Effectiveness of Non-pharmaceutical Measures in Preventing Pediatric Influenza: A Case–Control Study

Núria Torner; Núria Soldevila; Juan Jose Garcia; Cristian Launes; Pere Godoy; Jesús Castilla; Angela Domínguez

BMC Public Health. 2015;15(543)

Conclusion

The success of an NPI or a set of NPIs depends on both its efficacy and the feasibility of implementing it with relevant populations. If NPIs are to be used in community settings during a severe influenza season or pandemic, to increase acceptability on the part of the adults is of utmost importance. Without such acceptance, it is highly unlikely that children and their supervising adults will participate.^[33]

This study emphasizes the importance of simple infection prevention measures, such as hand hygiene which have been proven effective to reduce the transmission of infection in schools and the spread to household contacts by Papenburg J,et al..^[34] Frequent hand washing should be recommended to prevent influenza infection in the family and community setting and in special in the school age group.

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Acknowledgements
We want to thank all primary care pediatricians and sentinel physicians involved in the study for their collaboration in contacting the children's family and providing clinical data.
The other members of the CIBERESP Cases and Controls in Pediatric Pandemic Influenza Working Group are: E Azor, J Carrillo, MF Bautista, M Delgado, V Fuentes, V Gallardo, JR Maldonado, JM Mayoral, R Moyano, A Morillo, JA Navarro, JM Navarro, I Pedrosa, E Pérez, M Pérez, MC Ubago, M Vazquez, F Zafra, M Zarzuelo [Andalusia]; J Blanquer, F González, M Morales [Valencia Community]; JJ Castrodeza, V Martín, R Ortiz de Lejarazu, A Pérez, S Tamames [Castile and Leon]; L Blanch , X Bonfill, E Borrás, J Caylà, J Gea, JP Horcajada, J López-Contreras, A Martínez, F Moraga, G Navarro, V Pomar, MT Puig, C Tortajada, I García, T Pumarola [Catalonia]; J Astray, A Castro, JC Galán, R Génova, M Ordobás, F Pozo, A Robustillo [Madrid]; F Gil, A Martínez, L Martínez, V Martínez-Artola, F Perez-Afonso, M Sota [Navarra]; G Cilla, A Escobar, F Esteban, C Garaizar, S García, E Pérez-Trallero, JI Pijoan, M Santiago, C Sarasqueta, E Tato [The Basque Country].
This study was supported by the Ministry of Science and Innovation, Institute of Health Carlos III, Research Program on Influenza A/H1N1 [Grant GR09/0030], and the Catalan Agency for the Management of Grants for University Research [AGAUR Grant number 2009/SGR 42]. The funders had no role in the study design, data collection, analysis, the decision to publish or the preparation of the manuscript.

Table 1. Distribution of sociodemographic variables and underlying medical conditions for confirmed outpatient cases and controls
	Cases (n = 239)	Controls (n = 239)	P value		Cases (n = 239)	Controls (n = 239)	Crude OR (95 % CI)	P value
Age. Mean (SD)	5.4 ± 4.5	5.3 ± 4.6	0.48	Pneumonia in previous 2 years	23 (9.6 %)	8 (3.3 %)	3.23 (1.38 – 7.58)	0.007
Age group				Asthma	27 (11.3 %)	13 (5.4 %)	2.45 (1.17 – 5.14)	0.02
0–4	134 (56.1 %)	135 (56.5 %)	0.29	Renal failure or nephritic syndrome	4 (1.7 %)	2 (0.8 %)	2.00 (0.37 – 10.92)	0.42
5–17	205 (44.0 %)	104 (43.5 %)		Diabetes	1 (0.4 %)	2 (0.8 %)	0.50 (0.04 – 5.51)	0.57
Female	101 (42.3 %)	108 (45.2 %)	0.49	Disabling neurological disease	8 (3.3 %)	3 (1.3 %)	2.67 (0.71 – 10.05)	0.15
Ethnicity				Transplantation	4 (1.7 %)	1 (0.4 %)	4.00 (0.45 – 35.79)	0.21
White	209 (88.9 %)	218 (92.8 %)	0.56	Obesity	2 (1.1 %)	3 (1.6 %)	0.01 (0 – 1239.59)	0.44
Romany	9 (3.8 %)	5 (2.1 %)		Previous antibiotics	31 (13.0 %)	41 (17.2 %)	0.67 (0.38 – 1.18)	0.16
Amerindian	7 (3.0 %)	6 (2.6 %)		Systemic corticosteroids	10 (4.2 %)	4 (1.7 %)	3.20 (0.86 – 11.91)	0.08
Arab or North African	6 (2.6 %)	3 (1.3 %)		Inhaled corticosteroids	21 (8.8 %)	13 (5.4 %)	1.73 (0.82 – 3.63)	0.15
Other	4 (1.7 %)	3 (1.3 %)		≥1 risk factors	47 (19.7 %)	32 (13.4 %)	1.67 (0.99 – 2.82)	0.05
Education level parents				≥2 risk factors	7 (2.9 %)	3 (1.3 %)	2.52 (0.65 – 9.81)	0.18
Secondary or higher	168 (74.3 %)	160 (70.5 %)	0.35
Smoker parents	87 (36.6 %)	98 (41.4 %)	0.36

