essay on covid and its preventive measures

Masks Strongly Recommended but Not Required in Maryland, Starting Immediately

Due to the downward trend in respiratory viruses in Maryland, masking is no longer required but remains strongly recommended in Johns Hopkins Medicine clinical locations in Maryland. Read more .

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Staying Safe from COVID-19

Reviewed By:

Lisa Lockerd Maragakis, M.D., M.P.H.

The coronavirus that causes COVID-19 spreads primarily from person to person through respiratory droplets. This can happen when someone with the virus coughs, sneezes, sings or talks when close to others. By closely following a few safety measures, you can help protect yourself and others from getting sick.

Lisa Maragakis , senior director of infection prevention at Johns Hopkins, shares these guidelines: 

Get vaccinated for COVID-19 and get a booster as soon as you’re eligible

Several COVID-19 vaccines have been approved or authorized by the U.S. Food and Drug Administration (FDA) for emergency use among specific age groups and recommended by the Centers for Disease Control and Prevention (CDC). Johns Hopkins Medicine views all authorized COVID-19 vaccines as highly effective at preventing serious disease, hospitalization and death from COVID-19. 

Learn more about coronavirus vaccine safety and COVID-19 boosters .

Be aware of infection rates in your area

As more people get vaccinated, the rates of infection and hospitalization will vary in your area. For the foreseeable future, it’s a good idea to be familiar with the vaccination and COVID-19 data for your area and follow the local, state and federal safety guidelines.

Practice physical distancing

The coronavirus spreads mainly from person to person. If an infected person coughs or sneezes, their droplets can infect people nearby. People, including children, may be infected and have only mild symptoms, so physical distancing (staying at least 6 feet apart from others) is an important part of coronavirus protection.

Wear a mask

Wear a face mask in crowded, indoor situations since people carrying the SARS-CoV-2 virus and unvaccinated or vulnerable people might be present. Johns Hopkins Medicine and other health care institutions require all visitors, patients and staff to wear masks in all of their hospitals, treatment centers and offices. Learn more information about how  masks  help prevent the spread of COVID-19.

Practice hand hygiene

• After being in public places and touching door handles, shopping carts, elevator buttons or handrails
• After using the bathroom
• Before preparing food or eating
• If soap and water are not available, use hand sanitizer with at least 60% alcohol.
• Avoid touching your eyes, nose or mouth, especially with unwashed hands.
• If you cough or sneeze, do so in the bend of your elbow. If you use a tissue, throw it away immediately.

Take precautions if you are living with or caring for someone who is sick

• Wear a mask if you are caring for someone who has respiratory symptoms.
• Clean counters, door knobs, phones and tablets frequently, using disinfectant cleaners or wipes.

If you feel sick, follow these guidelines:

• Stay home  if you feel sick  unless you are experiencing a medical emergency such as severe shortness of breath.
• Take measures to keep others in your home safe, and follow precautions recommended by the CDC to avoid infecting others .
• Call your doctor or urgent care facility and explain your symptoms over the phone.
• If you leave your home to get medical care, wear a mask if you have respiratory symptoms.

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Effectiveness of public health measures in reducing the incidence of covid-19, SARS-CoV-2 transmission, and covid-19 mortality: systematic review and meta-analysis

Linked editorial.

Public health measures for covid-19

• Related content
• Peer review
• Shivangi Shah , honours student 1 ,
• Holly Wild , lecturer and honours student 1 3 ,
• Danijela Gasevic , senior lecturer in epidemiology and chronic disease prevention 1 4 ,
• Ashika Maharaj , lecturer quality and safety and cancer epidemiology 1 ,
• Zanfina Ademi , associate professor of medical outcomes and health economics 1 2 ,
• Xue Li , assistant professor 4 6 ,
• Wei Xu , research student 4 ,
• Ines Mesa-Eguiagaray , statistical geneticist 4 ,
• Jasmin Rostron , research student 4 ,
• Evropi Theodoratou , professor of cancer epidemiology and global health 4 5 ,
• Xiaomeng Zhang , research student 4 ,
• Ashmika Motee , research student 4 ,
• Danny Liew , professor of medical outcomes and health economics 1 2 ,
• Dragan Ilic , professor of medical education and public health 1
• 1 School of Public Health and Preventive Medicine, Monash University, Melbourne, 3004 VIC, Australia
• 2 Monash Outcomes Research and health Economics (MORE) Unit, Monash University, VIC, Australia
• 3 Torrens University, VIC, Australia
• 4 Centre for Global Health, The Usher Institute, University of Edinburgh, Edinburgh, UK
• 5 Cancer Research UK Edinburgh Centre, MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
• 6 School of Public Health and The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
• Correspondence to: S Talic stella.talic{at}monash.edu
• Accepted 21 October 2021

Objective To review the evidence on the effectiveness of public health measures in reducing the incidence of covid-19, SARS-CoV-2 transmission, and covid-19 mortality.

Design Systematic review and meta-analysis.

Data sources Medline, Embase, CINAHL, Biosis, Joanna Briggs, Global Health, and World Health Organization COVID-19 database (preprints).

Eligibility criteria for study selection Observational and interventional studies that assessed the effectiveness of public health measures in reducing the incidence of covid-19, SARS-CoV-2 transmission, and covid-19 mortality.

Main outcome measures The main outcome measure was incidence of covid-19. Secondary outcomes included SARS-CoV-2 transmission and covid-19 mortality.

Data synthesis DerSimonian Laird random effects meta-analysis was performed to investigate the effect of mask wearing, handwashing, and physical distancing measures on incidence of covid-19. Pooled effect estimates with corresponding 95% confidence intervals were computed, and heterogeneity among studies was assessed using Cochran’s Q test and the I 2 metrics, with two tailed P values.

Results 72 studies met the inclusion criteria, of which 35 evaluated individual public health measures and 37 assessed multiple public health measures as a “package of interventions.” Eight of 35 studies were included in the meta-analysis, which indicated a reduction in incidence of covid-19 associated with handwashing (relative risk 0.47, 95% confidence interval 0.19 to 1.12, I 2 =12%), mask wearing (0.47, 0.29 to 0.75, I 2 =84%), and physical distancing (0.75, 0.59 to 0.95, I 2 =87%). Owing to heterogeneity of the studies, meta-analysis was not possible for the outcomes of quarantine and isolation, universal lockdowns, and closures of borders, schools, and workplaces. The effects of these interventions were synthesised descriptively.

Conclusions This systematic review and meta-analysis suggests that several personal protective and social measures, including handwashing, mask wearing, and physical distancing are associated with reductions in the incidence covid-19. Public health efforts to implement public health measures should consider community health and sociocultural needs, and future research is needed to better understand the effectiveness of public health measures in the context of covid-19 vaccination.

Systematic review registration PROSPERO CRD42020178692.

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Introduction

The impact of SARS-CoV-2 on global public health and economies has been profound. 1 As of 14 October 2021, there were 239 007 759 million cases of confirmed covid-19 and 4 871 841 million deaths with covid-19 worldwide. 2

A variety of containment and mitigation strategies have been adopted to adequately respond to covid-19, with the intention of deferring major surges of patients in hospitals and protecting the most vulnerable people from infection, including elderly people and those with comorbidities. 3 Strategies to achieve these goals are diverse, commonly based on national risk assessments that include estimation of numbers of patients requiring hospital admission and availability of hospital beds and ventilation support.

Globally, vaccination programmes have proved to be safe and effective and save lives. 4 5 Yet most vaccines do not confer 100% protection, and it is not known how vaccines will prevent future transmission of SARS-CoV-2, 6 given emerging variants. 7 8 9 The proportion of the population that must be vaccinated against covid-19 to reach herd immunity depends greatly on current and future variants. 10 This vaccination threshold varies according to the country and population’s response, types of vaccines, groups prioritised for vaccination, and viral mutations, among other factors. 6 Until herd immunity to covid-19 is reached, regardless of the already proven high vaccination rates, 11 public health preventive strategies are likely to remain as first choice measures in disease prevention, 12 particularly in places with a low uptake of covid-19 vaccination. Measures such as lockdown (local and national variant), physical distancing, mandatory use of face masks, and hand hygiene have been implemented as primary preventive strategies to curb the covid-19 pandemic. 13

Public health (or non-pharmaceutical) interventions have been shown to be beneficial in fighting respiratory infections transmitted through contact, droplets, and aerosols. 14 15 Given that SARS-CoV-2 is highly transmissible, it is a challenge to determine which measures might be more effective and sustainable for further prevention.

Substantial benefits in reducing mortality were observed in countries with universal lockdowns in place, such as Australia, New Zealand, Singapore, and China. Universal lockdowns are not, however, sustainable, and more tailored interventions need to be considered; the ones that maintain social lives and keep economies functional while protecting high risk individuals. 16 17 Substantial variation exists in how different countries and governments have applied public health measures, 18 and it has proved a challenge for assessing the effectiveness of individual public health measures, particularly in policy decision making. 19

Previous systematic reviews on the effectiveness of public health measures to treat covid-19 lacked the inclusion of analytical studies, 20 a comprehensive approach to data synthesis (focusing only on one measure), 21 a rigorous assessment of effectiveness of public health measures, 22 an assessment of the certainty of the evidence, 23 and robust methods for comparative analysis. 24 To tackle these gaps, we performed a systematic review of the evidence on the effectiveness of both individual and multiple public health measures in reducing the incidence of covid-19, SARS-CoV-2 transmission, and covid-19 mortality. When feasible we also did a critical appraisal of the evidence and meta-analysis.

This systematic review and meta-analysis were conducted in accordance with PRISMA 25 (supplementary material 1, table 1) and with PROSPERO (supplementary material 1, table 2).

Eligibility criteria

Articles that met the population, intervention, comparison, outcome, and study design criteria were eligible for inclusion in this systematic review (supplementary material 1, table 3). Specifically, preventive public health measures that were tested independently were included in the main analysis. Multiple measures, which generally contain a “package of interventions”, were included as supplementary material owing to the inability to report on the individual effectiveness of measures and comparisons on which package led to enhanced outcomes. The public health measures were identified from published World Health Organization sources that reported on the effectiveness of such measures on a range of communicable diseases, mostly respiratory infections, such as influenza.

Given that the scientific community is concerned about the ability of the numerous mathematical models, which are based on assumptions, to predict the course of virus transmission or effectiveness of interventions, 26 this review focused only on empirical studies. We excluded case reports and case studies, modelling and simulation studies, studies that provided a graphical summary of measures without clear statistical assessments or outputs, ecological studies that provided a descriptive summary of the measures without assessing linearity or having comparators, non‐empirical studies (eg, commentaries, editorials, government reports), other reviews, articles involving only individuals exposed to other pathogens that can cause respiratory infections, such as severe acute respiratory syndrome or Middle East respiratory syndrome, and articles in a language other than English.

Information sources

We carried out electronic searches of Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature, Ebsco), Global Health, Biosis, Joanna Briggs, and the WHO COVID-19 database (for preprints). A clinical epidemiologist (ST) developed the initial search strategy, which was validated by two senior medical librarians (LR and MD) (supplementary material 1, table 4). The updated search strategy was last performed on 7 June 2021. All citations identified from the database searches were uploaded to Covidence, an online software designed for managing systematic reviews, 27 for study selection.

Study selection

Authors ST, DG, SS, AM, ET, JR, XL, WX, IME, and XZ independently screened the titles and abstracts and excluded studies that did not match the inclusion criteria. Discrepancies were resolved in discussion with the main author (ST). The same authors retrieved full text articles and determined whether to include or exclude studies on the basis of predetermined selection criteria. Using a pilot tested data extraction form, authors ST, SS, AM, JR, XL, WX, AM, IME, and XZ independently extracted data on study design, intervention, effect measures, outcomes, results, and limitations. ST, SS, AM, and HW verified the extracted data. Table 5 in supplementary material 1 provides the specific criteria used to assess study designs. Given the heterogeneity and diversity in how studies defined public health measures, we took a common approach to summarise evidence of these interventions (supplementary material 1, table 6).

Risk of bias within individual studies

SS, JR, XL, WX, IME, and XZ independently assessed risk of bias for each study, which was cross checked by ST and HW. For non-interventional observational studies, a ROBINS-I (risk of bias in non-randomised studies of interventions) risk of bias tool was used. 28 For interventional studies, a revised tool for assessing risk of bias in randomised trials (RoB 2) tool was used. 29 Reviewers rated each domain for overall risk of bias as low, moderate, high, or serious/critical.

Data synthesis

The DerSimonian and Laird method was used for random effects meta-analysis, in which the standard error of the study specific estimates was adjusted to incorporate a measure of the extent of variation, or heterogeneity, among the effects observed for public health measures across different studies. It was assumed that the differences between studies are a result of different, yet related, intervention effects being estimated. If fewer than five studies were included in meta-analysis, we applied a recommended modified Hartung-Knapp-Sidik-Jonkman method. 30

Statistical analysis

Because of the differences in the effect metrics reported by the included studies, we could only perform quantitative data synthesis for three interventions: handwashing, face mask wearing, and physical distancing. Odds ratios or relative risks with corresponding 95% confidence intervals were reported for the associations between the public health measures and incidence of covid-19. When necessary, we transformed effect metrics derived from different studies to allow pooled analysis. We used the Dersimonian Laird random effects model to estimate pooled effect estimates along with corresponding 95% confidence intervals for each measure. Heterogeneity among individual studies was assessed using the Cochran Q test and the I 2 test. 31 All statistical analyses were conducted in R (version 4.0.3) and all P values were two tailed, with P=0.05 considered to be significant. For the remaining studies, when meta-analysis was not feasible, we reported the results in a narrative synthesis.

Public and patient involvement

No patients or members of the public were directly involved in this study as no primary data were collected. A member of the public was, however, asked to read the manuscript after submission.

A total of 36 729 studies were initially screened, of which 36 079 were considered irrelevent. After exclusions, 650 studies were eligible for full text review and 72 met the inclusion criteria. Of these studies, 35 assessed individual interventions and were included in the final synthesis of results ( fig 1 ) and 37 assessed multiple interventions as a package and are included in supplementary material 3, tables 2 and 3. The included studies comprised 34 observational studies and one interventional study, eight of which were included in the meta-analysis.

Flow of articles through the review. WHO=World Health Organization

Risk of bias

According to the ROBINS-I tool, 28 the risk of bias was rated as low in three studies, 32 33 34 moderate in 24 studies, 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 and high to serious in seven studies. 59 60 61 62 63 64 65 One important source of serious or critical risk of bias in most of the included studies was major confounding, which was difficult to control for because of the novel nature of the pandemic (ie, natural settings in which multiple interventions might have been enforced at once, different levels of enforcement across regions, and uncaptured individual level interventions such as increased personal hygiene). Variations in testing capacity and coverage, changes to diagnostic criteria, and access to accurate and reliable outcome data on covid-19 incidence and covid-19 mortality, was a source of measurement bias for numerous studies ( fig 2 ). These limitations were particularly prominent early in the pandemic, and in low income environments. 47 52 62 63 65 The randomised controlled trial 66 was rated as moderate risk of bias according to the ROB-2 tool. Missing data, losses to follow-up, lack of blinding, and low adherence to intervention all contributed to the reported moderate risk. Tables 1 and 2 in supplementary material 2 summarise the risk of bias assessment for each study assessing individual measures.

Summary of risk of bias across studies assessing individual measures using risk of bias in non-randomised studies of interventions (ROBINS-I) tool

Study characteristics

Studies assessing individual measures.

Thirty five studies provided estimates on the effectiveness of an individual public health measures. The studies were conducted in Asia (n=11), the United States (n=9), Europe (n=7), the Middle East (n=3), Africa (n=3), South America (n=1), and Australia (n=1). Thirty four of the studies were observational and one was a randomised controlled trial. The study designs of the observational studies comprised natural experiments (n=11), quasi-experiments (n=3), a prospective cohort (n=1), retrospective cohorts (n=8), case-control (n=2), and cross sectional (n=9). Twenty six studies assessed social measures, 32 34 35 37 38 39 40 41 42 44 46 47 48 52 53 55 56 57 58 59 60 61 63 64 65 67 12 studies assessed personal protective measures, 36 43 45 49 50 57 58 60 63 66 68 three studies assessed travel related measures, 54 58 62 and one study assessed environmental measures 57 (some interventions overlapped across studies). The most commonly measured outcome was incidence of covid-19 (n=18), followed by SARS-CoV-2 transmission, measured as reproductive number, growth number, or epidemic doubling time (n=13), and covid-19 mortality (n=8). Table 1 in supplementary material 3 provides detailed information on each study.

Effects of interventions

Personal protective measures.

Handwashing and covid-19 incidence —Three studies with a total of 292 people infected with SARS-CoV-2 and 10 345 participants were included in the analysis of the effect of handwashing on incidence of covid-19. 36 60 63 Overall pooled analysis suggested an estimated 53% non-statistically significant reduction in covid-19 incidence (relative risk 0.47, 95% confidence interval 0.19 to 1.12, I 2 =12%) ( fig 3 ). A sensitivity analysis without adjustment showed a significant reduction in covid-19 incidence (0.49, 0.33 to 0.72, I 2 =12%) ( fig 4 ). Risk of bias across the three studies ranged from moderate 36 60 to serious or critical 63 ( fig 2 ).

