Research due to be presented at this year’s European Congress on Clinical Microbiology and Infectious Diseases (ECCMID)* shows that using paper towels is substantially more effective than jet dryers for removing microbes when still contaminated hands are dried. The study is by Dr Ines Moura, University of Leeds, UK, and colleagues Duncan Ewin and Professor Mark Wilcox, from the University of Leeds and Leeds Teaching Hospitals NHS Trust.

Hand drying is important to minimise the spread of dangerous microbes – including the novel coronavirus – since failure to remove them increases transfer to environmental surfaces and increases the opportunities for transmission and spread. In this study, the authors investigated whether there are differences in extent of virus transmission, according to hand drying method, beyond the toilet/washroom to the hospital environment.

Four volunteers simulated contamination of their hands/gloved hands using a bacteriophage (which is a virus that infects bacteria – and so is harmless to humans). Their hands were not washed after contamination – this was to simulate poorly/inadequately washed hands. Hands were dried using either paper towels (PT) or a jet air dryer (JAD). Each volunteer wore an apron, to enable measurement of body/clothing contamination during hand drying. Hand drying was performed in a hospital public toilet and, after exiting, samples were collected from public and ward areas.

Environmental/surface sites (n=11) were sampled following contact with hands or apron. The sites samples were doors (both push- and pull-type doors), stairs handrails, lift buttons, chairs in public and ward areas, phones, buttons on access intercoms to wards, stethoscope tubing, stethoscope head piece and chest piece, the aprons themselves, and armchairs that had been indirectly in contact with the apron. For the latter, volunteers were asked to cross their arms across their chest while using the apron, before resting on the arms of the chair.

The team found that both JAD and PT methods statistically significantly reduced virus contamination of hands (by ~100 and ~1000 virus units/μl, respectively, see figure in full abstract). For 10 out of 11 surfaces, significantly greater environmental contamination was detected after JAD versus PT use. All surfaces sampled following JAD use showed phage contamination, compared with only 6 surfaces after PT use. Average surface contamination following hand contact was more than 10 times higher after JAD versus PT use (shown by a difference of 1.1 on the log scale: 4.1 vs 3.0 log10 copies/μl). Viral dispersal to apron/clothing was 5-fold higher with JAD compared to PT (3.5 and 2.8 log10 copies/μl, respectively). Phage transfer from apron to the armchairs via the crossed arms was detected only after JAD use (average 3.2 log10 copies/μl). This suggests transference of microbes to environmental surfaces can occur directly from hands that remain contaminated after hand drying, but also indirectly from a person’s body that has itself been contaminated during hand drying.

The authors conclude: “There are clear differences, according to hand drying method, in the residual microbial contamination of the subject’s hands and body. Crucially, these differences in contamination translate into significantly greater levels of microbe contamination after jet air drying versus paper towel use from hands and body beyond the toilet/washroom. As public toilets are used by patients, visitors and staff, the hand drying method chosen has the potential to increase (using jet dryers) or reduce (using paper towels) pathogen transmission in hospital settings.”

They also note their findings have particular importance since there has been a general migration from use of paper towels to hand dryers in many settings and areas of the world, especially within healthcare environments in the UK. Both UK NHS** and WHO hand washing guidelines recommend use of a paper towel to dry hands (and also using a paper towel to turn off the tap).

They conclude: “We believe that our results are relevant to the control of the novel coronavirus that is spreading at pace worldwide. Paper towels should be the preferred way to dry hands after washing and so reduce the risk of virus contamination and spread.”

Today, Cochrane publishes a new Rapid Review looking at quarantine during the COVID-19 pandemic.

The review summarizes evidence available from modelling studies that show how quarantining affects the spread of COVID-19. The studies included in the review consistently conclude that quarantine can play a role in controlling the spread of coronavirus SARS-CoV-2. While early implementation of quarantine and its combination with other public health measures may reduce spread of the disease, key uncertainties remain as to how these measures can best be adopted and when they can be relaxed.

Currently, there are no effective medicines or vaccines available to treat or prevent COVID-19. For this reason, restrictive public health measures such as isolation, physical distancing, and quarantine have been used in a number of countries to reduce transmission of the virus. Isolation refers to the separation of people with symptoms from others, whereas quarantine is the restriction of people who have no symptoms, but who have had contact with people with confirmed or suspected infection. Quarantine can be implemented on a voluntary basis or can be legally enforced by authorities, and it may be applied at an individual, group, or community level.