Table 2. Distribution of health information and non-pharmaceutical measures for confirmed outpatient cases and negative controls
	Cases (n = 239)	Controls (n = 239)	Crude OR (95 % CI)	P value	Adjusted OR^a (95 % CI)	P value
Received information on influenza prevention
No	56 (23.6 %)	51 (22.0 %)	1		1
Yes	181 (76.4 %)	181 (78.0 %)	0.83 (0.48 – 1.44)	0.51	0.72 (0.40 – 1.31)	0.29
Frequency of daily hand washing
1–4 times	123 (52.3 %)	107 (45.7 %)	1		1
>5 times	112 (47.7 %)	127 (54.3 %)	0.69 (0.45 – 1.04)	0.07	0.62 (0.39 – 0.99)	0.04
Use of alcohol-based hand sanitizers
Never	158 (67.2 %)	170 (72.3 %)	1		1
Sometimes	77 (32.8 %)	65 (27.7 %)	1.36 (0.85 – 2.17)	0.21	1.54 (0.8 – 2.66)	0.13
Hand washing after touching contaminated surfaces
Never	50 (21.4 %)	43 (18.3 %)	1		1
Sometimes	184 (78.6 %)	192 (81.7 %)	0.73 (0.41 – 1.32)	0.30	0.62 (0.29 – 1.31)	0.21
Influenza vaccine	2 (0.9 %)	5 (2.2 %)	0.44 (0.08 – 2.26)	0.32	0.27 (0.02 – 1.28)	0.09
Pneumococcal vaccine	79 (35.9 %)	69 (31.7 %)	1.52 (0.85 – 2.70)	0.15	1.47 (0.79 – 2.75)	0.22

^aAdjusted for pneumonia in previous 2 years, asthma and disabling neurological disease