Meta-analysis of evidence on association between handwashing and incidence of covid-19 using modified Hartung-Knapp-Sidik-Jonkman adjusted random effect model

Meta-analysis of evidence on association between handwashing and incidence of covid-19 using unadjusted random effect model

Mask wearing and covid-19 incidence —Six studies with a total of 2627 people with covid-19 and 389 228 participants were included in the analysis examining the effect of mask wearing on incidence of covid-19 ( table 1 ). 36 43 57 60 63 66 Overall pooled analysis showed a 53% reduction in covid-19 incidence (0.47, 0.29 to 0.75), although heterogeneity between studies was substantial (I 2 =84%) ( fig 5 ). Risk of bias across the six studies ranged from moderate 36 57 60 66 to serious or critical 43 63 ( fig 2 ).

Study characteristics and main results from studies that assessed individual personal protective and environmental measures

• View inline

Meta-analysis of evidence on association between mask wearing and incidence of covid-19 using unadjusted random effect model

Mask wearing and transmission of SARS-CoV-2, covid-19 incidence, and covid-19 mortality —The results of additional studies that assessed mask wearing (not included in the meta-analysis because of substantial differences in the assessed outcomes) indicate a reduction in covid-19 incidence, SARS-CoV-2 transmission, and covid-19 mortality. Specifically, a natural experiment across 200 countries showed 45.7% fewer covid-19 related mortality in countries where mask wearing was mandatory ( table 1 ). 49 Another natural experiment study in the US reported a 29% reduction in SARS-CoV-2 transmission (measured as the time varying reproductive number Rt) (risk ratio 0.71, 95% confidence interval 0.58 to 0.75) in states where mask wearing was mandatory. 58

A comparative study in the Hong Kong Special Administrative Region reported a statistically significant lower cumulative incidence of covid-19 associated with mask wearing than in selected countries where mask wearing was not mandatory ( table 1 ). 68 Similarly, another natural experiment involving 15 US states reported a 2% statistically significant daily decrease in covid-19 transmission (measured as case growth rate) at ≥21 days after mask wearing became mandatory, 50 whereas a cross sectional study reported that a 10% increase in self-reported mask wearing was associated with greater odds for control of SARS-CoV-2 transmission (adjusted odds ratio 3.53, 95% confidence interval 2.03 to 6.43). 45 The five studies were rated at moderate risk of bias ( fig 2 ).

Environmental measures

Disinfection in household and covid-19 incidence.

Only one study, from China, reported the association between disinfection of surfaces and risk of secondary transmission of SARS-CoV-2 within households ( table 1 ). 57 The study assessed disinfection retrospectively by asking participants about their “daily use of chlorine or ethanol-based disinfectant in households,” and observed that use of disinfectant was 77% effective at reducing SARS-CoV-2 transmission (odds ratio 0.23, 95% confidence interval 0.07 to 0.84). The study did not collect data on the concentration of the disinfectant used by participants and was rated at moderate risk of bias ( fig 2 ).

Social measures

Physical distancing and covid-19 incidence.

Five studies with a total of 2727 people with SARS-CoV-2 and 108 933 participants were included in the analysis that examined the effect of physical distancing on the incidence of covid-19. 37 53 57 60 63 Overall pooled analysis indicated a 25% reduction in incidence of covid-19 (relative risk 0.75, 95% confidence interval 0.59 to 0.95, I 2 =87%) ( fig 6 ). Heterogeneity among studies was substantial, and risk of bias ranged from moderate 37 53 57 60 to serious or critical 63 ( fig 2 ).

Meta-analysis of evidence on association between physical distancing and incidence of covid-19 using unadjusted random effect model

Physical distancing and transmission of SARS-CoV-2 and covid-19 mortality

Studies that assessed physical distancing but were not included in the meta-analysis because of substantial differences in outcomes assessed, generally reported a positive effect of physical distancing ( table 2 ). A natural experiment from the US reported a 12% decrease in SARS-CoV-2 transmission (relative risk 0.88, 95% confidence interval 0.86 to 0.89), 40 and a quasi-experimental study from Iran reported a reduction in covid-19 related mortality (β −0.07, 95% confidence interval −0.05 to −0.10; P<0.001). 47 Another comparative study in Kenya also reported a reduction in transmission of SARS-CoV-2 after physical distancing was implemented, reporting 62% reduction in overall physical contacts (reproductive number pre-intervention was 2.64 and post-intervention was 0.60 (interquartile range 0.50 to 0.68)). 61 These three studies were rated at moderate risk of bias 40 61 to serious or critical risk of bias 47 ( fig 2 ).

Study characteristics and main results from studies assessing individual social measures

Stay at home or isolation and transmission of SARS-CoV-2

All the studies that assessed stay at home or isolation measures reported reductions in transmission of SARS-CoV-2 ( table 2 ). A retrospective cohort study from the US reported a significant reduction in the odds of having a positive reproductive number (R0) result (odds ratio 0.07, 95% confidence interval 0.01 to 0.37), 41 and a natural experiment reported a 51% reduction in time varying reproductive number (Rt) (risk ratio 0.49, 95% confidence interval 0.43 to 0.54). 58

A study from the UK reported a 74% reduction in the average daily number of contacts observed for each participant and estimated a decrease in reproductive number: the reproductive number pre-intervention was 3.6 and post-intervention was 0.60 (95% confidence interval 0.37 to 0.89). 65 Similarly, an Iranian study projected the reproductive number using serial interval distribution and the number of incidence cases and found a significant decrease: the reproductive number pre-intervention was 2.70 and post-intervention was 1.13 (95% confidence interval 1.03 to 1.25). 55 Three of the studies were rated at moderate to serious or critical risk of bias, 55 58 65 and one study was rated at low risk of bias 41 ( fig 2 ).

Quarantine and incidence and transmission of SARS-CoV-2

Quarantine was assessed in two studies ( table 2 ). 34 59 A prospective cohort study from Saudi Arabia reported a 4.9% decrease in the incidence of covid-19 at eight weeks after the implementation of quarantine. 34 This study was rated at low risk of bias ( fig 2 ). A retrospective cohort study from India reported a 14 times higher risk of SARS-CoV-2 transmission associated with no quarantine compared with strict quarantine (odds ratio 14.44, 95% confidence interval 2.42 to 86.17). 59 This study was rated at moderate risk of bias ( fig 2 ).

School closures and covid-19 incidence and covid-19 mortality

Two studies assessed the effectiveness of school closures on transmission of SARS-CoV-2, incidence of covid-19, or covid-19 mortality ( table 2 ). 44 48 A US population based longitudinal study reported on the effectiveness of state-wide closure of primary and secondary schools and observed a 62% decrease (95% confidence interval −49% to −71%) in incidence of covid-19 and a 58% decrease (−46% to−68%) in covid-19 mortality. 48 Conversely, a natural experiment from Japan reported no effect of school closures on incidence of covid-19 (α coefficient 0.08, 95% confidence interval −0.36 to 0.65). 44 Both studies were rated at moderate risk of bias ( fig 2 ).

School closures and transmission of SARS-CoV-2

Two natural experiments from the US reported a reduction in transmission (ie, reproductive number); with one study reporting a reduction of 13% (relative risk 0.87, 95% confidence interval 0.86 to 0.89) 40 and another reporting a 10% (0.90, 0.86 to 0.93) reduction ( table 2 ). 58 A Swedish study reported an association between school closures and a small increase in confirmed SARS-CoV-2 infections in parents (odds ratio 1.17, 95% confidence interval 1.03 to 1.32), but observed that teachers in lower secondary schools were twice as likely to become infected than teachers in upper secondary schools (2.01, 1.52 to 2.67). 32 All three studies were rated at moderate risk of bias ( fig 2 ).

Business closures and transmission of SARS-CoV-2

Two natural experiment studies assessed business closures across 50 US states and reported reductions in transmission of SARS-CoV-2 ( table 2 ). 40 58 One of the studies observed a significant reduction in transmission of 12% (relative risk 0.88, 95% confidence interval 0.86 to 0.89) 40 and the other reported a significant 16% (risk ratio 0.84, 0.79 to 0.90) reduction. 58 Both studies were rated at moderate risk of bias ( fig 2 ).

Lockdown and incidence of covid-19

A natural experiment involving 202 countries suggested that countries that implemented universal lockdown had fewer new cases of covid-19 than countries that did not (β coefficient −235.8 (standard error −11.04), P<0.01) ( table 2 ). 52 An Indian quasi-experimental study reported a 10.8% reduction in incidence of covid-19 post-lockdown, 56 whereas a South African retrospective cohort study observed a 14.1% reduction in risk after implementation of universal lockdown ( table 2 ). 46 These studies were rated at high risk of bias 52 and moderate risk of bias 46 56 ( fig 2 ).

Lockdown and covid-19 mortality

The three studies that assessed universal lockdown and covid-19 mortality generally reported a decrease in mortality ( table 2 ). 35 38 42 A natural experiment study involving 45 US states reported a decrease in covid-19 related mortality of 2.0% (95% confidence interval −3.0% to 0.9%) daily after lockdown had been made mandatory. 35 A Brazilian quasi-experimental study reported a 27.4% average difference in covid-19 related mortality rates in the first 25 days of lockdown. 42 In addition, a natural experiment study reported about 30% and 60% reductions in covid-19 related mortality post-lockdown in Italy and Spain over four weeks post-intervention, respectively. 38 All three studies were rated at moderate risk of bias ( fig 2 ).

Lockdown and transmission of SARS-CoV-2

Four studies assessed universal lockdown and transmission of SARS-CoV-2 during the first few months of the pandemic ( table 2 ). The decrease in reproductive number (R0) ranged from 1.27 in Italy (pre-intervention 2.03, post-intervention 0.76) 39 to 2.09 in India (pre-intervention 3.36, post-intervention 1.27), 64 and 3.97 in China (pre-intervention 4.95, post-intervention 0.98). 33 A natural experiment from the US reported that lockdown was associated with an 11% reduction in transmission of SARS-CoV-2 (relative risk 0.89, 95% confidence interval 0.88 to 0.91). 40 All the studies were rated at low risk of bias 33 39 to moderate risk 40 64 ( fig 2 ).

Travel related measures

Restricted travel and border closures.

Border closure was assessed in one natural experiment study involving nine African countries ( table 3 ). 62 Overall, the countries recorded an increase in the incidence of covid-19 after border closure. These studies concluded that the implementation of border closures within African countries had minimal effect on the incidence of covid-19. The study had important limitations and was rated at serious or critical risk of bias. In the US, a natural experiment study reported that restrictions on travel between states contributed about 11% to a reduction in SARS-CoV-2 transmission ( table 3 ). 36 The study was rated at moderate risk of bias ( fig 2 ).

Study characteristics and main results from studies that assessed individual travel measures

Entry and exit screening (virus or symptom screening)

One retrospective cohort study assessed screening of symptoms, which involved testing 65 000 people for fever ( table 3 ). 54 The study found that screening for fever lacked sensitivity (ranging from 18% to 24%) in detecting people with SARS-CoV-2 infection. This translated to 86% of the population with SARS-CoV-2 remaining undetected when screening for fever. The study was rated at moderate risk of bias ( fig 2 ).

Multiple public health measures

Overall, 37 studies provided estimates on the effectiveness of multiple public health measures, assessed as a collective group. Studies were mostly conducted in Asia (n=15), the US (n=11), Europe (n=6), Africa (n=4), and South America (n=1). All the studies were observational. The most commonly measured outcome was transmission of disease (ie, measured as reproductive number, growth number, or epidemic doubling time) (n=23), followed by covid-19 incidence (n=19) and covid-19 mortality (n=8). This review attempted to assess the overall effectiveness of the public health intervention packages by reporting the percentage difference in outcome before and after implementation of measures or between regions or countries studied. Eleven of the 37 included studies noted a difference of between 26% and 50% in transmission of SARS-CoV-2 and incidence of covid-19, 70 71 72 73 74 75 76 77 78 79 80 nine noted a difference of between 51% and 75% in SARS-CoV-2 transmission, covid-19 incidence, and covid-19 mortality, 81 82 83 84 85 86 87 88 89 and 14 noted a difference of more than 75% in transmission of SARS-CoV-2, covid-19 incidence and covid-19 mortality. 79 80 89 90 91 92 93 94 95 96 97 98 99 100 For the remaining studies, the overall effectiveness was not assessed owing to a lack of comparators (see supplementary material 3, table 3). Two studies that assessed universal lockdown and physical distancing reported a decrease of between 0% and 25% in SARS-CoV-2 transmission and covid-19 incidence. 79 101 Studies that included school and workplace closures, 91 95 96 isolation or stay at home measures, 80 94 or a combination of both 79 89 93 97 98 99 reported decreases of more than 75% in SARS-CoV-2 transmission. Supplementary material 3, table 2 provides detailed information on each study.

Worldwide, government and public health organisations are mitigating the spread of SARS-CoV-2 by implementing various public health measures. This systematic review identified a statistically significant reduction in the incidence of covid-19 through the implementation of mask wearing and physical distancing. Handwashing interventions also indicated a substantial reduction in covid-19 incidence, albeit not statistically significant in the adjusted model. As the random effects model tends to underestimate confidence intervals when a meta-analysis includes a small number of individual studies (<5), the adjusted model for handwashing showed a statistically non-significant association in reducing the incidence of covid-19 compared with the unadjusted model.

Overall effectiveness of these interventions was affected by clinical heterogeneity and methodological limitations, such as confounding and measurement bias. It was not possible to evaluate the impact of type of face maks (eg, surgical, fabric, N95 respirators) and compliance and frequency of wearing masks owing to a lack of data. Similarly, it was not feasible to assess the differences in effect that different recommendations for physical distancing (ie, 1.5 m, 2m, or 3 m) have as preventive strategies.

The effectiveness of measures such as universal lockdowns and closures of businesses and schools for the containment of covid-19 have largely been effective, but depended on early implementation when incidence rates of covid-19 were still low. 42 52 58 Only Japan reported no decrease in covid-19 incidence after school closures, 44 and other studies found that different public health measures were sometimes implemented simultaneously or soon after one another, thus the results should be interpreted with caution. 32 46 56

Isolation or stay at home was an effective measure in reducing the transmission of SARS-CoV-2, but the included studies used results for mobility to assess stay at home or isolation and therefore could have been limited by potential flaws in publicly available phone data, 41 58 102 and variations in the enforcement of public health measures in different states or regions were not assessed. 55 58 102 Quarantine was found to be as effective in reducing the incidence of covid-19 and transmission of SARS-CoV-2, yet variation in testing and case detection in low income environments was substantial. 59 96 98 Another study reported that quarantine was effective in reducing the transmission of SARS-CoV-2 in a cohort with a low prevalence of the virus, yet it is unknown if the same effect would be observed with higher prevalence. 34

It was not possible to draw conclusions about the effectiveness of restricted travel and full border closures because the number of empirical studies was insufficient. Single studies identified that border closure in Africa had a minimal effect in reducing SARS-CoV-2 transmission, but the study was assessed as being at high risk of bias. 62 Screening for fever was also identified to be ineffective, with only 24% of positive cases being captured by screening. 54

Comparison with other studies

Previous literature reviews have identified mask wearing as an effective measure for the containment of SARS-CoV-2 103 ; the caveat being that more high level evidence is required to provide unequivocal support for the effectiveness of the universal use of face masks. 104 105 Additional empirical evidence from a recent randomised controlled trial (originally published as a preprint) indicates that mask wearing achieved a 9.3% reduction in seroprevalence of symptomatic SARS-CoV-2 infection and an 11.9% reduction in the prevalence of covid-19-like symptoms. 106 Another systematic review showed stronger effectiveness with the use of N95, or similar, respirators than disposable surgical masks, 107 and a study evaluating the protection offered by 18 different types of fabric masks found substantial heterogeneity in protection, with the most effective mask being multilayered and tight fitting. 108 However, transmission of SARS-CoV-2 largely arises in hospital settings in which full personal protective measures are in place, which suggests that when viral load is at its highest, even the best performing face masks might not provide adequate protection. 51 Additionally, most studies that assessed mask wearing were prone to important confounding bias, which might have altered the conclusions drawn from this review (ie, effect estimates might have been underestimated or overestimated or can be related to other measures that were in place at the time the studies were conducted). Thus, the extent of such limitations on the conclusions drawn remain unknown.

A 2020 rapid review concluded that quarantine is largely effective in reducing the incidence of covid-19 and covid-19 mortality. However, uncertainty over the magnitude of such an effect still remains, 109 with enhanced management of quality quarantine facilities for improved effective control of the epidemics urgently needed. 110 In addition, findings on the application of school and workplace closures are still inconclusive. Policy makers should be aware of the ambiguous evidence when considering school closures, as other potentially less disruptive physical distancing interventions might be more appropriate. 21 Numerous findings from studies on the efficacy of school closures showed that the risk of transmission within the educational environment often strongly depends on the incidence of covid-19 in the community, and that school closures are most successfully associated with control of SARS-CoV-2 transmission when other mitigation strategies are in place in the community. 111 112 113 114 115 116 117 School closures have been reported to be disruptive to students globally and are likely to impair children’s social, psychological, and educational development 118 119 and to result in loss of income and productivity in adults who cannot work because of childcare responsibilities. 120

Speculation remains as how best to implement physical distancing measures. 121 Studies that assess physical distancing measures might interchangeably study physical distancing with lockdown 35 52 56 64 and other measures and thus direct associations are difficult to assess.