This Rapid Review was done in a short space of time as part of Cochrane’s organizational effort to meet the need for up-to-date summaries of evidence to support decision-making in combating the effects and impact of COVID-19.

Cochrane researchers used abbreviated systematic review methods to address the following questions as quickly as possible:

• Is quarantine of asymptomatic individuals who were in contact with a confirmed or suspected case of COVID-19 effective to control the COVID-19 outbreak?
• Are there differences in the effectiveness of quarantine in different settings?
• How effective is quarantine when combined with other interventions, such as case isolation, school closures, or antiviral drugs, in reducing transmission, incidence of diseases, and death?
• Is quarantine of individuals coming from a country with a declared COVID-19 outbreak effective in controlling the COVID-19 outbreak?
• 
  

The authors identified 29 relevant studies. Of these, 10 focused on COVID-19, 15 focused on related evidence on SARS (severe acute respiratory syndrome), two focused on SARS and other viruses, and two focused on MERS (Middle East respiratory syndrome). The 10 studies addressing COVID-19 were all modelling studies simulating outbreak scenarios in China, the UK, and South Korea, and on a cruise ship.

The COVID-19 modelling studies included in the review consistently report a benefit of quarantine measures and show similar findings from studies on SARS and MERS.

The authors of this Cochrane Review concluded that:

• Quarantine of people exposed to confirmed cases may avert high proportions of infections and deaths compared to no measures.
• The effect of quarantine of travelers from a country with a declared outbreak to avert transmission and deaths was small.
• In general, the combination of quarantine with other prevention and control measures, such as school closures, travel restrictions, and physical distancing, had a greater effect on the reduction of transmissions, cases which required critical care beds, and deaths compared with quarantine alone.
• More comprehensive and early implementation of prevention and control measures may be more effective in containing the COVID-19 outbreak.

The researchers rate their confidence in the results to be low or very low because of the way that the models used in the studies were developed. They are based on assumptions about the true prevalence of infection, which could be updated when we know more about this aspect of the COVID-19 pandemic.

However, the authors also stress the importance of using information about the local context in deciding on how measures such as quarantining should be adopted and when they can be lifted. Lead author Barbara Nußbaumer-Streit said “This Cochrane Review shows that while quarantine may help in containing the COVID-19 outbreak, decision-makers will need to constantly monitor the outbreak situation locally in order to maintain the best possible balance of measures in place, and that there is an acceptable trade-off between benefits and harms.”

Cochrane Editor in Chief, Karla Soares-Weiser, added, “The spread of coronavirus presents a major challenge for governments all over the world. Cochrane has a duty to provide the best available evidence to support policy-making, balancing rigour with speed. We have fast-tracked this review because it addresses one of the highest priority questions we have identified. This review is particularly helpful for decision makers looking for evidence to inform their decisions around the implementation of quarantine measures.”

A team of researchers in Wuhan, China have developed a multidisciplinary self-managed home quarantine method that was effective in controlling the source of COVID-19 infection and was useful in alleviating the shortage of medical resources. Click here to read the article free on the Telemedicine and e-Health website.

The case study “Implications for Online Management: Two Cases with COVID-19” describes the use of an online/offline multidisciplinary quarantine observation form, online monitoring, and strict compliance with quarantine measures to treat one mild and one severe case of COVID-19 infection. The mild case was able to be treated entirely at home, while the severe case ultimately required hospitalization.

“In late 2019 and early 2020, the province of Wuhan, China began to see patients with what was eventually known as COVID-19. While the pandemic has now spread across the globe, this group in China has implemented some effective ways of managing patients via telemedicine tools. These tools proved quite useful and can be seen as one effective example to follow,” says Charles R. Doarn, MBA, Editor-in-Chief of Telemedicine and e-Health.

The multidisciplinary quarantine team was comprised of experts in medicine, rehabilitation, psychology, and nursing. Patients described their symptoms and conditions online using a quarantine observation form at least two times per day. The quarantine team created a WeChat group to ease communication. Nursing experts provided guidance on quarantine and disinfection and oversaw patients’ diets and sleep schedule. Rehabilitation experts developed a feasible rehabilitation plan, and psychotherapists encouraged patients to stay optimistic. Importantly, the quarantined patients were not alone, as they had regular contact with the quarantine team, aimed at increasing their confidence in recovery and enhancing self-management capabilities.

