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Reduction in the Incidence of Influenza A But Not Influenza B Associated With Use of Hand Sanitizer and Cough Hygiene in Schools: A Randomized Controlled Trial

Stebbins, Samuel MD, MPH*; Cummings, Derek A. T. PhD; Stark, James H. MPH*; Vukotich, Chuck MS*; Mitruka, Kiren MD, MPH; Thompson, William PhD§; Rinaldo, Charles PhD; Roth, Loren MD; Wagner, Michael PhD§; Wisniewski, Stephen R. PhD*; Dato, Virginia MD, MPH; Eng, Heather MS*; Burke, Donald S. MD*

The Pediatric Infectious Disease Journal: November 2011 - Volume 30 - Issue 11 - p 921-926
doi: 10.1097/INF.0b013e3182218656
Original Studies

Background: Laboratory-based evidence is lacking regarding the efficacy of nonpharmaceutical interventions (NPIs) such as alcohol-based hand sanitizer and respiratory hygiene to reduce the spread of influenza.

Methods: The Pittsburgh Influenza Prevention Project was a cluster-randomized trial conducted in 10 elementary schools in Pittsburgh, PA, during the 2007 to 2008 influenza season. Children in 5 intervention schools received training in hand and respiratory hygiene, and were provided and encouraged to use hand sanitizer regularly. Children in 5 schools acted as controls. Children with influenza-like illness were tested for influenza A and B by reverse-transcriptase polymerase chain reaction.

Results: A total of 3360 children participated in this study. Using reverse-transcriptase polymerase chain reaction, 54 cases of influenza A and 50 cases of influenza B were detected. We found no significant effect of the intervention on the primary study outcome of all laboratory-confirmed influenza cases (incidence rate ratio [IRR]: 0.81; 95% confidence interval [CI]: 0.54, 1.23). However, we did find statistically significant differences in protocol-specified ancillary outcomes. Children in intervention schools had significantly fewer laboratory-confirmed influenza A infections than children in control schools, with an adjusted IRR of 0.48 (95% CI: 0.26, 0.87). Total absent episodes were also significantly lower among the intervention group than among the control group; adjusted IRR 0.74 (95% CI: 0.56, 0.97).

Conclusions: NPIs (respiratory hygiene education and the regular use of hand sanitizer) did not reduce total laboratory-confirmed influenza. However, the interventions did reduce school total absence episodes by 26% and laboratory-confirmed influenza A infections by 52%. Our results suggest that NPIs can be an important adjunct to influenza vaccination programs to reduce the number of influenza A infections among children.


From the *Department of Epidemiology, Graduate School of Public Health at the University of Pittsburgh, Pittsburgh, PA; †Infectious Diseases Division, Department of Epidemiology, the Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; ‡Center for Public Health Practice, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; §Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, US Centers for Disease Control and Prevention, Atlanta, GA; ¶National Center for Chronic Disease Prevention & Health Promotion, Office of Noncommunicable Diseases, Injury and Environmental Health, US Centers for Disease Control and Prevention, Atlanta, GA; ‖Department of Infectious Diseases and Microbiology, Graduate School of Public Health at the University of Pittsburgh, Pittsburgh, PA; **Graduate School of Public Health at the University of Pittsburgh, Pittsburgh, PA; and ††Pennsylvania Department of Health, Harrisburg, PA.

Accepted for publication April 26, 2011.

Supported by NIH MIDAS program (1U01-GM070708) (to D.C. and D.B.) and Cooperative Agreement number 5UCI000435–02 from the Centers for Disease Control and Prevention (CDC). D.C. holds a Career Award at the Scientific Interface from the Burroughs Welcome Fund.

The authors have no other funding or conflicts of interest to disclose.

The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

Address for correspondence: Samuel Stebbins, MD, MPH, University of Pittsburgh Graduate School of Public Health, 130 DeSoto St, Room A733, Pittsburgh, PA 15261. E-mail:

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© 2011 by Lippincott Williams & Wilkins, Inc.