Empirical evidence from restricted travel and full border closures is also limited, as it is almost impossible to study these strategies as single measures. Current evidence from a recent narrative literature review suggested that control of movement, along with mandated quarantine, travel restrictions, and restricting nationals from entering areas of high infection, are effective measures, but only with good compliance. 122 A narrative literature review of travel bans, partial lockdowns, and quarantine also suggested effectiveness of these measures, 123 and another rapid review further supported travel restrictions and cross border restrictions to stop the spread of SARS-CoV-2. 124 It was impossible to make such observations in the current review because of limited evidence. A German review, however, suggested that entry, exit, and symptom screening measures to prevent transmission of SARS-CoV-2 are not effective at detecting a meaningful proportion of cases, 125 and another review using real world data from multiple countries found that border closures had minimal impact on the control of covid-19. 126

Although universal lockdowns have shown a protective effect in lowering the incidence of covid-19, SARS-CoV-2 transmission, and covid-19 mortality, these measures are also disruptive to the psychosocial and mental health of children and adolescents, 127 global economies, 128 and societies. 129 Partial lockdowns could be an alternative, as the associated effectiveness can be high, 125 especially when implemented early in an outbreak, 85 and such measures would be less disruptive to the general population.

It is important to also consider numerous sociopolitical and socioeconomic factors that have been shown to increase SARS-CoV-2 infection 130 131 and covid-19 mortality. 132 Immigration status, 82 economic status, 81 101 and poverty and rurality 98 can influence individual and community compliance with public health measures. Poverty can impact the ability of communities to physically distance, 133 especially in crowded living environments, 134 135 as well as reduce access to personal protective measures. 134 135 A recent study highlights that “a one size fits all” approach to public health measures might not be effective at reducing the spread of SARS-CoV-2 in vulnerable communities 136 and could exacerbate social and economic inequalities. 135 137 As such, a more nuanced and community specific approach might be required. Even though screening is highly recommended by WHO 138 because a proportion of patients with covid-19 can be asymptomatic, 138 screening for symptoms might miss a larger proportion of the population with covid-19. Hence, temperature screening technologies might need to be reconsidered and evaluated for cost effectiveness, given such measures are largely depended on symptomatic fever cases.

Strengths and limitations of this review

The main strength of this systematic review was the use of a comprehensive search strategy to identify and select studies for review and thereby minimise selection bias. A clinical epidemiologist developed the search strategy, which was validated by two senior medical librarians. This review followed a comprehensive appraisal process that is recommended by the Cochrane Collaboration 31 to assess the effectiveness of public health measures, with specifically validated tools used to independently and individually assess the risk of bias in each study by study design.

This review has some limitations. Firstly, high quality evidence on SARS CoV-2 and the effectiveness of public health measures is still limited, with most studies having different underlying target variables. Secondly, information provided in this review is based on current evidence, so will be modified as additional data become available, especially from more prospective and randomised studies. Also, we excluded studies that did not provide certainty over the effect measure, which might have introduced selection bias and limited the interpretation of effectiveness. Thirdly, numerous studies measured interventions only once and others multiple times over short time frames (days v month, or no timeframe). Additionally, the meta-analytical portion of this study was limited by significant heterogeneity observed across studies, which could neither be explored nor explained by subgroup analyses or meta-regression. Finally, we quantitatively assessed only publications that reported individual measures; studies that assessed multiple measures simultaneously were narratively analysed with a broader level of effectiveness (see supplementary material 3, table 3). Also, we excluded studies in languages other than English.

Methodological limitations of studies included in the review

Several studies failed to define and assess for potential confounders, which made it difficult for our review to draw a one directional or causal conclusion. This problem was mainly because we were unable to study only one intervention, given that many countries implemented several public health measures simultaneously; thus it is a challenge to disentangle the impact of individual interventions (ie, physical distancing when other interventions could be contributing to the effect). Additionally, studies measured different primary outcomes and in varied ways, which limited the ability to statistically analyse other measures and compare effectiveness.

Further pragmatic randomised controlled trials and natural experiment studies are needed to better inform the evidence and guide the future implementation of public health measures. Given that most measures depend on a population’s adherence and compliance, it is important to understand and consider how these might be affected by factors. A lack of data in the assessed studies meant it was not possible to understand or determine the level of compliance and adherence to any of the measures.

Conclusions and policy implications

Current evidence from quantitative analyses indicates a benefit associated with handwashing, mask wearing, and physical distancing in reducing the incidence of covid-19. The narrative results of this review indicate an effectiveness of both individual or packages of public health measures on the transmission of SARS-CoV-2 and incidence of covid-19. Some of the public health measures seem to be more stringent than others and have a greater impact on economies and the health of populations. When implementing public health measures, it is important to consider specific health and sociocultural needs of the communities and to weigh the potential negative effects of the public health measures against the positive effects for general populations. Further research is needed to assess the effectiveness of public health measures after adequate vaccination coverage has been achieved. It is likely that further control of the covid-19 pandemic depends not only on high vaccination coverage and its effectiveness but also on ongoing adherence to effective and sustainable public health measures.

What is already known on this topic

Public health measures have been identified as a preventive strategy for influenza pandemics

The effectiveness of such interventions in reducing the transmission of SARS-CoV-2 is unknown

What this study adds

The findings of this review suggest that personal and social measures, including handwashing, mask wearing, and physical distancing are effective at reducing the incidence of covid-19

More stringent measures, such as lockdowns and closures of borders, schools, and workplaces need to be carefully assessed by weighing the potential negative effects of these measures on general populations

Further research is needed to assess the effectiveness of public health measures after adequate vaccination coverage

Ethics statements

Ethical approval.

Not required.

Data availability statement

No additional data available.

Acknowledgments

We thank medical subject librarians Lorena Romero (LR) and Marshall Dozier (MD) for their expert advice and assistance with the study search strategy.

Contributors: ST, DG, DI, DL, and ZA conceived and designed the study. ST, DG, SS, AM, HW, WX, JR, ET, AM, XL, XZ, and IME collected and screened the data. ST, DG, and DI acquired, analysed, or interpreted the data. ST, HW, and SS drafted the manuscript. All authors critically revised the manuscript for important intellectual content.. XL and ST did the statistical analysis. NA obtained funding. LR and MD provided administrative, technical, or material support. ST and DI supervised the study. ST and DI had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. ST is the guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding: No funding was available for this research. ET is supported by a Cancer Research UK Career Development Fellowship (grant No C31250/A22804). XZ is supported by The Darwin Trust of Edinburgh.

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: ET is supported by a Cancer Research UK Career Development Fellowship and XZ is supported by The Darwin Trust of Edinburgh; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

The lead author (ST) affirms that the manuscript is an honest, accurate, and transparent account of the study reported; no important aspects of the study have been omitted. Dissemination to participants and related patient and public communities: It is anticipated to disseminate the results of this research to wider community via press release and social media platforms.

Provenance and peer review: Not commissioned; externally peer reviewed.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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Prevent COVID-19: How to Protect Yourself from the Coronavirus

Follow these simple precautions to reduce your chances of contracting covid-19..

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The COVID-19 pandemic has been a part of our daily lives since March 2020, but with about 151,000 new cases a day in the United States, it remains as important as ever to stay vigilant and know how to protect yourself from coronavirus.

According to the  Centers for Disease Control and Prevention (CDC) , “The best way to prevent illness is to avoid being exposed to this virus.” As the vaccines continue their roll out, here are the simple steps you can take to help prevent the spread of COVID-19 and protect yourself and others.

Know how it spreads

Scientists are still learning about COVID-19, the disease caused by the coronavirus, but according to the CDC, this highly contagious virus appears to be most commonly spread during close (within 6 feet) person-to-person contact through respiratory droplets.

“The means of transmission can be through respiratory droplets produced when a person coughs or sneezes, or by direct physical contact with an infected person, such as shaking hands,” says  Dr. David Goldberg , an internist and infectious disease specialist at NewYork-Presbyterian Medical Group Westchester and an assistant professor of medicine at Columbia University Vagelos College of Physicians and Surgeons.

The CDC also notes that COVID-19 can spread by airborne transmission , although this is less common than close contact with a person. “Some infections can be spread by exposure to virus in small droplets and particles that can linger in the air for minutes to hours,” the CDC states. “These viruses may be able to infect people who are further than 6 feet away from the person who is infected or after that person has left the space. These transmissions occurred within enclosed spaces that had inadequate ventilation.”

Finally, it’s possible for coronavirus to spread through contaminated surfaces, but this is also less likely. According to the CDC, “Based on data from lab studies on COVID-19 and what we know about similar respiratory diseases, it may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this isn’t thought to be the main way the virus spreads.”

Practice social distancing

Since close person-to-person contact appears to be the main source of transmission, social distancing remains a key way to mitigate spread. The CDC recommends maintaining a distance of approximately 6 feet from others in public places. This distance will help you avoid direct contact with respiratory droplets produced by coughing or sneezing.

In addition, studies have found that outdoor settings with enough space to distance and good ventilation will reduce risk of exposure. “There is up to 80% less transmission of the virus happening outdoors versus indoors,” says Dr. Ashwin Vasan , an assistant attending physician in the Department of Medicine at NewYork-Presbyterian/Columbia University Irving Medical Center and an assistant professor at the Mailman School of Public Health and Columbia University Vagelos College of Physicians and Surgeons. “One  study  found that of 318 outbreaks that accounted for 1,245 confirmed cases in China, only one outbreak occurred outdoors. That’s significant. I recommend spending time with others outside. We’re not talking about going to a sporting event or a concert. We’re talking about going for a walk or going to the park, or even having a conversation at a safe distance with someone outside.”

Wash your hands

Practicing good hygiene is an important habit that helps prevent the spread of COVID-19. Make these CDC recommendations part of your routine:

• Wash your hands often with soap and water for at least 20 seconds, especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.
• Before eating or preparing food
• Before touching your face
• After using the restroom
• After leaving a public place
• After blowing your nose, coughing, or sneezing
• After handling your mask
• After changing a diaper
• After caring for someone who’s sick
• After touching animals or pets
• If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands with the sanitizer and rub them together until they feel dry.
• Avoid touching your eyes, nose, and mouth with unwashed hands.

Visit the CDC website for guidelines on how to properly  wash your hands  and  use hand sanitizer . And see our video below on how soap kills the coronavirus. There’s plenty of  science  behind this basic habit. “Soap molecules disrupt the fatty layer or coat surrounding the virus, ” says Dr. Goldberg. “Once the viral coat is broken down, the virus is no longer able to function.”

In addition to hand-washing, disinfect frequently touched surfaces daily. This includes tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks.

Wear a mask

Face masks have become essential accessories in protecting yourself and others from contracting COVID-19. The CDC recommends that people wear face coverings in public settings, especially since studies have shown that individuals with the novel coronavirus could be asymptomatic or presymptomatic. (Face masks, however, do not replace  social distancing  recommendations.)

“Face masks are designed to provide a barrier between your airway and the outside world,” says  Dr. Ole Vielemeyer , medical director of Weill Cornell ID Associates and Travel Medicine in the Division of Infectious Diseases at NewYork-Presbyterian/Weill Cornell Medical Center and Weill Cornell Medicine. “By wearing a mask that covers your mouth and nose, you will reduce the risk of serving as the source of disease spread by trapping your own droplets in the mask, and also reduce the risk of getting sick via droplets that contain the coronavirus by blocking access to your own airways.”

Restrict your travel

Traveling can increase the spread of COVID-19 and put you at risk for contracting the disease. The CDC recommends avoiding non-essential travel to many international destinations  during the pandemic. It also advises people to  weigh the risks when it comes to domestic travel: “Travel increases your chance of getting and spreading COVID-19,” states the CDC. “Staying home is the best way to protect yourself and others from COVID-19.”

“For people at risk for the complications of COVID-19, such as those with underlying medical conditions or those who are older, it’s prudent to avoid travel,” says Dr. Goldberg.

If you must travel, take safety measures,  consider your mode of transportation, and stay up to date on the  restrictions that are in place at your destination. Adhering to your state’s quarantine rules after traveling will help prevent the spread of COVID-19.

Watch for symptoms

The symptoms of infection for the coronavirus are often similar to those of other respiratory virus infections, such as influenza. Symptoms can include:

• Fever or chills
• Shortness of breath or difficulty breathing
• Muscle or body aches
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting

With the COVID-19 pandemic now coinciding with flu season, it’s important to recognize the differences in symptoms — as well as get a flu shot. “The medical community is concerned that if we have an increased number of influenza cases, it will strain the hospital system on top of what’s already going on with the COVID-19 pandemic,” says  Dr. Ting Ting Wong , an attending physician and infectious disease specialist at NewYork-Presbyterian Brooklyn Methodist Hospital.

If you think you may have been  exposed to a person with COVID-19  and have symptoms, call ahead to a doctor’s office to see if you can get tested. You can also use a virtual care platform, such as NewYork-Presbyterian’s  NYP OnDemand,  to meet with a healthcare professional by videoconference. Avoid contact with others and wear a face mask if you need to leave your home when you are sick.

How NewYork-Presbyterian is prepared

NewYork-Presbyterian continues to follow the situation closely and implement the recommendations provided by our local and state departments of health and the CDC. Our medical staff is trained to recognize patients who may have the virus and will help prevent COVID-19 from spreading.

We understand how important the support of loved ones and friends is to patients during their hospital stay. Stay up to date with NewYork-Presbyterian’s  visitor guidelines . It’s our priority to keep patients and visitors safe from infection.

For more information on the evolving situation and how to protect yourself from coronavirus, visit the  CDC  and check  NewYork-Presbyterian  for more updates.

View all of our COVID-19 outbreak articles  here .

Additional Resources

If you have concerns regarding COVID-19, please call NewYork-Presbyterian’s hotline at 646-697-4000. This hotline is available as a public service to provide information only and not diagnose, treat, or render a medical opinion.

If you are not feeling well, consider using NewYork-Presbyterian’s Virtual Urgent Care for non-life-threatening symptoms such as fever, cough, upset stomach, or nausea. Learn more by visiting nyp.org/urgentcare .

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Students’ Essays on Infectious Disease Prevention, COVID-19 Published Nationwide

As part of the BIO 173: Global Change and Infectious Disease course, Professor Fred Cohan assigns students to write an essay persuading others to prevent future and mitigate present infectious diseases. If students submit their essay to a news outlet—and it’s published—Cohan awards them with extra credit.

As a result of this assignment, more than 25 students have had their work published in newspapers across the United States. Many of these essays cite and applaud the University’s Keep Wes Safe campaign and its COVID-19 testing protocols.

Cohan, professor of biology and Huffington Foundation Professor in the College of the Environment (COE), began teaching the Global Change and Infectious Disease course in 2009, when the COE was established. “I wanted very much to contribute a course to what I saw as a real game-changer in Wesleyan’s interest in the environment. The course is about all the ways that human demands on the environment have brought us infectious diseases, over past millennia and in the present, and why our environmental disturbances will continue to bring us infections into the future.”

Over the years, Cohan learned that he can sustainably teach about 170 students every year without running out of interested students. This fall, he had 207. Although he didn’t change the overall structure of his course to accommodate COVID-19 topics, he did add material on the current pandemic to various sections of the course.

“I wouldn’t say that the population of the class increased tremendously as a result of COVID-19, but I think the enthusiasm of the students for the material has increased substantially,” he said.

To accommodate online learning, Cohan shaved off 15 minutes from his normal 80-minute lectures to allow for discussion sections, led by Cohan and teaching assistants. “While the lectures mostly dealt with biology, the discussions focused on how changes in behavior and policy can solve the infectious disease problems brought by human disturbance of the environment,” he said.

Based on student responses to an introspective exam question, Cohan learned that many students enjoyed a new hope that we could each contribute to fighting infectious disease. “They discovered that the solution to infectious disease is not entirely a waiting game for the right technologies to come along,” he said. “Many enjoyed learning about fighting infectious disease from a moral and social perspective. And especially, the students enjoyed learning about the ‘socialism of the microbe,’ how preventing and curing others’ infections will prevent others’ infections from becoming our own. The students enjoyed seeing how this idea can drive both domestic and international health policies.”

A sampling of the published student essays are below:

Alexander Giummo ’22 and Mike Dunderdale’s ’23  op-ed titled “ A National Testing Proposal: Let’s Fight Back Against COVID-19 ” was published in the Journal Inquirer in Manchester, Conn.

They wrote: “With an expansive and increased testing plan for U.S. citizens, those who are COVID-positive could limit the number of contacts they have, and this would also help to enable more effective contact tracing. Testing could also allow for the return of some ‘normal’ events, such as small social gatherings, sports, and in-person class and work schedules.

“We propose a national testing strategy in line with the one that has kept Wesleyan students safe this year. The plan would require a strong push by the federal government to fund the initiative, but it is vital to successful containment of the virus.

“Twice a week, all people living in the U.S. should report to a local testing site staffed with professionals where the anterior nasal swab Polymerase Chain Reaction (PCR) test, used by Wesleyan and supported by the Broad Institute, would be implemented.”

Kalyani Mohan ’22 and Kalli Jackson ’22 penned an essay titled “ Where Public Health Meets Politics: COVID-19 in the United States ,” which was published in Wesleyan’s Arcadia Political Review .

They wrote: “While the U.S. would certainly benefit from a strengthened pandemic response team and structural changes to public health systems, that alone isn’t enough, as American society is immensely stratified, socially and culturally. The politicization of the COVID-19 pandemic shows that individualism, libertarianism and capitalism are deeply ingrained in American culture, to the extent that Americans often blind to the fact community welfare can be equivalent to personal welfare. Pandemics are multifaceted, and preventing them requires not just a cultural shift but an emotional one amongst the American people, one guided by empathy—towards other people, different communities and the planet. Politics should be a tool, not a weapon against its people.”

