVID-19, as aerosolisation in the hospital setting has been documented.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: found
              Is Open Access

              Facemasks, Hand Hygiene, and Influenza among Young Adults: A Randomized Intervention Trial

              Limited vaccine availability and the potential for resistance to antiviral medications have led to calls for establishing the efficacy of non-pharmaceutical measures for mitigating pandemic influenza. Our objective was to examine if the use of face masks and hand hygiene reduced rates of influenza-like illness (ILI) and laboratory-confirmed influenza in the natural setting. A cluster-randomized intervention trial was designed involving 1,178 young adults living in 37 residence houses in 5 university residence halls during the 2007–2008 influenza season. Participants were assigned to face mask and hand hygiene, face mask only, or control group during the study. Discrete-time survival models using generalized estimating equations to estimate intervention effects on ILI and confirmed influenza A/B infection over a 6-week study period were examined. A significant reduction in the rate of ILI was observed in weeks 3 through 6 of the study, with a maximum reduction of 75% during the final study week (rate ratio [RR] = 0.25, [95% CI, 0.07 to 0.87]). Both intervention groups compared to the control showed cumulative reductions in rates of influenza over the study period, although results did not reach statistical significance. Generalizability limited to similar settings and age groups. Face masks and hand hygiene combined may reduce the rate of ILI and confirmed influenza in community settings. These non-pharmaceutical measures should be recommended in crowded settings at the start of an influenza pandemic. Trail Registration Clinicaltrials.gov NCT00490633
                Bookmark

                Author and article information

                Contributors
                Journal
                Int J Nurs Stud
                Int J Nurs Stud
                International Journal of Nursing Studies
                Published by Elsevier Ltd.
                0020-7489
                1873-491X
                19 August 2020
                19 August 2020
                : 103750
                Affiliations
                [0001]Nutritional Epidemiologist, Oklahoma State University, Center for Indigenous Health Research and Policy, USA
                Article
                S0020-7489(20)30236-4 103750
                10.1016/j.ijnurstu.2020.103750
                7434616
                5b9af3d7-5338-4668-916e-484b043a882b
                © 2020 Published by Elsevier Ltd.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                Categories
                Article

                Nursing
                Nursing

                Comments

                Comment on this article