Table 3. Distribution of medical conditions for confirmed outpatient cases and negative controls according to age group
	0–4 years				5–17 years
	Cases (n = 122)	Controls (n = 122)	Crude OR (95 % CI)	P value	Cases (n = 93)	Controls (n = 93)	Crude OR (95 % CI)	P value
Pneumonia in previous 2 years	12 (9.8 %)	2 (1.6 %)	6.00 (1.34 – 26.81)	0.02	8 (8.6 %)	6 (6.5 %)	1.48 (0.47 – 4.70)	0.50
Asthma	10 (8.2 %)	4 (3.3 %)	3.00 (0.81 – 11.08)	0.10	16 (17.2 %)	9 (9.7 %)	2.07 (0.83 – 5.15)	0.12
Renal failure or nephritic syndrome	1 (0.8 %)	0 (0.0 %)	-	-	3 (3.2 %)	2 (2.2 %)	1.50 (0.25 – 8.98)	0.66
Diabetes	0 (0.0 %)	0 (0.0 %)	-	-	1 (1.1 %)	2 (2.2 %)	0.50 (0.04 – 5.51)	0.57
Disabling neurological disease	1 (0.8 %)	3 (2.4 %)	0.33 (0.03 – 3.20)	0.34	6 (6.5 %)	0 (0.0 %)	65.29(0.09– 46313)	0.21
Transplantation	0 (0.0 %)	0 (0.0 %)	-	-	4 (4.3 %)	0 (0.0 %)	65.29 (0.02 – 202501.6)	0.31
Obesity	0 (0.0 %)	1 (1.1 %)	-	-	2 (2.6 %)	2 (2.6 %)	0.01 (0 – 500061.3)	0.58
Previous antibiotics	18 (14.8 %)	27 (22.0 %)	0.50 (0.22 – 1.11)	0.09	9 (9.7 %)	11 (11.8 %)	0.83 (0.33 – 2.11)	0.69
Systemic corticosteroids	4 (3.3 %)	1 (0.8 %)	4.00 (0.45 – 35.79)	0.21	5 (5.4 %)	2 (2.2 %)	4.70 (0.52 – 42.78)	0.17
Inhaled corticosteroids	13 (10.7 %)	7 (5.7 %)	2.20 (0.76 – 6.33)	0.14	7 (7.5 %)	5 (5.4 %)	1.40 (0.44 – 4.41)	0.57
≥1 risk factors	16 (13.1 %)	12 (9.8 %)	1.50 (0.61 – 3.67)	0.37	29 (31.2 %)	18 (19.4 %)	1.97 (0.97 – 3.96)	0.06
≥2 risk factors	1 (0.8 %)	2 (1.6 %)	0.50 (0.04 – 5.51)	0.57	6 (6.5 %)	1 (1.1 %)	6.77 (0.81 – 56.84)	0.08

Table 4. Distribution of health information and non-pharmaceutical measures for confirmed outpatient cases and negative controls according to age group
	0–4 years					5–17 years
	Cases (n = 122)	Controls (n = 122)	Crude OR (95 % CI)	Adjusted OR^a (95 % CI)	P value	Cases (n = 93)	Controls (n = 93)	Crude OR (95 % CI)	Adjusted OR^b (95 % CI)	P value
Received information on influenza prevention
No	37 (30.6 %)	32 (26.0 %)	1	1		15 (16.3 %)	14 (15.9 %)	1	1
Yes	84 (69.4 %)	91 (74.0 %)	0.71 (0.34–1.48)	0.74 (0.33 1.63)	0.45	77 (83.7 %)	74 (84.1 %)	0.83 (0.33 – 2.11)	0.72 (0.21 –2.50)	0.61
Frequency of daily hand washing
1–4 times	57 (48.3 %)	54 (45.0 %)	1	1		58 (62.4 %)	42 (46.2 %)	1	1
>5 times	61 (51.7 %)	66 (55.0 %)	0.80 (0.44- 1.47)	0.91 (0.46–1.78)	0.77	35 (37.6 %)	49 (53.8 %)	0.45 (0.23 – 0.87)	0.47 (0.22 – 0.99)	0.04
Use of alcohol-based hand sanitizers
Never	84 (71.2 %)	96 (79.3 %)	1	1		62 (66.7 %)	62 (68.1 %)	1	1
Sometimes	34 (28.8 %)	25 (20.7 %)	1.59 (0.85 -2.98)	1.45 (0.72 2.91)	0.29	31 (33.3 %)	29 (31.9 %)	1.09 (0.48 – 2.47)	1.29 (0.49 – 3.37)	0.60
Hand washing after touching contaminated surfaces
Never	22 (18.8 %)	26 (21.5 %)	1	1		26 (28.0 %)	16 (17.6 %)	1	1
Sometimes	95 (81.2 %)	95 (78.5 %)	1.36 (0.63–2.97)	1.06 (0.44–2.56)	0.90	67 (72.0 %)	75 (82.4 %)	0.27 (0.09 – 0.83)	0.19 (0.04 – 0.86)	0.03

^aAdjusted for: pneumonia in previous 2 years and previous antibiotics. ^bAdjusted for: frequency of daily hand washing and hand washing after touching contaminated surface