Sydnee Goyer ’21 and Marcel Thompson’s ’22  essay “ This Flu Season Will Be Decisive in the Fight Against COVID-19 ” also was published in Arcadia Political Review .

“With winter approaching all around the Northern Hemisphere, people are preparing for what has already been named a “twindemic,” meaning the joint threat of the coronavirus and the seasonal flu,” they wrote. “While it is known that seasonal vaccinations reduce the risk of getting the flu by up to 60% and also reduce the severity of the illness after the contamination, additional research has been conducted in order to know whether or not flu shots could reduce the risk of people getting COVID-19. In addition to the flu shot, it is essential that people remain vigilant in maintaining proper social distancing, washing your hands thoroughly, and continuing to wear masks in public spaces.”

An op-ed titled “ The Pandemic Has Shown Us How Workplace Culture Needs to Change ,” written by Adam Hickey ’22 and George Fuss ’21, was published in Park City, Utah’s The Park Record .

They wrote: “One review of academic surveys (most of which were conducted in the United States) conducted in 2019 found that between 35% and 97% of respondents in those surveys reported having attended work while they were ill, often because of workplace culture or policy which generated pressure to do so. Choosing to ignore sickness and return to the workplace while one is ill puts colleagues at risk, regardless of the perceived severity of your own illness; COVID-19 is an overbearing reminder that a disease that may cause mild, even cold-like symptoms for some can still carry fatal consequences for others.

“A mandatory paid sick leave policy for every worker, ideally across the globe, would allow essential workers to return to work when necessary while still providing enough wiggle room for economically impoverished employees to take time off without going broke if they believe they’ve contracted an illness so as not to infect the rest of their workplace and the public at large.”

Women’s cross country team members and classmates Jane Hollander ’23 and Sara Greene ’23 wrote a sports-themed essay titled “ This Season, High School Winter Sports Aren’t Worth the Risk ,” which was published in Tap into Scotch Plains/Fanwood , based in Scotch Plains, N.J. Their essay focused on the risks high school sports pose on student-athletes, their families, and the greater community.

“We don’t propose cutting off sports entirely— rather, we need to be realistic about the levels at which athletes should be participating. There are ways to make practices safer,” they wrote. “At [Wesleyan], we began the season in ‘cohorts,’ so the amount of people exposed to one another would be smaller. For non-contact sports, social distancing can be easily implemented, and for others, teams can focus on drills, strength and conditioning workouts, and skill-building exercises. Racing sports such as swim and track can compete virtually, comparing times with other schools, and team sports can focus their competition on intra-team scrimmages. These changes can allow for the continuation of a sense of normalcy and team camaraderie without the exposure to students from different geographic areas in confined, indoor spaces.”

Brook Guiffre ’23 and Maddie Clarke’s ’22  op-ed titled “ On the Pandemic ” was published in Hometown Weekly,  based in Medfield, Mass.

“The first case of COVID-19 in the United States was recorded on January 20th, 2020. For the next month and a half, the U.S. continued operating normally, while many other countries began their lockdown,” they wrote. “One month later, on February 29th, 2020, the federal government approved a national testing program, but it was too little too late. The U.S. was already in pandemic mode, and completely unprepared. Frontline workers lacked access to N-95 masks, infected patients struggled to get tested, and national leaders informed the public that COVID-19 was nothing more than the common flu. Ultimately, this unpreparedness led to thousands of avoidable deaths and long-term changes to daily life. With the risk of novel infectious diseases emerging in the future being high, it is imperative that the U.S. learn from its failure and better prepare for future pandemics now. By strengthening our public health response and re-establishing government organizations specialized in disease control, we have the ability to prevent more years spent masked and six feet apart.”

In addition, their other essay, “ On Mass Extinction ,” was also published by Hometown Weekly .

“The sixth mass extinction—which scientists have coined as the Holocene Extinction—is upon us. According to the United Nations, around one million plant and animal species are currently in danger of extinction, and many more within the next decade. While other extinctions have occurred in Earth’s history, none have occurred at such a rapid rate,” they wrote. “For the sake of both biodiversity and infectious diseases, it is in our best interest to stop pushing this Holocene Extinction further.”

An essay titled “ Learning from Our Mistakes: How to Protect Ourselves and Our Communities from Diseases ,” written by Nicole Veru ’21 and Zoe Darmon ’21, was published in My Hometown Bronxville, based in Bronxville, N.Y.

“We can protect ourselves and others from future infectious diseases by ensuring that we are vaccinated,” they wrote. “Vaccines have high levels of success if enough people get them. Due to vaccines, society is no longer ravaged by childhood diseases such as mumps, rubella, measles, and smallpox. We have been able to eradicate diseases through vaccines; smallpox, one of the world’s most consequential diseases, was eradicated from the world in the 1970s.

“In 2000, the U.S. was nearly free of measles, yet, due to hesitations by anti-vaxxers, there continues to be cases. From 2000–2015 there were over 18 measles outbreaks in the U.S. This is because unless a disease is completely eradicated, there will be a new generation susceptible.

“Although vaccines are not 100% effective at preventing infection, if we continue to get vaccinated, we protect ourselves and those around us. If enough people are vaccinated, societies can develop herd immunity. The amount of people vaccinated to obtain herd immunity depends on the disease, but if this fraction is obtained, the spread of disease is contained. Through herd immunity, we protect those who may not be able to get vaccinated, such as people who are immunocompromised and the tiny portion of people for whom the vaccine is not effective.”

Dhruvi Rana ’22 and Bryce Gillis ’22 co-authored an op-ed titled “ We Must Educate Those Who Remain Skeptical of the Dangers of COVID-19 ,” which was published in Rhode Island Central .

“As Rhode Island enters the winter season, temperatures are beginning to drop and many studies have demonstrated that colder weather and lower humidity are correlated with higher transmissibility of SARS-CoV-2, the virus that causes COVID-19,” they wrote. “By simply talking or breathing, we release respiratory droplets and aerosols (tiny fluid particles which could carry the coronavirus pathogen), which can remain in the air for minutes to hours.

“In order to establish herd immunity in the US, we must educate those who remain skeptical of the dangers of COVID-19.  Whether community-driven or state-funded, educational campaigns are needed to ensure that everyone fully comprehends how severe COVID-19 is and the significance of airborne transmission. While we await a vaccine, it is necessary now more than ever that we social distance, avoid crowds, and wear masks, given that colder temperatures will likely yield increased transmission of the virus.”

Danielle Rinaldi ’21 and Verónica Matos Socorro ’21 published their op-ed titled “ Community Forum: How Mask-Wearing Demands a Cultural Reset ” in the Ewing Observer , based in Lawrence, N.J.

“In their own attempt to change personal behavior during the pandemic, Wesleyan University has mandated mask-wearing in almost every facet of campus life,” they wrote. “As members of our community, we must recognize that mask-wearing is something we are all responsible and accountable for, not only because it is a form of protection for us, but just as important for others as well. However, it seems as though both Covid fatigue and complacency are dominating the mindsets of Americans, leading to even more unwillingness to mask up. Ultimately, it is inevitable that this pandemic will not be the last in our lifespan due to global warming creating irreversible losses in biodiversity. As a result, it is imperative that we adopt the norm of mask-wearing now and undergo a culture shift of the abandonment of an individualistic mindset, and instead, create a society that prioritizes taking care of others for the benefit of all.”

Shayna Dollinger ’22 and Hayley Lipson ’21  wrote an essay titled “ My Pandemic Year in College Has Brought Pride and Purpose. ” Dollinger submitted the piece, rewritten in first person, to Jewish News of Northern California . Read more about Dollinger’s publication in this News @ Wesleyan article .

“I lay in the dead grass, a 6-by-6-foot square all to myself. I cheer for my best friend, who is on the stage constructed at the bottom of Foss hill, dancing with her Bollywood dance group. Masks cover their ordinarily smiling faces as their bodies move in sync. Looking around at friends and classmates, each in their own 6-by-6 world, I feel an overwhelming sense of normalcy.

“One of the ways in which Wesleyan has prevented outbreaks on campus is by holding safe, socially distanced events that students want to attend. By giving us places to be and things to do on the weekends, we are discouraged from breaking rules and causing outbreaks at ‘super-spreader’ events.”

An op-ed written by Luna Mac-Williams ’22 and Daëlle Coriolan ’24 titled “ Collectivist Practices to Combat COVID-19 ” was published in the Wesleyan Argus .

“We are embroiled in a global pandemic that disproportionately affects poor communities of color, and in the midst of a higher cultural consciousness of systemic inequities,” they wrote. “A cultural shift to center collectivist thought and action not only would prove helpful in disease prevention, but also belongs in conversation with the Black Lives Matter movement. Collectivist models of thinking effectively target the needs of vulnerable populations including the sick, the disenfranchised, the systematically marginalized. Collectivist systems provide care, decentering the capitalist, individualist system, and focusing on how communities can work to be self-sufficient and uplift our own neighbors.”

An essay written by Maria Noto ’21 , titled “ U.S. Individualism Has Deadly Consequences ,” is published in the Oneonta Daily Star , based in Oneonta, N.Y.

She wrote, “When analyzing the cultures of certain East Asian countries, several differences stand out. For instance, when people are sick and during the cold and flu season, many East Asian cultures, including South Korea, use mask-wearing. What is considered a threat to freedom by some Americans is a preventive action and community obligation in this example. This, along with many other cultural differences, is insightful in understanding their ability to contain the virus.

“These differences are deeply seeded in the values of a culture. However, there is hope for the U.S. and other individualistic cultures in recognizing and adopting these community-centered approaches. Our mindset needs to be revolutionized with the help of federal and local assistance: mandating masks, passing another stimulus package, contact tracing, etc… However, these measures will be unsuccessful unless everyone participates for the good of a community.”

A published op-ed by Madison Szabo ’23 , Caitlyn Ferrante ’23 ran in the Two Rivers Times . The piece is titled “ Anxiety and Aspiration: Analyzing the Politicization of the Pandemic .”

John Lee ’21 and Taylor Goodman-Leong ’21 have published their op-ed titled “ Reassessing the media’s approach to COVID-19 ” in Weekly Monday Cafe 24 (Page 2).

An essay by Eleanor Raab ’21 and Elizabeth Nefferdorf ’22 titled “ Preventing the Next Epidemic ” was published in The Almanac .

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• School Education /

Essay On Covid-19: 100, 200 and 300 Words

• Updated on  
• Apr 30, 2024

COVID-19, also known as the Coronavirus, is a global pandemic that has affected people all around the world. It first emerged in a lab in Wuhan, China, in late 2019 and quickly spread to countries around the world. This virus was reportedly caused by SARS-CoV-2. Since then, it has spread rapidly to many countries, causing widespread illness and impacting our lives in numerous ways. This blog talks about the details of this virus and also drafts an essay on COVID-19 in 100, 200 and 300 words for students and professionals. 

Table of Contents

• 1 Essay On COVID-19 in English 100 Words
• 2 Essay On COVID-19 in 200 Words
• 3 Essay On COVID-19 in 300 Words
• 4 Short Essay on Covid-19

Essay On COVID-19 in English 100 Words

COVID-19, also known as the coronavirus, is a global pandemic. It started in late 2019 and has affected people all around the world. The virus spreads very quickly through someone’s sneeze and respiratory issues.

COVID-19 has had a significant impact on our lives, with lockdowns, travel restrictions, and changes in daily routines. To prevent the spread of COVID-19, we should wear masks, practice social distancing, and wash our hands frequently. 

People should follow social distancing and other safety guidelines and also learn the tricks to be safe stay healthy and work the whole challenging time. 

Also Read: National Safe Motherhood Day 2023

Essay On COVID-19 in 200 Words

COVID-19 also known as coronavirus, became a global health crisis in early 2020 and impacted mankind around the world. This virus is said to have originated in Wuhan, China in late 2019. It belongs to the coronavirus family and causes flu-like symptoms. It impacted the healthcare systems, economies and the daily lives of people all over the world. 

The most crucial aspect of COVID-19 is its highly spreadable nature. It is a communicable disease that spreads through various means such as coughs from infected persons, sneezes and communication. Due to its easy transmission leading to its outbreaks, there were many measures taken by the government from all over the world such as Lockdowns, Social Distancing, and wearing masks. 

There are many changes throughout the economic systems, and also in daily routines. Other measures such as schools opting for Online schooling, Remote work options available and restrictions on travel throughout the country and internationally. Subsequently, to cure and top its outbreak, the government started its vaccine campaigns, and other preventive measures. 

In conclusion, COVID-19 tested the patience and resilience of the mankind. This pandemic has taught people the importance of patience, effort and humbleness. 

Also Read : Essay on My Best Friend

Essay On COVID-19 in 300 Words

COVID-19, also known as the coronavirus, is a serious and contagious disease that has affected people worldwide. It was first discovered in late 2019 in Cina and then got spread in the whole world. It had a major impact on people’s life, their school, work and daily lives. 

COVID-19 is primarily transmitted from person to person through respiratory droplets produced and through sneezes, and coughs of an infected person. It can spread to thousands of people because of its highly contagious nature. To cure the widespread of this virus, there are thousands of steps taken by the people and the government. 

Wearing masks is one of the essential precautions to prevent the virus from spreading. Social distancing is another vital practice, which involves maintaining a safe distance from others to minimize close contact.

Very frequent handwashing is also very important to stop the spread of this virus. Proper hand hygiene can help remove any potential virus particles from our hands, reducing the risk of infection. 

In conclusion, the Coronavirus has changed people’s perspective on living. It has also changed people’s way of interacting and how to live. To deal with this virus, it is very important to follow the important guidelines such as masks, social distancing and techniques to wash your hands. Getting vaccinated is also very important to go back to normal life and cure this virus completely.

Also Read: Essay on Abortion in English in 650 Words

Short Essay on Covid-19

Please find below a sample of a short essay on Covid-19 for school students:

Also Read: Essay on Women’s Day in 200 and 500 words

to write an essay on COVID-19, understand your word limit and make sure to cover all the stages and symptoms of this disease. You need to highlight all the challenges and impacts of COVID-19. Do not forget to conclude your essay with positive precautionary measures.

Writing an essay on COVID-19 in 200 words requires you to cover all the challenges, impacts and precautions of this disease. You don’t need to describe all of these factors in brief, but make sure to add as many options as your word limit allows.

The full form for COVID-19 is Corona Virus Disease of 2019.

Related Reads

Hence, we hope that this blog has assisted you in comprehending with an essay on COVID-19. For more information on such interesting topics, visit our essay writing page and follow Leverage Edu.

Simran Popli

An avid writer and a creative person. With an experience of 1.5 years content writing, Simran has worked with different areas. From medical to working in a marketing agency with different clients to Ed-tech company, the journey has been diverse. Creative, vivacious and patient are the words that describe her personality.

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• Open access
• Published: 29 May 2021

Effective public health measures to mitigate the spread of COVID-19: a systematic review

• Imen Ayouni 1 ,
• Jihen Maatoug 1 ,
• Wafa Dhouib 1 ,
• Nawel Zammit 1 ,
• Sihem Ben Fredj 1 ,
• Rim Ghammam 1 &
• Hassen Ghannem 1  

BMC Public Health volume  21 , Article number:  1015 ( 2021 ) Cite this article

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In December 2019, a novel coronavirus (2019-nCoV) was recognized in Wuhan, China. It was characterised by rapid spread causing a pandemic. Multiple public health interventions have been implemented worldwide to decrease the transmission of the 2019 novel coronavirus disease (COVID-19). The objective of this systematic review is to evaluate the implemented public health interventions to control the spread of the outbreak of COVID-19. Methods: We systematically searched PubMed, Science Direct and MedRxiv for relevant articles published in English up to March 16, 2021. We included quasi experimental studies, clinical trials, cohort studies, longitudinal studies, case-control studies and interrupted time series. We included the studies that investigated the effect of the implemented public health measures to prevent and control the outbreak of 2019 novel coronavirus disease (COVID-19).

The database search using the predefined combinations of Mesh terms found 13,497 studies of which 3595 in PubMed, 7393 in Science Direct 2509 preprints in MedRxiv. After removal of the duplicates and the critical reading only 18 articles were included in this systematic review and processed for data extraction.

Conclusions

Public health interventions and non-pharmaceutical measurements were effective in decreasing the transmission of COVID-19. The included studies showed that travel restrictions, borders measures, quarantine of travellers arriving from affected countries, city lockdown, restrictions of mass gathering, isolation and quarantine of confirmed cases and close contacts, social distancing measures, compulsory mask wearing, contact tracing and testing, school closures and personal protective equipment use among health workers were effective in mitigating the spread of COVID-19.