Virus shedding by participants was measured using the Gesundheit II machine developed by the University of Maryland’s Dr. Don Milton University of Maryland School of Public Health

Surgical masks may help prevent infected people from making others sick with seasonal viruses, including coronaviruses, according to new research that could help settle a fierce debate spanning clinical and cultural norms.

In laboratory experiments, the masks significantly reduced the amounts of various airborne viruses coming from infected patients, measured using the breath-capturing “Gesundheit II machine” developed by Dr. Don Milton, a professor of applied environmental health in the University of Maryland School of Public Health and a senior author of the study published April 3 in the journal Nature Medicine.

Milton has already conferred with federal and White House health officials on the findings, which closely follow statements this week from the head of the Centers for Disease Control and Prevention saying the agency was reconsidering oft-stated advice that surgical masks aren’t a useful precaution outside of medical settings. (The debate takes place at a time when clinicians themselves face dangerously inadequate supplies of masks–a shortfall other UMD researchers are scrambling to help solve.)

The question of masks has roiled society as well, with some retailers refusing to let employees wear them for fear of sending negative signals to customers, and cases of slurs and even physical attacks in the United States and elsewhere against Asians or Asian Americans who were wearing masks, a measure some consider a necessity during a disease outbreak.

The study, conducted prior to the current pandemic with a student of Milton’s colleagues on the Faculty of Medicine at the University of Hong Kong, does not address the question of whether surgical masks protect wearers from infection. It does suggest that masks may limit how much the infected–who in the case of the novel coronavirus often don’t have symptoms–spread diseases including influenza, rhinoviruses and coronaviruses.

Milton, who runs the Public Health Aerobiology, Virology, and Exhaled Biomarker Laboratory in the School of Public Health, demonstrated in a 2013 study that surgical masks could help limit flu transmission. However, he cautions that the effect may not be as great outside of controlled settings.

Nevertheless, he said, the chance they could help justifies taking a new look at whether all people should be encouraged to wear them when they venture out of their houses to stores or other populated locations during the current COVID-19 lockdown.

“In normal times we’d say that if it wasn’t shown statistically significant or the effective in real-world studies, we don’t recommend it,” he said. “But in the middle of a pandemic, we’re desperate. The thinking is that even if it cuts down transmission a little bit, it’s worth trying.”

Previous studies have shown that coronavirus and other respiratory infections are mostly spread during close contact, which has been interpreted by some infectious disease specialists to mean that the disease could spread only through contact and large droplets, such as from a cough or sneeze–a message that has often been shared with the public.

“What they don’t understand is that is merely a hypothesis,” Milton said. The current study (along with earlier ones) shows, by contrast, that tiny, aerosolized droplets can indeed diffuse through the air. That means it may be possible to contract COVID-19 not only by being coughed on, but by simply inhaling the breath of someone nearby who has it, whether they have symptoms or not. Surgical masks, however, catch a lot of the aerosolized virus as it’s exhaled, he said.

The study was conducted at the University of Hong Kong as part of the dissertation research of the lead author, Dr. Nancy Leung, who, under the supervision of the co-senior authors Drs. Cowling and Milton, recruited 246 people with suspected respiratory viral infections. Milton’s Gesundheit machine compared how much virus they exhaled with and without a surgical mask.

“In 111 people infected by either coronavirus, influenza virus or rhinovirus, masks reduced detectable virus in respiratory droplets and aerosols for seasonal coronaviruses, and in respiratory droplets for influenza virus,” Leung said. “In contrast, masks did not reduce the emission of rhinoviruses.”

Although the experiment took place before the current pandemic, COVID-19 and seasonal coronaviruses are closely related and may be of similar particle size. The report’s other senior author, Professor Benjamin Cowling, division head of epidemiology and biostatistics, School of Public Health, HKUMed, and co-director of the World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, said, “The ability of surgical masks to reduce seasonal coronavirus in respiratory droplets and aerosols implies that such masks can contribute to slowing the spread of (COVID-19) when worn by infected people.”

Milton pointed to other measures his research has found is even more effective than masks, such as improving ventilation in public places like grocery stores, or installing UV-C lights near the ceiling that works in conjunction with ceiling fans to pull air upwards and destroy viruses and bacteria.

“Personal protective equipment like N95 masks are not our first line of defense,” Milton said. “They are our last desperate thing that we do.”