title: Do we have enough evidence how seasonal influenza is transmitted and can be prevented in hospitals to implement a comprehensive policy?
abstract: To identify if there is enough evidence at low risk-of-bias to prevent influenza transmission by vaccinating health-care workers (HCWs), patients and visitors; screening for laboratory-proven influenza all entering hospitals; screening asymptomatic individuals; identifying influenza supershedders; hand-washing and mask-wearing by HCWs, patients and visitors; and cleaning hospital rooms and equipment.
  
  
  
  Vaccination reduces influenza episodes of vaccinated (4.81/100 HCW) compared to unvaccinated (7.54/100) HCWs/influenza season. A Cochrane review found for inactivated vaccines the Number Needed to Vaccinate (NNV)=71 (95%CI 64%, 80%) for adults 18-60 (same age as HCWs) to prevent laboratory-proven influenza. There are no RCTs of screening HCWs, patients, visitors and influenza supershedders to prevent transmission. None of four RCTs of HCWs mask-wearing (two directly observed, two not) showed an effect because they were underpowered either due to small size or low circulation of influenza. Hospital rooms and equipment can effectively be cleaned of influenza by many chemicals and hydrogen peroxide vapor machines but the cleaning cycle needs shortening to increase the likelihood of adoption.
  
  
  
  HCW vaccination is a partial solution with current vaccination levels. There are no RCTs of screening HCWs, patients and visitors demonstrating preventing influenza transmission. Only one study costed furloughing HCWs with influenza and no RCTs have identified benefits of isolating influenza supershedders. RCTs of directly- and electronically continuously-observed mask-wearing and hand-hygiene and RCTs of incentives for meticulous hygiene are required. RCTs of engineering solutions (external venting, frequent room air changes) are needed. A wide range of chemicals effectively cleans hospital rooms and equipment from influenza. Hydrogen peroxide vapor is effective against influenza and a wide range of bacterial pathogens with patient room changes, and clean areas cleaners do not clean but its cleaning cycle needs shortening to increase the likelihood of adoption of cleaning rooms vacated by influenza patients.
authors.affiliation: Department of Family Medicine, Faculty of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, Canada T2N 4N1. Electronic address: rthomas@ucalgary.ca.
authors.forename: Roger E
authors.initials: RE
authors.lastname: Thomas
mesh_terms: D003428:Cross Infection / Q000517:prevention & control*; D004866:Equipment Contamination / Q000517:prevention & control; D019317:Evidence-Based Medicine; D006235:Hand Disinfection; D006282:Health Personnel; D006761:Hospitals; D006801:Humans; D006861:Hydrogen Peroxide / Q000494:pharmacology; D007252:Influenza Vaccines / Q000627:therapeutic use*; D007251:Influenza, Human / Q000517:prevention & control* / Q000635:transmission; D008397:Masks; D008403:Mass Screening / Q000379:methods; D016032:Randomized Controlled Trials as Topic; D014611:Vaccination; D017201:Virus Shedding
chemical_list: D007252:Influenza Vaccines; D006861:Hydrogen Peroxide
keywords: Hand-washing; Hospital cleaning; Masks; Respirators; Screening; Seasonal influenza; Transmission; Vaccination