Peer Review reports

Introduction

In the twenty-first century, two highly pathogenic human coronaviruses (HCoVs) severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) emerged from animal reservoirs to cause global epidemics. In December 2019, yet another pathogenic HCoV, 2019 novel coronavirus (2019-nCoV), was recognized in Wuhan, China, and has caused serious illness and death [ 1 ]. This novel coronavirus is characterised by rapid spread and high contagiousness [ 2 ] which caused a pandemic as it was spreading rapidly between and within the countries. As of 18 March 2021 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused more than 121.8 million cases and 2.69 deaths [ 3 ] affecting 221 countries and territories. Since the beginning of the COVID-19 pandemic several public health interventions have been implemented worldwide to reduce the transmission of the SARS-CoV-2. In previous experiences, like the 1918–19 H1N1 influenza pandemic where no treatments or vaccines were available to treat or prevent the disease multiple non-pharmaceutical interventions were successful at reducing case numbers and have shown to be effective when implemented early in the epidemic. Those interventions include travel bans and restrictions, schools and workplace closures, isolating infected persons, quarantine of exposed persons, social distancing and cancellation of mass gathering events. Those interventions have shown to be effective ways to respond to the outbreak when implemented early in the epidemic [ 4 , 5 , 6 , 7 , 8 , 9 ]. However the effectiveness of those interventions whether applied alone or simultaneously still unclear and results from previous modelling studies are inconsistent [ 10 ].

Within this systematic review we aimed to evaluate the public health interventions and the non-pharmaceutical control measures that have been implemented worldwide to mitigate and control the spread of the outbreak of 2019 novel coronavirus disease (COVID-19).

Search strategy and selection criteria

We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 11 ]. The protocol of this systematic review was published on PROSPERO (registration number CRD42020196018). Given the nature of this research study no approval by an institutional review board was necessary. We systematically searched PubMed, Science Direct and MedRxiv for relevant articles published in English up to March 16, 2021 using the following combinations of terms in PubMed: (((“public health”[MeSH Terms]) OR “preventive medicine”[MeSH Terms])) AND “covid 19”[MeSH Terms]; (health knowledge, attitudes, practice [MeSH Terms]) AND covid 19[MeSH Terms]; (((“covid 19”[MeSH Terms]) AND (“epidemiology”[MeSH Terms])) OR (public health interventions [Title/Abstract])) OR (epidemiological assessment [Title/Abstract]); (((“covid 19”[MeSH Terms]) AND (“social distancing”[Title/Abstract])) OR (“quarantine”[MeSH Terms])) OR (“isolation”[Title/Abstract]); (“covid 19”[MeSH Terms]) AND (“contact tracing”[MeSH Terms]); (“covid 19”[MeSH Terms]) AND (“lockdown”[Title/Abstract]). In Science Direct and MedRxiv we used the following terms: “Public Health measures” and “covid-19”.

Study eligibility and quality assessment

We included articles published only in English language up to March 16, 2021, clinical trials, quasi experimental studies, cohort studies, longitudinal studies, case-control studies, and interrupted time series. The studies that investigated the effect of the non-pharmaceutical interventions such as social distancing, lockdown, quarantine, mobility and travel restrictions, border control measures, contact tracing, isolation of cases that have been implemented to mitigate, prevent and control the outbreak of 2019 novel coronavirus disease (COVID-19). We excluded articles published in a language other than English; narrative literature reviews, policy reviews, case studies, case reports, case series, cross-sectional studies, ecological studies, commentaries, editorials, letters, point of views, simulation studies, modelling studies, prediction studies, qualitative studies,systematic reviews and meta-analysis.

The database search was conducted by one author (AI) who did the tiles and abstracts screening in order to identify the eligible studies for full text review with referral to (MJ) and (DW). Both authors (AI, DW) did the full text review of the studies that potentially met eligibility criteria and checked their relevance with referral to a third author (MJ) in case of discordance. Any discrepancy between the reviewers was resolved by discussion.

Data analysis

Two authors (AI, DW) did the data extraction using a standardized form to collect the relevant data from each article. The form included study identification features (authors, article title, country of origin), study characteristics (aim of the study, study design), characteristics of the studied population, public health interventions that has been implemented (description of the intervention(s) and control(s) if applicable), outcomes and authors’ conclusions. The included studies were evaluated for quality and risk of bias using the Effective Public Health Practice Project (EPHPP) quality assessment tool quantitative studies [ 12 ]. All studies were independently assessed for quality by two reviewers (AI, DW), with disagreements resolved by discussion until full consensus was reached with referral to (MJ) and (ZN). Level of evidence and grade of recommendation of the included studies were assessed according to the Scottish Intercollegiate Guidelines Network (SIGN) system [ 13 ].

The database search in PubMed and Science Direct using the predefined combinations of Mesh terms found 13,497 studies of which 3595 in PubMed, 7393 in Science Direct 2509 preprints in MedRxiv. After removal of the duplicates 12,433 articles remained. During the screening stage one article was excluded as it was retracted and 12,139 records were excluded on basis of title and abstract. After the critical reading of the 293 remaining articles, 275 articles were excluded seeing that they didn’t meet the eligibility criteria and only 18 articles were included in this systematic review and processed for data extraction. Fig.  1 summarized the described outcomes. The characteristics of the included studies and the main results were summarized Table  1 including the following items: authors, country, study design, objective, methods and main outcomes. For the quality assessment results the quality of 14 (77.77%) included studies [ 14 , 15 , 16 , 19 , 20 , 21 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 31 ] was moderate, the quality of two studies [ 18 , 22 ] was strong and the quality was weak for the two remaining studies [ 17 , 30 ] (Table  2 ). As for the results of the level of evidence and grade of recommendation assessment, six studies had low level of evidence and low grade of recommendation [ 16 , 17 , 19 , 21 , 24 , 30 ]. Ten studies had moderate level of evidence and low grade of recommendation [ 14 , 15 , 20 , 22 , 23 , 25 , 26 , 27 , 28 , 29 ], one study had moderate level of evidence and moderate grade of recommendation [ 18 ] and only one study had high level of evidence and high grade of recommendation [ 31 ] (Table  3 ). Three studies [ 16 , 22 , 26 ] have found that travel entry restrictions and bans, borders control measures and quarantine of travellers especially the ones arriving from affected countries along with other interventions was effective in reducing the spread of COVID-19. Seven studies [ 14 , 15 , 23 , 24 , 27 , 30 , 31 ] have shown that city lockdown, stay at home orders, traffic suspension and restrictions of mass gathering are strongly associated with reduced growth rate of COVID-19 confirmed cases and reduction in the epidemic growth. Moreover in their study Salvatore M et al. [ 23 ] found that lockdown was partly effective due to state level variations which should be considered in implementing lockdown. Adding to that Meo SA et al. [ 24 ] demonstrated that lockdown alone will not be effective unless it is implemented with other interventions such as social distancing and community wide mask wearing and in their quasi experimental study Kepp KP et al. [ 31 ] suggested that efficient infection surveillance and voluntary compliance may make full lockdowns unnecessary at least in some circumstances. Six studies [ 14 , 15 , 16 , 18 , 25 , 26 ] found that identification of cases with isolation, quarantine of close contacts adding to home quarantine have been effective in suppressing transmission of COVID-19. Social and physical distancing measures have been proven in eight of the included studies [ 14 , 16 , 17 , 20 , 21 , 22 , 28 , 29 ] to decrease the transmission of COVID-19. Thu TPB et al. [ 20 ] showed in their study that the time of promulgating the social distancing measures partly influences the intervention outcomes, adding to that population densities, crowding and socio-economic variables as it was suggested by Krishnamachari B et al [ 29 ] Three studies [ 14 , 19 , 26 ] showed that compulsory mask wearing and community wide masking may contribute to the control of COVID-19 when they are implemented with other non-pharmaceutical control measures. In addition to that three studies [ 16 , 18 , 19 ] demonstrated that testing in conjunction with active case finding and contact tracing especially when implemented with isolation of cases and close contacts and social distancing are effective in reducing the transmission of COVID-19 and particularly important in maintaining suppression. Two studies [ 16 , 17 ] suggested that school closures together with the restrictions of mass gathering and physical distancing measures may have an effect in reducing the transmission of SARS-COV-2.Pan A et al [ 14 ], found in their study conducted in Wuhan, China that the rate of cases among health workers was substantially higher than in the general population in the period with there is no strong public health interventions which indicated a high risk of nosocomial infections and which might be inadequate use of personal protective equipment and lower awareness. However after increasing awareness and wider use of personal protective equipment adding to hospital-level prevention and management in parallel with the implementation of strong public heath interventions the rate of confirmed cases quickly decreased and furthermore no new case were reported among local health workers which prove that protecting heath care workers is an important measure in controlling an outbreak of a high transmissible infectious disease. Finally Zeng K et al. [ 26 ] and Seong H et al. [ 21 ] suggested that early community mask wearing and timely border control interventions using modern digital tools in addition to early and timely measures with strengthened social distancing interventions should be implemented to suppress and control the COVID-19 pandemic effectively.

Study selection

We found that public health interventions and non-pharmaceutical control measures were effective in reducing the transmission of COVID-19 and were associated with reduced epidemic growth. The identified studies showed that travel restrictions, borders measures, quarantine of travellers arriving from affected countries, city lockdown, restrictions of mass gathering, isolation and quarantine of confirmed cases and close contacts, social distancing measures, compulsory mask wearing, contact tracing and testing, school closures and personal protective equipment use among health workers were effective in mitigating the spread of COVID-19 with varying degrees. Our results are in line with the findings of other studies [ 32 , 33 , 34 ] that demonstrated that public health measures and non-pharmaceutical control strategies are effective in mitigating the current pandemic of COVID-19 and in some countries aggressive and extreme interventions are probably needed to bring the epidemic under control and to prevent very large number of deaths and excess hospitals capacities.

Travel and entry restrictions, borders measures and quarantine of travellers arriving from affected countries were effective in controlling the spread of infection caused by SARS-CoV 2. Those interventions have been shown to be effective as well in other studies [ 6 , 35 ], which suggest that travel restrictions and border control measures including surveillance targeting inbound travellers from affected countries and 14-day quarantine for arriving passengers adding to other public health interventions were associated with a stabilization of case numbers.

City lockdown, restriction of mass gathering physical distancing and stay at home policies has been shown to be effective as well in reducing the spread of SARS-CoV2 in the current study. Further studies support these findings and showed that lockdown measurements and stay at home orders were efficient in controlling and slowing down the spread of the epidemic [ 36 , 37 , 38 , 39 ] were strongly associated with the containment of COVID-19 [ 40 ]. A rapid review of modelling studies [ 41 ] found that quarantine is crucial in decreasing incidence and mortality in the pandemic of COVID-19. Moreover in order to ensure effectiveness it is very important implement quarantine measures especially in combination with other public health interventions at the early stage of the epidemic. Adding to that, in their study Marco Vinceti et al [ 42 ] showed the less rigid lockdown measurements led to an insufficient reduction in transmission to reverse the outbreak and with a tighter lockdown mobility and person to person transmission decreased enough to bring down transmission straight off below the level required to counteract spread of SARS-CoV-2 infection. In addition to that physical distancing strategies and restriction of human mobility [ 43 , 44 ] has been showed to have a notable effect on controlling the spread of the COVID-19 outbreak.

Isolation and quarantine measures of contacts and close contacts adding to contact tracing are crucial to control the outbreak of COVID-19 and reduce the human to human transmission. Those results are consistent with the findings of other studies [ 45 , 46 , 47 , 48 ] which indicate successful contact tracing and isolation of cases and close contacts are highly important to control the outbreak and to ensure a lower reproduction number below 1. These interventions might be more effective if combined with other measures such as physical distancing, self-isolation and testing. Testing is a key intervention in mitigating the spread of COVID-19 especially when it is applied in conjunction with tracing and isolation of cases and close contacts [ 49 ].

Compulsory mask wearing and community wide masking policies are essential in controlling the pandemic of COVID-19. Authors of a rapid systematic review [ 50 ] on the efficacy of face masks suggest that masking wearing could be beneficial in the context of COVID-19 outbreak especially universal community mask use and in the health care settings as well. Findings from a systematic review and meta-analysis [ 51 ] showed that mask wearing by health workers and non-health workers and in the general community is and efficient in preventing the infection by SARS-CoV2. Another study [ 52 ] showed that wearing masks in public is crucial as a preventive measure to ensure a significant reduction in the daily infected cases. In addition to that a prospective cohort study [ 53 ] found that the risk of infection by SARS-CoV-2 is increase among frontline health workers, therefore adequate strategies should be implemented to ensure the availability of personal protective equipments in order to protect health workers from COVID-19. Moreover timing is very important while implementing non-pharmaceutical interventions which should be initiated early when the numbers of COVID-19 cases are low as it was demonstrated in an observational study conducted by Qureshi A I et al [ 54 ]

School closures had been found to be effective in reducing the transmission of COVID-19, recently this intervention has been widely discussed; some studies [ 55 , 56 ] found that school closures were associated with a reduction in the transmission of COVID-19 and in the mortality rate as well. However, other studies [ 57 , 58 ] showed that school closures don’t have any mitigating impact on the transmission of COVID-19 as children are likely to be asymptomatic and they don’t seem to be greater transmitters in comparison with adults.

Further studies [ 59 , 60 ] found additional tools that help prevent and control the COVID-19 pandemic such as internet hospitals and virtual care which presents a promising potential in the control of the COVID-19 outbreak as they are capable of reducing the emergency room visits, reducing the risk of nosocomial cross-infection by treating patients remotely, prevent the shortage of health care resources and promote personal prevention measures such as social distancing, mask wearing and hand hygiene. A systematic review [ 61 ] showed that telehealth is capable of minimizing the risk of COVID-19 transmission by decreasing the physical contacts adding to providing continuous community care.

This systematic review has several limitations, the included studies have heterogeneous methodology and most of them lack a control group and a vigorous study design. Although most of the included studies have moderate quality and for the remaining studies; two studies have low quality and only two studies have strong quality. Also, most of the included studies have moderate level of evidence and low grade of recommendation, six studies have low level of evidence and low grade of recommendation, only one study has moderate level of evidence and grade of recommendation and only one study as well has high level of evidence and grade of recommendation. In addition to that most of the public health interventions are implemented simultaneously or within a short period of time which means that it is difficult to evaluate the effect of each intervention alone accurately, consequently we can either underestimate or overestimate their impact on the COVID-19 pandemic. Future research studies which have rigorous methodology especially experimental and quasi experimental studies are needed to properly evaluate the outcomes of these public health interventions and non-pharmaceutical measures.

With no effective treatment and vaccine against SARS-CoV-2, public health measures and non-pharmaceutical interventions are vital to reduce the infection and mortality rate. Some interventions are not efficient enough when implemented alone and could not contain the outbreak, thus, depending on the country and the phase of the epidemic multiple interventions are needed to be applied together in order to bring the outbreak under control.

Availability of data and materials

Protocol of this systematic review could be found at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=196018

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Ayouni, I., Maatoug, J., Dhouib, W. et al. Effective public health measures to mitigate the spread of COVID-19: a systematic review. BMC Public Health 21 , 1015 (2021). https://doi.org/10.1186/s12889-021-11111-1

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COVID-19 vaccination, preventive behaviours and pro-social motivation: panel data analysis from Japan

• Eiji Yamamura   ORCID: orcid.org/0000-0002-5903-3582 1 ,
• Yoshiro Tsutsui 2 &
• Fumio Ohtake 3  

Humanities and Social Sciences Communications volume  11 , Article number:  476 ( 2024 ) Cite this article

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The COVID-19 vaccine reduces infection risk; even if one contracts COVID-19, the probability of complications such as death or hospitalisation is lower. However, vaccination may prompt people to decrease preventive behaviours, such as staying home, washing hands, and wearing a mask. Therefore, if vaccinated people pursue only self-interest, the vaccine’s effect may be lower than expected. However, if vaccinated people are pro-social (motivated toward benefits for the whole society), they might maintain preventive behaviours to reduce the spread of infection. We conducted 26 surveys almost once a month from March 2020 (the early stage of COVID-19) to September 2022 in Japan. By corresponding with identical individuals, we independently constructed the original panel data ( N  = 70,908). Based on the data, we identified the timing of the second vaccine shot and compared preventive behaviours before and after vaccination. We investigated whether second-shot vaccination correlated with changes in preventive behaviours. Furthermore, we explored whether the vaccination effect differed between the older and younger groups. We then investigated the effect of pro-social motivation on preventive behaviours. Major findings are as follows: (1) Being vaccinated led people to increase preventive behaviours, such as mask-wearing by 1.04 (95% confidence intervals [Cis]: 0.96–1.11) points, and hand hygiene by 0.34 (95% CIs: 0.30–0.38) points on a 5-point scale. (2) Vaccinated people under 65 are less likely to stay home. (3) People with pro-social motivation to be vaccinated are more likely to maintain prevention than those not so motivated; on a 5-point scale, the difference is 0.08 (95% CIs: 0.01–0.15) points for mask-wearing and 0.05 (95% CIs: 0.001–0.10) points for hand hygiene. After vaccination, the opportunity cost of staying home outweighs its benefits, and people are less inclined to stay at home. This effect is lower in older people who are at a higher risk of serious illness. The opportunity cost of wearing masks and hand hygiene is lower than that of staying home, and the benefit persists after vaccination if people are motivated to maintain these behaviours for others’ well-being.

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Introduction.

Various preventive behaviours were required during the COVID-19 pandemic, especially in the early stages, because vaccines against COVID-19 had not been developed. Preventive behaviours can be considered a kind of public good that is not sufficiently supplied through market mechanisms in which people pursue self-interest (Cato et al., 2022 , 2020 ). Mitigating the pandemic necessitated the collective action of citizens. However, according to the Peltzman effect, people tend to increase their risky behaviours if safety measures are implemented (Trogen and Caplan, 2021 ).

Since 2021, vaccines against COVID-19 have been distributed worldwide and have played a vital role in curbing the spread of COVID-19. Newly reported cases have decreased in countries where vaccines have been rapidly adopted (World Health Organization, WHO, 2022 ). If rational, people tend to engage in risky behaviours when security measures are mandated (Peltzman, 1975 ). In economic terms, this is considered a moral hazard. An empirical question arises as to how the spread of the vaccine influences preventive behaviours (Zhang et al., 2021a ; Si et al., 2021 ). As a result of the reduction in the risk of COVID-19 infection, risk-taking behaviours increase and preventive behaviours such as staying home, wearing masks, and washing hands change (Zhang et al., 2021b ; Hossain et al., 2022 ). However, some studies show no clear evidence that vaccinated people have decreased preventive behaviours compared to those who have not been vaccinated (Zhang et al., 2021a ; Wright et al., 2022 ).

The influence of vaccination on preventive behaviours may vary according to the type of behaviour (Corea et al., 2022 ). A study found that, in China, vaccination reduced the frequency of hand hygiene but did not change mask-wearing (Si et al., 2021 ). This study aimed to explore the mechanisms that prevent vaccinated people from developing preventive behaviours. To this end, we investigated how preventive measures can be pro-socially motivated based on altruism and social solidarity (Cheng et al., 2022 ).

We investigated whether preventive behaviours changed after vaccination using monthly individual-level panel data. Furthermore, we examined how the influence of vaccination on preventive behaviours differed according to age and pro-social motivation.

Data and methods

Data collection.

COVID-19 vaccination was not developed when we initially planned to collect the data. Inevitably, the sampling method was not specifically designed to investigate how COVID-19 vaccination changes preventive behaviours. However, prior to starting the survey, we planned to construct panel data by pursuing individual behavioural changes through repeated surveys. Then, in response to the real situation after the development of COVID-19, we added a question about vaccination.

We commissioned the research company INTAGE, Inc. to conduct an online survey because of their experience and reliability in academic research. The first wave of queries was conducted from 13 March to 16 March 2020, and 4,359 observations were recorded. Participants registered with the INTAGE were recruited for this study. The participation rate was 54.7%. The sampling method was designed to collect representatives of the Japanese adult population in terms of educational background, sex, and residential area. For this purpose, INTAGE recruited participants for a survey of preregistered individuals. However, individuals aged 17 years and below were too young to be registered with INTAGE, and individuals over 78 years of age could not be collected because they were unlikely to use the Internet. Inevitably, the sample population was restricted to 18–78 years, and participants were randomly selected to fill the pre-specified quotas. INTAGE provided monetary incentives to participants upon completion of the study.

Internet surveys were conducted 26 times (‘waves’) almost every month with identical individuals to construct the panel data. The exceptional period was July-September 2020 when the survey could not be conducted because of a shortage of research funds. We resumed the survey after receiving additional funds in October 2020. Vaccination was implemented in April 2021; therefore, the data cover the periods before and after the implementation of vaccination.

Respondents from the first wave were targeted in subsequent waves to record how some respondents changed their behaviour during the COVID-19 pandemic. From the 12th wave of surveys, we asked about the experience of getting the first and second shots of vaccination. Accordingly, the data allowed us to compare the preventive behaviours of identical individuals against COVID-19 before and after vaccination. During the study period, some identical respondents were dropped from the study sample because some stopped taking the surveys, while others did not take the surveys at all. Furthermore, the sample was restricted to those who were completely vaccinated after obtaining a second shot. Therefore, some respondents who continuously participated in the first wave were excluded from this study’s sub-sample. In this way, we compared their behaviours before and after vaccination. Eventually, the number of identical individuals was reduced from 4359 to 3019 and the total number of observations used in this study was 70,979.

The survey questionnaire contained basic questions about demographics such as birth year, gender, and educational background. These characteristics were observed at different time points. The surveys were conducted 26 times between March 2020 and September 2022. During the study period, conditions such as the spread of infection and policies against COVID-19 changed drastically. Table 1 lists the key variables used in the regression estimations. As outcome variables, the respondents were asked questions concerning preventive behaviours, such as:

‘Within a week, to what degree have you practised the following behaviours? Please answer on a scale of 1 (I have not practised this behaviour at all) to 5 (I have completely practised this behaviour).’

Staying home

Mask wearing

Wash my hands thoroughly

The answers to these questions served as proxies for the following variables for preventive behaviours: staying home, frequency of hand hygiene, and degree of wearing masks. Larger values indicate that respondents are more likely to engage in preventive behaviours. Further, the motivation to get a shot of COVID-19 vaccination was asked in the following question: ‘Did you get the shot to decrease the spread of COVID-19 infection?’

We also asked about the subjective probability of contracting COVID-19 and their perceptions of the severity of COVID-19. We asked whether they received a second shot of the vaccine because vaccination was effective only after completing the second shot. The latter question was included in the questionnaire from the 12th wave, conducted in May 2021, directly after the vaccine was introduced in Japan. The question was included until the 18th wave in November 2021, when most participants in the sample completed the second shot. The question was then excluded from the questionnaire, starting with the 19th wave of January 2022. In the 12th wave, we also added questions about the motivation to get the vaccination. We defined a proxy for ‘pro-social’ motivation based on the following question:

‘In deciding whether to get the shot of the COVID-19 vaccine, is it important that it prevents the spread of COVID-19?’

The question had five choices: 1 (strongly disagree) to 5 (strongly agree).

Most of the respondents chose ‘5’. Therefore, the proxy dummy, ‘Pro-social’, is defined as 1 if a respondent chooses 5; otherwise, it is 0. On the basic assumption of classical economics, individualistic persons are motivated to pursue self-interests and do not consider others’ interests. Human beings who consider others’ interests are out of accordance with this assumption. The spread of COVID-19 depends on the degree that surrounding people were infected with the virus. If persons are motivated to prevent the spread of COVID-19, their personality can be considered prosocial.

We pursued identical respondents from the first-wave survey to the 26th wave for 30 months, although some of the respondents quit the survey. This study aimed to explore how the preventive behaviours of identical persons changed before and after vaccination. Therefore, we limited the sample to those who completed the second shot by the 18th wave and then pursued identical persons until the 26th wave on September 2022. We used panel data containing 3,019 individuals, covering 26 time points from March 2021 to September 2022.

We used a fixed-effects (FE) model regression based on panel data. The FE model is a linear regression model widely used in economics. The estimation result using an FE model is equivalent to the result of a linear regression model with dummies for individuals frequently included in each period (Wooldridge, 2009 ; Hsiao, 1986 ; Baltagi, 1995 ). In this study, 3019 dummies were included to control for individuals’ characteristics that did not change during the period, such as gender, educational background, and childhood experience. Hence, 3019 confounders were included, reflecting differences between individuals. Therefore, the estimated results for the time-invariant confounders could not be obtained. Even if various time-variant confounders are included, unobserved individual characteristics cannot be identified. This inevitably results in omitted variable biases (Wooldridge, 2009 ; Baltagi, 1995 ). For instance, an increasing trend in the number of newly infected individuals has been observed throughout Japan. This effect is common among all residents of Japan and has changed over time. This can be regarded as a time-fixed effect and can be controlled by including time-period dummies. This study included 25 time-period dummies when one base period was fixed. However, some variables changed not only over time but also between individuals. Examples include proxy variables for preventive behaviours, which are outcome variables, or the number of newly infected persons and deaths due to COVID-19 in residential areas. Furthermore, the timing of obtaining the second vaccine shot changes over time and between individuals; therefore, the dummy for vaccination is included in the estimated function as a confounder.

As explained, we controlled not only for unobservable individual fixed effects but also for unobservable time-fixed effects. This type of FE model is called a two-way error component regression model (Baltagi, 1995 ). This study focused on the correlation between vaccination and preventive behaviours. The statistical software used in this study was Stata/MP 15.0 multiprocessor (StataCorp, LLC.

The estimated function of an FE model takes the following form:

where Y it represents the outcome variables for individual i and wave t , respectively. X is vector of various control variables such as ‘Probability COVID-19’, ‘Severity COVID-19’, ‘Number of people infected with COVID-19,’ and ‘Number of deaths caused by COVID-19’, while B is vector of their coefficient. Time-invariant individual-level fixed effects are represented by m i . Furthermore, k t represents the effects of different time points controlled by 25 wave dummies, where the first wave is the reference group. k t captures the various shocks that occur simultaneously throughout Japan at each time point. Y includes preventive behaviours captured by three proxy variables: STAYING HOME, HAND HYGIENE , and WEARING MASK . These outcome variables are discrete-ordered variables ranging from 1 to 5. Larger values of these variables can be interpreted as indicating that respondents are more likely to exhibit preventive behaviour. As explained in the next subsection, the mean value of the proxy variable for the three preventive behaviours varied widely. Hence, standardised value is calculated and used for FE model estimations. In the same specification, we conduct three separate estimations and the regression parameters are denoted as α. The error term is denoted by u it . A simple FE linear regression model was used in this study.

The key confounder is the vaccination dummy; VACCINE is 1 if respondents have completed the second shot of the COVID-19 vaccine; otherwise, 0. People are obliged to get a second shot within a month of the first shot to make the vaccine effective. Hence, in the sample, there was hardly any time lag between the first and second shots because the survey was conducted every month after the vaccine was approved. There were two age groups: young age (AGE_25) and middle working age (AGE_26_64). The senior group was used as the reference group. PRO_SOCIAL is a dummy variable that captures the pro-social motivation to be vaccinated. The mean value of PRO_SOCIAL is 0.86, which shows that 86% of people have pro-social motivation.

To explore how the effect of vaccination differs according to age groups, we incorporate ‘Vaccine’ interacted with age group dummies such as ‘Ages below 25’ and ‘Ages 26–64’;

Age group dummies are defined by individual i ’s age in the first wave and hence, do not change during the study period. The coefficient cannot be calculated because the FE estimation approves its effect. However, interaction terms such as Vaccine it × Ages below 25 i and Vaccine it × Ages 26–64 i can be calculated. The reference age group was those over 65 years. Interpretation of interaction terms is as follows: For example, β 2 , coefficient of Vaccine it × Ages below 25, is negative if young people below 25 years are less likely to display preventive behaviour than those over 65 years.

Next, we also investigate how the effect of vaccination depends on pro-social characteristics by incorporating ‘Vaccine’ interaction with ‘Pro-social’ dummy;

Similar to the interaction term between vaccine and age groups, ‘Pro-social i ’ is asked in the first wave and, therefore, does not vary throughout the studied period. If γ 2 , the coefficient of Vaccine it \(\times\) Pro-social i shows a positive sign, then pro-social people are more likely to exhibit preventive behaviour after vaccination than before vaccination.

Baseline estimations

Table 2 presents the basic statistics for the dataset. The mean values of ‘Wearing mask’ and ‘Hand hygiene’ are over 4, which are remarkably higher than that of ‘Staying home’. ‘Pro-social’ is 0.90, which shows that 90% of people have pro-social motivation. In other words, most Japanese people are pro-social and keep wearing masks and washing their hands.

Comparison of preventive behaviours before and after the second-shot vaccination. There was a distinct difference in the mean values between preventive behaviours. Hence, we calculated the standardised values of behaviours as follows:

where \({x}_{i}\) is individual i ’s value while \(\bar{x}\) is the mean value of all respondents. We calculate the standardised mean values of \(\hat{{x}_{i}}\) . The mean value \(\hat{{x}_{i}}\) is 0 a full sample is used. Vaccinated people become more (less) likely to display preventive behaviours than before being vaccinated if the mean value \(\hat{{x}_{i}}\) using a sub-sample of the post-vaccination period, is positive (negative).

Figures 1 – 3 compare the mean values of \(\hat{{x}_{i}}\) before and after the second shot of COVID-19 vaccination. Figure 1 shows that the mean values of \(\hat{{x}_{i}}\) is 0.02 before vaccination and −0.017 after, respectively. The difference was approximately 0.037 before and after vaccination and was statistically significant. Therefore, vaccination reduced stay-home behaviour by 3.7%.

Staying home behaviour.

Mask-wearing behaviour.

Hands washing behaviour.

In contrast, Figs. 2 and 3 illustrate that the mean values of \(\hat{{x}_{i}}\) were negative before and positive after vaccination. The difference in values before and after vaccination was statistically significant. The difference is approximately 0.065 in Fig. 2 , showing that vaccinated people become more likely to wear masks by 6.5% than before vaccination. The difference is approximately 0.035 in Fig. 3 , showing that vaccinated people become more likely to wash their hands by 3.5% than before vaccination.

To examine the effect of vaccination on preventive behaviours more closely, we see the results of the FE model estimation to control various variables and unobservable individual and time-fixed effects. The coefficient of confounders indicates marginal effects (ME), which are multiplied by 100 to easily interpret the results. We can interpret the ME of ‘Vaccination’ as the % change in preventive behaviours when compared with before vaccination.

Table 3 presents the estimation results for the baseline FE model. Here, we focus on key variables, although the estimation results of control variables are also presented. The effect of events is controlled by including time point dummies for the surveys. Timepoint dummies are shown as survey periods in Table 3 . ‘Vaccine’ shows a positive sign and is statistically significant at the 1% level, except for Column (1), where ‘Stay home’ is the outcome variable. The effects of ‘Vaccine’ are ME 22.7 (95% CI: 21.0–24.3) and ME 8.03 (95% CI: 7.10–8.95) in columns (2) and (3), respectively. Thus, people after vaccination are 22.7% more likely to wear masks than before and 8.0% more likely to wash their hands. People’s behaviours depend on the behaviours of others; hence, they follow social norms (Habersaat et al., 2020 ; Ohtake, 2022 ; Sasaki et al., 2022 ; van der Westhuizen et al., 2020 ). Peer pressure is stronger for wearing masks than for washing hands because surrounding people in a public place can more easily see whether one wears a mask than whether one washes one’s hands.

We interpreted the significant positive sign of ‘Vaccine’ as follows: The prevalence of vaccination is predicted to reduce preventive behaviour because the risk of infection or deaths due to COVID-19 became lower than before the emergence of the vaccine. In contrast, we found that preventive behaviour improved rather than remaining unchanged before and after vaccination. This is a kind of a paradox. One possible interpretation is that we considered an individual’s reaction to the subjective prediction about others’ behaviour. Individuals predict the prevalence of the vaccine to reduce others’ preventive behaviours. This might in turn increase the risk of COVID-19. Based on the prediction, an individual might improve his/her preventive behaviours.

Estimations with interaction-terms

In panel A, Tables 4 and 5 report the results of the model where the interaction terms are included. Panel B of Tables 4 and 5 show the results using sub-samples divided by age cohorts and the degree of ‘Prosocial’ behaviour to consider the results of Panel A from different angles. As below, we mainly interpret the results of Panel A, where the main results are provided.

The probability and seriousness of contracting COVID-19 differ according to age. COVID-19 is more likely lethal in adults 65 years and older than younger people (Wu and McGoogan, 2020 ; Koh et al., 2021 ). Mask-wearing by elderly people is motivated by their self-regarding risk preferences, whereas younger people are motivated by other-regarding concerns (Asri et al., 2021 ). We explored how the effect of COVID-19 vaccination on preventive behaviours differed between age groups. For this purpose, the interaction terms between ‘Vaccine’ and age groups (‘Ages below 25’ and ‘Ages 26–64’) were included as key confounders. The reference age group was those over 65 years. Panel A of Table 4 presents the results. We find a significant negative sign in ‘Ages below 25’ and ‘Ages 26–64’ in column (1), where ‘Stay home’ is the outcome variable. The effects of ‘Vaccine × Ages below 25’ and ‘Vaccine × Ages 26–64’ are ME −18.8% (95% CI: −23.0 to −14.5) and ME -10.3 (95% CI: −12.3 to −8.3). This means that those under 25 are less likely to stay home by 18.8% than those over 65, while those aged between 26 and 64 are less likely to stay home by 10.3% than those over 65. However, no differences in the effects of vaccination were observed when wearing masks and washing hands.

We investigated how pro-social motivation affects preventive behaviours. The interaction term between ‘Vaccine’ and ‘Pro-social’ was included as the key confounder. Panel A of Table 5 shows the significant positive sign of ‘Vaccine×Pro-social’ where ‘Wearing mask’ and ‘Hand hygiene’ are the outcome variables. The effects of ‘Vaccine × Pro-social’ are ME 2.44 (95% CI: 0.73–4.15) and ME 1.85 (95% CI: 0.39–3.31) on ‘Wearing mask’ and ‘Hand hygiene’, respectively. This suggests that pro-social persons are more likely than non-pro-social persons to wear masks and 2.4% and to wash their hands by 1.9%. Effects of ‘Vaccine’ are ME 20.5 (95% CI: 18.5–22.6) and ME 6.5 (95% CI: 4.9–8.0) on ‘Wearing mask’ and ‘Hand hygiene’, respectively. This is the effect of vaccination on the preventive behaviours of non-pro-social individuals. Considering the results jointly, pro-social persons are 20.5% more likely than non-pro-social persons to wear masks and 6.5% more likely to wash their hands. That is, for pro-social persons, the degree of the effects of vaccination on hand hygiene is more than twice as great as it is for wearing masks. Wearing masks and washing hands are different because the benefit of wearing a mask is more likely to depend on the situation. Wearing masks in open air is only marginally effective in mitigating pandemics (Javid et al., 2021 ). Pro-social vaccinated persons may consider the cost-benefit ratio of preventive behaviours and, therefore, place more importance on washing hands than wearing masks.

Implications

One of the main goals of this study was to explore the preventive behaviours of the COVID-19 vaccination in Japan. Further, we aimed to determine how pro-social motivation leads to differences in preventive behaviours after vaccination.

Peltzman argued that rational individuals engage in risky behaviours if security measures are mandated (Peltzman, 1975 ). As a whole, people stay home even after being vaccinated. However, there is a variation in staying-home behaviour. As expected, people under 65 years of age were more likely to go out than older people. In contrast, we found that individuals were more likely to wash and wear masks after vaccination. This is in line with the argument that preventive behaviours are considered an investment in public goods to mitigate the spread of COVID-19 (Cato et al., 2020 ). The motivation for vaccination for 90% of respondents is to mitigate the spread of infection in society. Most people are pro-socially motivated and, therefore, are more likely than others to wash their hands and wear masks after vaccination. However, the ‘Stay home’ behaviour of pro-social people is not different from that of others.

Staying home differs from wearing masks and washing hands when considering the cost-benefit aspects of preventive behaviours. Staying home leads people to sacrifice their vacation activities in the real world. Using economic terms, sacrifice is the ‘opportunity cost’ of staying home. They would stay at home if their benefits exceeded their costs. After vaccination, the opportunity cost of staying home was higher than the benefit. Accordingly, younger people were more likely to go out.

Both vaccination and preventive behaviours are considered public goods for coping with pandemics. As a result of vaccination, people tend to leave, which may reduce public goods. To compensate for this, vaccinated pro-social persons are more likely to be motivated to wear masks and wash their hands by considering the benefits to society. Other possible interpretations of the estimation results are related to the cost of vaccination, including the physical and psychological costs of side effects. From an economic viewpoint, the cost of vaccination can be considered the ‘sunk cost’—an investment already incurred that cannot be recovered. Due to sunk costs, vaccinated people continue to invest in public goods by strengthening their mask-wearing and hand hygiene behaviours.

Strengths of the study

Previous studies have not shown that individuals reduce preventive behaviours even after vaccination (Zhang et al., 2021a ; Wright et al., 2022 ; Corea et al., 2022 ). This is contrary to rational behaviour in terms of economics (Peltzman, 1975 ). However, no study has yet examined the underlying mechanisms. The strength of this study is that it provides evidence that pro-social motivation plays a vital role in enhancing mask-wearing and hand hygiene. This compensated for the decrease in staying home after getting the COVID-19 vaccination. This leads us to argue that people pro-socially make decisions by comparing the costs and benefits of preventive behaviours.

For aged persons, the benefit of staying home was greater than its cost even after being vaccinated. Meanwhile, for younger active persons, the cost of staying home was greater than its benefit, thus reducing their staying home. However, the risk of being infected with COVID-19 would increase if people were more likely to go out. Based on this prediction, people are motivated to engage in other preventive behaviours such as mask-wearing and hand hygiene partly because its cost is far lower than staying home.

Limitations of the study

This study has several limitations. First, we restrict the sample to those who received a second shot during the study period. This allowed us to compare the behaviour of identical individuals before and after vaccination. However, those who were not vaccinated seemed to differ from the respondents included in the sub-sample used for the estimations. Naturally, the results of this study may have been affected by selection bias. While the number of retired individuals has increased drastically in Japan, older people were less able to participate in the survey because of their reduced cognitive ability. Hence, the number of retired people included in the sample was far lower than that in the real setting of Japan, leading to selection bias.

Second, as shown in Table 2 , 90% of people are pro-social by definition in this study. As explained in the ‘Methods’ section, we define ‘Pro-social’ as respondents who chose ‘5’ among five choices because most of the respondents chose ‘5’. Therefore, in the definition, respondents who chose ‘1’, ‘2’, ‘3’, and ‘4’ are not ‘pro-social’ despite the wide variation between them. ‘Pro-social’ is arbitrarily defined. We obtain similar results to those reported in this study if we use linear variables varying from 1 to 5 as a proxy for ‘Pro-social’. Footnote 1 However, we did not obtain statistically significant results if ‘Pro-social’ is defined to choose ‘4’ or ‘5’. Footnote 2 In our interpretation, the number of respondents who chose ‘4’ is far smaller than those who chose ‘5’. Therefore, there is a significant gap in the characteristics between them.

According to the 2000 Population Census of Japan, foreign residents occupied only 2% of the population (Komatsu, 2022 ). Japan is a distinctly homogenous society compared with Western countries. This might be one of the reasons people have ‘Pro-social’ motivation to get a COVID-19 vaccine shot. It should be noted that the results of this study were obtained from a homogenous society. It is unknown whether these results can be generalised to a more heterogeneous society.

We employed an FE model to control for the time-invariant individual characteristics. Furthermore, as confounder variables, time-point dummies are used to control various time events throughout Japan, such as the declaration of the state of emergency and school closure, which influenced individuals’ behaviours and mental health (Yamamura and Tsutsui, 2021 , 2022 ). However, there seem to be factors that vary depending on time periods and individuals. Unfortunately, our model cannot control for these factors, which may cause omitted-variable biases.

It is valuable to scrutinise how preventive behaviours changed just after being vaccinated. However, we conducted the survey almost every month. Therefore, we could scrutinise the change of preventive behaviour immediately after getting the first shot only if the timing of the survey was conducted directly after getting ‘the first shot’. Further, we did not ask about the exact date of inoculation. Owing to the limitation of data, we could not investigate ‘what happened just after vaccination’.

Besides staying home, hand hygiene, and wearing a mask, as the World Health Organisation recommended, self-isolation and maintaining physical distance are also important preventive behaviours. However, we could not collect data on these preventive behaviours owing to the shortage of research funds. People were obliged to get the second shot three weeks after the first shot. In other words, the period between the first and second shots was so short that we could not gather sufficient data from those who got the first shot before getting second one. This study (1) was an Internet survey, (2) only included vaccinated participants, (3) only included those participating in the follow-up survey, and (4) excluded participants aged 78 or older. This resulted in selection bias. Hence, careful attention should be paid when interpreting the estimation results.

Conclusions

In some studies, individuals were unlikely to reduce preventive behaviours even after vaccination (Zhang et al., 2021a ; Wright et al., 2022 ; Corea et al., 2022 ). This cannot be explained by rational behaviour in terms of economics (Peltzman, 1975 ). However, to date, no studies have investigated the underlying mechanisms. This study contributes to the understanding of this mechanism by considering pro-social motivation.

On the one hand, vaccinated people under 65 years of age are less likely to stay home than older people. On the other hand, pro-social individuals were more inclined to wash their hands and wear masks after being vaccinated than before getting their second shot. These observations prove that vaccinated people continue to engage in preventive behaviours to invest in public goods to cease the COVID-19 pandemic.

Wearing masks in open air is only marginally effective in mitigating pandemics (Javid et al., 2021 ); this might result in over-investment in public goods. Owing to data limitations, we could not analyse the situation in which vaccinated people wore masks. It is necessary to determine how and to what extent the preventive behaviours of vaccinated people are effective in mitigating COVID-19.

Data availability

The data sets used or analysed during the current study are provided as supplementary files.

The results can be available upon request for the corresponding author.

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Acknowledgements

We would like to thank Editage ( http://www.editage.com ) for editing and reviewing this manuscript for the English language. This study was supported by Fostering Joint International Research B (Grant No.18KK0048) and Grant-in-Aid for Scientific Research S (Grant No. 20H05632) from the Japan Society for the Promotion of Science to YT and FO, respectively.

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Department of Economics, Seinan Gakuin University, Fukuoka, Japan

Eiji Yamamura

Faculty of Social Relations, Kyoto Bunkyo University, Uji, Japan

Yoshiro Tsutsui

Center for Infectious Disease Education and Research (CiDER), Osaka University, Suita, Japan

Fumio Ohtake

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Contributions

EY and FO conceptualised the study and analysed patient data. YT designed the panel survey and collected data. EY wrote the main text and created the tables for the original manuscript. All authors reviewed, edited, and approved the final manuscript. The authors are responsible for the errors.

Corresponding author

Correspondence to Eiji Yamamura .

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The authors declare no competing interests.

Ethics approval

This study was conducted with the ex-ante approval of the Ethics Committee of the Graduate School of Economics, Osaka University, and all methods were carried out in accordance with the relevant guidelines and regulations. The Principal Investigator is Prof. Ohtake. The ethics approval number of this study is R021014.

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Yamamura, E., Tsutsui, Y. & Ohtake, F. COVID-19 vaccination, preventive behaviours and pro-social motivation: panel data analysis from Japan. Humanit Soc Sci Commun 11 , 476 (2024). https://doi.org/10.1057/s41599-024-02979-6

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COVID-19: Prevention and control measures in community

Affiliations.

• 1 Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine,Yıldırım Beyazıt University,Ankara City Hospital, Ankara,Turkey
• 2 COVID-19 Advisory Committee of the Ministry of Health of Turkey
• PMID: 32293835
• PMCID: PMC7195988
• DOI: 10.3906/sag-2004-146

On January 30, 2020, the WHO declared the COVID-19 outbreak a public health emergency of international concern and, in March 2020, began to characterize it as a pandemic in order to emphasize the gravity of the situation and urge all countries to take action in detecting infection and preventing spread. Unfortunately, there is no medication that has been approved by the FDA, gone through controlled studies and demonstrated an effect on the virus for this global pandemic. Although there are cures for illnesses and developments made by leaps and bounds in our day, the strongest and most effective weapon that society has against this virus that is affecting not just health but also economics, politics, and social order, is the prevention of its spread. The main points in preventing the spread in society are hand hygiene, social distancing and quarantine. With increased testing capacity, detecting more COVID-19 positive patients in the community will also enable the reduction of secondary cases with stricter quarantine rules.

Keywords: COVID-19; community; prevention; quarantine; social distancing; Turkey.

This work is licensed under a Creative Commons Attribution 4.0 International License.

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Conflict of interest statement

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

Poster regarding important prevention measures…

Poster regarding important prevention measures for COVID-19, prepared by Turkish Ministry of Health.

Poster regarding hand washing, prepared…

Poster regarding hand washing, prepared by Turkish Ministry of Health.

Timeline for prevention and control…

Timeline for prevention and control measures in Turkey.

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Measures implemented in the school setting to contain the COVID-19 pandemic: a rapid review

This review provides insight into the effectiveness of measures implemented in the school setting to contain the COVID-19 pandemic.

While there are limitations to this review, the review demonstrates that a range of different measures can be effective at reducing COVID-19 transmission, especially when multiple interventions are implemented together. Importantly, the review demonstrates that schools can stay open (or reopen) safely when prevention measures are implemented effectively. The effectiveness of interventions is influenced by many things, including the levels of community transmission. Given the rapid and widespread advancements in prevention and containment measures, most notably, the COVID-19 vaccines and increases in testing capacity, as well as the rise of more transmissible variants of the virus, an update to this review may yield very different results.

What was studied in the review? In order to reduce the spread of the virus that causes COVID-19, many governments and societies put mitigation measures in place in schools. However, we do not know whether these measures work with regards to reducing the spread of the virus, or how these measures affect other aspects of life, such as education, the economy or society as a whole.

Key messages Reopening schools or keeping schools open while having a broad range of measures in place can reduce transmission of the virus that causes COVID-19. Such measures can also reduce the number of people who will need to go to hospital due to developing COVID-19. However very little is known about other consequences of these measures, such as those linked to education, resources, and physical or mental health, as this knowledge is mostly based on studies modelling the real world. More studies set in the real world using real-world data are needed.

Lead author Shari Krishnaratne explains: “This review provides insight into the effectiveness of measures implemented in schools to contain the COVID-19 pandemic. Whilst the review addresses a very important question there are limitations to the evidence it provides. We searched for studies for the review in December 2020, at a time when there was a lack of real-world evidence. As such, most of the studies included in this review use modelling. This review therefore shows an overall absence of real-world evidence about the effectiveness of these measures. However, there is enough evidence from the modelling studies and in other reviews such as one on travel measures for us to have some confidence that there is likely to be a positive effect on transmission, but how an intervention works in one location might not be the same as in another.   There are limitations to the evidence, but it does suggest that schools can stay open (or reopen) safely when prevention measures are implemented effectively. The effectiveness of interventions is influenced by many things, including the levels of community transmission. Given the rapid and widespread advancements in prevention and containment measures, most notably, the COVID-19 vaccines and increases in testing capacity, as well as the rise of more transmissible variants of the virus, an update to this review may yield very different results.”

What are measures implemented in the school setting? Measures in the school setting can be grouped into the following four broad categories.

• Measures reducing the opportunity for contacts : by reducing the number of students in a class or a school, opening certain school types only (for example primary schools) or by creating a schedule by which students attend school on different days or in different weeks, the face-to-face contact between students can be reduced.
• Measures making contacts safer: by putting measures in place such as face masks, improving ventilation by opening windows or using air purifiers, cleaning, handwashing, or modifying activities like sports or music, contacts can be made safer.
• Surveillance and response measures: screening for symptoms or testing sick or potentially sick students, or teachers, or both, and putting them into isolation (for sick people) or quarantine (for potentially sick people).
• Multicomponent measures: measures from categories 1, 2 and 3 are combined.

What is the aim of the review? The authors aimed to find out which measures implemented in the school setting allow schools to safely reopen, stay open, or both, during the COVID-19 pandemic.

What did we do? They searched for studies that looked at the impact of these types of measures in the school setting on the spread of the virus that causes COVID-19, the impact on the healthcare system (i.e. how many hospital beds are needed), as well as important social aspects (i.e. how often students attended school). The studies could focus on students, teachers and other school staff, as well as on families and the whole community. They could use real-life data (observational studies) or data from computer-generated simulations (modelling studies).

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What are the main results of the review? The authors found 38 relevant studies. Most of these were modelling studies (33 studies). Five studies used real-world data. Twenty studies were conducted in North or South America, 16 in Europe and two in China.

Below we summarise the main findings by category.

• Measures reducing the opportunity for contacts The authors found 23 modelling studies assessing measures to reduce the opportunity for contacts. All studies showed reductions in the spread of the virus that causes COVID-19 and the use of the healthcare system. Some studies also showed a reduction in the number of days spent in school due to the intervention.
• Measures making contacts safer The authors found 11 modelling studies and two real-world studies looking at measures, such as mask wearing in schools, cleaning, handwashing, and ventilation. Five of these studies combined multiple measures, which means we cannot see which specific measures worked and which did not. Most studies showed reductions in the spread of the virus that causes COVID-19; some studies, however, showed mixed or no effects.
• Surveillance and response measures We found 13 modelling studies and one real-world study assessing surveillance and response measures. Twelve studies focused on mass testing and isolation measures, while two looked specifically at symptom-based screening and isolation. Most studies showed results in favour of the intervention, however some showed mixed or no effects
• Multicomponent measures They found three studies that looked at multicomponent interventions, where it was not possible to determine the effect of each individual intervention. These included one modelling study and two real-world studies. These studies assessed physical distancing, modification of activities, cancellation of sports or music classes, testing, exemption of high-risk students, handwashing, and face masks. Most studies showed reduced transmission of the virus that causes COVID-19, however some showed mixed or no effects.

How confident are we in the findings of this review? Confidence in these results is limited. Most studies used models, that is, they estimated the effects of the interventions rather than observing outcomes. As the models are built on assumptions about how the virus spreads and how people behave, we lack real-world evidence. Many studies were published as 'preprints' without undergoing rigorous checks of published studies, which further limits confidence. Also, the studies were very different from each other (for example, with regards to the levels of transmission in the community).

How up to date is this evidence? The evidence is up-to-date to December 2020. It is expected this review will be updated in Spring 2022.

• Read the full review
• Visit the Cochrane Public Health group website

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Understanding COVID-19 preventive behavior: An application of the health belief model in the Philippine setting

Engracia arceo.

Department of Medical Technology, College of Allied Medical Professions, Angeles University Foundation, Angeles City, Philippines

John Edlor Jurado

Leslee anne cortez.

1 Department of Education, Dasmarinas, Cavite, Philippines

Nestor Sibug

2 Department of Psychology, Holy Angel University, Angeles City Philippines

Gestrelle Lides Sarmiento

Amica coleen lawingco, carisse carbungco, raphael enrique tiongco, background:.

With the Philippines emerging as the hotspot in the Western Pacific Region for the COVID-19 cases, the study aimed to understand the COVID-19 preventive behavior of Filipinos using the health belief model (HBM).

MATERIALS AND METHODS:

The cross-sectional study included 304 respondents recruited for the whole month of July 2020 through various social media platforms. Participants were requested to answer an online questionnaire, and results were analyzed using SPSS software.

The majority of respondents were female (71.1%), with an average age of 29, college graduate (57.6%), and living in an area where modified general community quarantine is implemented (63.2%). Good preventive behavior was noted among the participants, and not shaking of hands with others and refraining from touching of surfaces were reported as the most practiced behavior. Spearman's correlation and Pearson's Chi-square showed that age and sex are significant predictors for the HBM constructs and preventive behavior. Furthermore, results showed that cues to action, self-efficacy, and perceived barrier have a significant association with COVID-19 preventive behavior.

CONCLUSION:

Findings prove that HBM is useful in understanding preventive behaviors in times of coronavirus pandemic. Strategies that promote a supportive environment and help overcome the perceived barriers can guide Filipinos to adopt the desired health behavior. Interventions to promote preventive behaviors should be focused on males and younger individuals.

Introduction

COVID-19 is a novel pandemic that has caused a tremendous negative impact on the health and economy of many countries around the world. Current evidence shows that SARS-CoV-2, the virus causing the disease, is transmitted between people through respiratory droplets and contact routes.[ 1 ] Efforts to minimize the spread of the infection focus on behavioral interventions and protective behaviors like home quarantine, frequent handwashing, and social distancing.

In the absence of vaccines, large-scale social distancing measures – workplace nonattendance, school closure, and lockdown – appear to be the most effective means of mitigation.[ 2 ] In the US, one study noted that 3–4 months of moderate distancing could actually save 1.7 million lives and lead to substantial economic benefits.[ 3 ] However, noncompliance to social distancing has been observed, and the behavior has been linked to several factors, including political reasons[ 4 ] and personal expectations like duration of self-isolation.[ 5 ]

Public health experts have used different theories and models to explain the various factors influencing health behavior. One of the most commonly used frameworks in public health research is the health belief model (HBM). The general acceptance and popularity of the theory are due to its reliability in predicting behavior. According to the HBM, the behavior is predicted by a person's perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action. The model is designed to explain the reasons why people are compliant or noncompliant to preventive health behaviors.

While there is one study that explored the COVID-19 preventive behavior in Iran,[ 6 ] cultural differences may influence the variables. Unlike other countries around the world, the Philippines has been in various forms of community quarantine and has the world's longest and strictest lockdown. Reports show that the end to this lockdown is still not in sight because of the failure in controlling the pandemic, thus making the country with the fastest rise in virus cases in the Western Pacific Region.[ 7 ] This situation raises a unique challenge for both public health practitioners and government authorities. There is a need to better understand the factors influencing COVID-19 preventive behaviors in order to ensure the public's compliance and cooperation. By obtaining the possible predictors of the said behavior using the HBM, this can serve as a pivotal point in the planning, promotion, and implementation of better health program protocols to prevent the further spread of the disease in the country.

Materials and Methods

Study population.

The cross-sectional study targeted participants who were currently living in the Philippines, at least 18 years old, and have access to the internet. Since this was an online survey study, participants were selected through convenience sampling technique. Eligible participants were recruited through Facebook, a popular social media platform in the country. The researchers posted the link of the online questionnaire on private accounts and shared in public pages and groups for the whole month of July 2020. Researchers requested the participation of their online friends through recruitment posts and personal messages with an included link to the online survey. To widen the coverage, they also asked their online friends to share the link. Furthermore, the link was also posted on public groups on Facebook and requested the administrators of organizations and institutions to post the questionnaire link on their respective pages. At the end of the online data collection period, the online survey was closed and data were then analyzed.

Research instrument

The research tool was adapted from one published study in Iran.[ 6 ] In order to fit the Philippine setting, the questionnaire was slightly modified, translated into the Filipino language, and pilot tested. To check for the internal consistency, Cronbach's alpha was calculated. A revision was done until the internal consistency for both English and Tagalog versions was within the acceptable range. The final English and Tagalog versions have an internal consistency of 0.776 and 0.644, respectively. Both were converted into Google Forms to facilitate the online survey.

The questionnaire included three sections – demographic profile, HBM constructs, and COVID-19 preventive behaviors. The demographic profile included age, birthdate, sex, educational background, and the lockdown category of the participants. The lockdown category was included because the government, through the interagency task force on emerging infectious diseases, classified each area in the country into various categories. They are the enhanced community quarantine (ECQ), modified ECQ (MECQ), general community quarantine (GCQ), and modified GCQ (MGCQ), which are enumerated based on decreasing restrictions in terms of social movement and business operations. ECQ is the strictest type of lockdown where most establishments were closed, only food businesses and health-care institutions were allowed to operate, and only one person per household was allowed to go out for essential errands.

The questionnaire also included 22 questions about HBM constructs and 7 questions on COVID-19 preventive behaviors. All were on 1–5 Likert scales, which range from strongly agree to strongly disagree. Participants were asked to click on the option that best describes their current status and their understanding of each statement. Once done, they only need to click the submit button and there was no incentive given for their participation.

Ethical consideration

Ethical clearance was obtained from an ethics review board prior to the conduct of the study. A voluntary informed consent form was included on the first page of Google forms. All participants who agreed were asked to click on the “I agree” box before proceeding to answer the rest of the questionnaire. All data obtained were treated with extreme confidentiality.

Statistical analysis

The Mann–Whitney U-test, Pearson's Chi-square, and Spearman's rank correlation analyses were run to determine the association between the participant's demographics (sex, lockdown category, and age) with both HBM constructs and their COVID-19 preventive behaviors. On the other hand, Spearman's rank correlation analysis was also used to investigate the effect of each HBM construct on the performance of COVID-19 preventive behavior. All P values were computed at a two-sided 5% level of significance.

A total of 304 responses from eligible participants were analyzed. The respondents of the online survey have an average age of 29.0 ± 10.4, mostly female (71.1%), college graduates (57.6%), and living in an area where MGCQ is implemented (63.2%). Of the different constructs in the study, Table 1 shows that the perceived benefits (4.7) and perceived self-efficacy (4.7) had the highest mean, followed by perceived severity (4.5), cues to action (4.4), preventive behavior (4.2), perceived susceptibility (3.6), and perceived barriers (3.5).

Demographic profile of the study participants

*Mean±SD. SD=Standard deviation, MGCQ=Modified general community quarantine, GCQ=General community quarantine, MECQ=Modified enhanced community quarantine, ECQ=Enhanced community quarantine

Table 2 summarizes the correlation result of the participant's demographic profile with the HBM constructs and preventive behavior. Based on the results, only age and sex have a significant association with the constructs under study. Age showed a significant positive relationship with perceived susceptibility ( P = 0.04), perceived barriers ( P < 0.001), and cues to action ( P < 0.001), which indicates that as age increases, the mean scores of these constructs also increase. Findings also revealed a significant association of the participant's sex on perceived self-efficacy ( P = 0.02), cues to action ( P = 0.01), and preventive behavior ( P = 0.001).

Association of the participants’ age, sex, educational attainment, and lockdown category with health belief model constructs

*Significant at P <0.05, **Spearman’s rank correlation, ***Pearson’s Chi-square

Further analysis of the association of sex with HBM constructs was done by comparing the mean scores among males and females using the Mann–Whitney U-test [ Table 3 ]. Based on our findings, mean scores for perceived severity, perceived self-efficacy, cues to action, and preventive behavior were significantly higher among females than in males.

Comparison of mean scores for the various health belief constructs and preventive behavior among males and females

*level of significance at < 0.05

In terms of COVID-19 preventive behavior, Table 4 shows that overall, there was a good practice among the participants of the study as represented by their mean score. Not shaking of hands with others and refraining from touching of surfaces was the most practiced behavior, and not touching the eyes, nose, or mouth and not taking of cellphone out from the pocket/bag was the least practiced.

Summary of the participant’s preventive behavior

Table 5 summarizes the result of Spearman's correlation of HBM constructs with the participants’ preventive behavior. Among the different constructs, only three showed a significant association. Both perceived self-efficacy and cues to action have a significant direct relationship with preventive behavior, whereas perceived barriers showed a significant indirect relationship.

Association of the health belief model constructs with COVID-19 preventive behavior

*Significant at P <0.05

COVID-19 is steadily increasing in the world, and in the Philippines, the cases continue to rise, necessitating a second round of stricter implementation of MECQ in the country's capital city and the continuous implementation of various types of community quarantine in different areas.[ 8 ] With the rising number of Filipinos infected with the novel disease, the researchers aimed to determine the COVID-19 preventive behaviors of Filipinos and the role of the HBM constructs to their adherence to health protocols.

Out of the demographic profile studied, age and sex were shown to be important variables affecting the HBM constructs. Participants have increasing perceived susceptibility as they age, and this is probably because age has always been considered as a predictor of fatal outcome in COVID-19 cases.[ 9 ] Older people are at higher risk of contracting COVID-19 due to the physiological body changes that come with aging as well as the potential underlying comorbidities and decreased immune function that they experience which can make them more susceptible to the complications of the disease. Furthermore, the elderly who have existing comorbidities are more likely to engage in health-promoting behaviors since they feel that noncompliance will render them more susceptible to the infection.[ 10 ]

It was also noted that female respondents have higher perceived severity, perceived self-efficacy, cues to action, and preventive behavior. When compared with a previous study involving hospital staff workers, females are also reported to have a higher score of perceived threat.[ 11 ] This result coincides with another published study which noted that men tend to have lower rates of handwashing, social distancing, wearing masks, and proactively seeking medical help.[ 12 ] The same result was noted in a large-scale international investigation that shows women are more likely to engage in health behaviors than men.[ 13 ] The result of the present and previous studies is interesting, considering that reports show that the number of men who died from COVID-19 is 2.4 times that of women.[ 14 ] This only shows the need to intensify public interventions that address the unique needs of men when it comes to COVID-19.

The results also showed that the participants have good COVID-19 preventive behavior. However, it is noted that when outside, taking out of cellphones from their pocket/bag is a common practice among the participants of the study. This result is not surprising given the fact that nowadays, most people use their cell phones when outside to communicate with their families and friends amid the pandemic. While there are no documented cases of COVID-19 transmission through cell phone use, Han et al . cited one study in China which reported that the virus has been isolated from door handles and cell phones[ 15 ] and that human coronaviruses can persist on inanimate surfaces for up to 9 days.[ 16 ] The evidence of transmitting various respiratory infections via contaminated hands and contaminated inanimate objects comes from several studies.[ 17 ] Therefore, individuals may have a higher risk of being infected with COVID-19 if they touch their nose, mouth, or eyes after contacting contaminated items.

Another area for improvement revealed in the study is the frequent touching of the nose, mouth, and eyes with hands. Face-touching behavior is a common practice and has been associated as a potential vector for self-inoculation and transmission of respiratory infections. As such, it is recommended that increasing awareness of face-touching behavior and improving the understanding of self-inoculation as a route for transmission can help break the transmission cycle of common respiratory diseases.[ 18 ] While the use of face mask has been mandatory in the country and many parts of the world, it has been noted that its use promotes face touching. In a study conducted in Mexico, patients with face mask touched their face 11.41 times on average and ranged up to 80 times. The study suggests that face-touching behavior has a role in COVID-19 transmission, and thus, mask use should be accompanied by proper hand hygiene and reminders not to touch one's face in order to be more effective in preventing COVID-19 infection.[ 19 ] These findings are consistent with what the WHO emphasizes on the importance of frequent hand hygiene, along with respiratory etiquette, environmental cleaning, and disinfection to prevent the transmission of COVID-19 infection.[ 1 ]

Of the HBM constructs, perceived self-efficacy and cues to action were noted to be positively correlated with the COVID-19 preventive behavior. Findings are congruent with the results conducted in Saudi Arabia and Iran, showing that participants with higher perceived self-efficacy and cues to action scores are more likely to adhere to the coronavirus preventive measures than those with lower scores. The researchers have emphasized the importance of the existence of high perceived self-efficacy as a way to overcome perceived barriers[ 6 , 20 ] .

Self-efficacy is an important construct considered to be a predictor of health behavior in various settings, and improvement of this can increase the likelihood of adopting a particular behavior.[ 21 , 22 , 23 ] Self-efficacy reflects people's confidence in their capacity to change behavior and deal with the problem. In the context of COVID-19, self-efficacy does not only lead to higher preventive behavior but also to better mental health status. Studies show that it is a mediating variable associated with lesser stress and anxiety. Individuals with higher self-efficacy scores have better mental health status. This is quite interesting, considering that the current pandemic has a strong negative impact on the lives of people.[ 11 , 24 , 25 ]

Cues to action is another construct found to be associated with the COVID-19 preventive behavior. This refers to the stimulus needed to trigger the decision-making process for a person to adopt a recommended health action. The theoretical construct is pivotal in influencing health behaviors.[ 26 , 27 ] In the present study, the stimulus includes external cues such as mass and social media information, government regulation, and the presence of supportive infrastructures. To help individuals take action, the Philippine government enforces mandatory use of face mask and compulsory infrastructure changes for businesses prior to re-opening like provision of barriers and foot markings, and adherence to several public health measures related to personal protection, environmental sanitation, physical and social distancing, and travel-related measures. Information as to COVID-19 is widely disseminated, and Filipinos identified traditional media such as television and radio as main sources of information about the virus.[ 28 ] It has been shown in various studies that when the environment is more supportive, people are more likely to adopt the desired behavior.[ 29 , 30 ] The existing laws and regulations in the country on COVID-19 prevention and the relatively conservative attitude of Filipinos may explain the higher preventive behavior observed in the study. In India, one study even mentioned that participants perceived the following government's protocols as an effective way to avoid infection.[ 10 ]

The last construct found that this time negatively associated with COVID-19 preventive behavior is the perceived barrier. This construct serves as a deterrent, and individuals must be able to overcome it to adopt the desired behavior. In the present study, the participants’ perceived barriers were hand hygiene, face touching, staying at home, social distancing, and non-readiness of businesses. These factors were strongly related to the scarcity of masks and disinfecting solutions, especially during the first part of the year, when the pandemic was just starting. In the country, it was this time when hoarding of face mask and alcohol, panic buying, establishments limiting the purchase of commodities, and price increase were very common.[ 31 ] In addition to the supply-related barriers, the mandatory home quarantine and social distancing were concepts new to people. Thus, they were perceived as barriers since many do not fully understand their benefits, and they have negative associations with it. Home quarantine is related to various psychological stresses such as fear, frustration, boredom, and financial loss.[ 32 ] During the H1N1 pandemic, researchers found that in order to increase compliance to home quarantine, clear, consistent, and simple information about it should be provided by authorities.[ 33 ]

Limitations

While the study offers a timely approach to understanding COVID-19 preventive behavior in a developing country like the Philippines, it has its own limitations. First, since it was conducted during community lockdown, the convenience sampling method and online survey were the only options available to the researchers. Thus, sample clustering may have limited the generalizability of the study. Second, the present work relied on the self-reported behaviors and responses of the participants, and thus, the actual behavior and responses may vary. The responses are also subject to recall bias as participants may be unable to report accurate estimates.

The study proved that the HBM is useful in understanding COVID-19 preventive behavior. Strategies that increase self-efficacy, promote cues to action, and overcome the perceived barriers can help Filipinos adopt the desired health behavior. This may include offering a more supportive environment like the availability of masks and hand sanitizers in public places, foot markings to remind social distancing measures, credible social media campaigns on promoting preventive behaviors, and intensified implementation of home quarantine measures for nonessential outdoor errands. In addition, dissemination of specific and actionable information through current media coverage (i.e., online and mobile platforms) may be impactful in delivering public health messages to increase positive attitude toward preventive behavior. It may also be important to leverage the influence of the community such as family and friends in inducing and sustaining behavior change. Finally, interventions to promote COVID-19 preventive behavior among Filipinos should be focused on males and younger individuals, and key health messages used to drive information must be contextualized in a manner that considers the culture and existing practices of local people in the country.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

• Open access
• Published: 08 February 2022

Hand sanitizers as a preventive measure in COVID-19 pandemic, its characteristics, and harmful effects: a review

• Parixit Prajapati   ORCID: orcid.org/0000-0001-9323-0179 1 ,
• Heli Desai 1 &
• Chandni Chandarana   ORCID: orcid.org/0000-0003-3049-0664 1  

Journal of the Egyptian Public Health Association volume  97 , Article number:  6 ( 2022 ) Cite this article

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In the global health emergency caused by COVID-19, multiple experts have mandated the use of hand sanitizers as a safety measure from COVID-19. The sale of hand sanitizers has increased many folds. Therefore, when there is such large use of hand sanitizers, it becomes extremely important to study and understand hand sanitizers in a comprehensive manner.

Main body of the abstract

This article starts with the importance of sanitizers as a defence mechanism that is employed by the hand to fight against the coronavirus. This article provides information about history, types, composition, various dosage forms, and marketed formulations of hand sanitizers. The article sheds a detailed light on industrial production techniques for hand sanitizers and also outlines new innovative techniques that were employed by the industry to mass produce hand sanitizers in the wake of the pandemic. The article further dives into a comparison between hand sanitizers and soaps so as to give pros and cons of the use of soap against the use of hand sanitizers. One of the aims of the article is to study the side effects of sanitizers so as to develop a cautious approach while using hand sanitizers and therefore a comprehensive list of side effects of the use of hand sanitizers is given.

The review article finds that hand sanitizers are extremely efficient in fight the virus but along with it, it brings along arrange of risks which are outlined in the article.

1 Background

Hand sanitizer, also known as a hand antiseptic or hand rub, is a product that is applied to the hands to remove common pathogen in the hands [ 1 ]. Hand sanitizers are usually available as foam, gel, or liquid [ 2 , 3 , 4 ]. They are recommended for use when there is unavailability of water and soap or there are other medical concerns (e.g., it causes cracks on the skin) [ 5 , 6 ]. In early 2020, WHO declared a pandemic “severe acute respiratory syndrome coronavirus 2”, better known as COVID-19. Exponential rise has been seen in the cases despite authorities setting down their best efforts. Prophylaxis is the easiest method to reduce transmission, proper hand washing and hygiene are the most effective pandemic strategies [ 7 ]. Hand sanitizers have emerged to be alternative to soap and water washing both in healthcare and public institutions. They are used to break the chain of infections, making them one of the important protocols for reducing the burden on healthcare [ 8 ].

2 History of hand sanitizers

The timeline of hand sanitizer’s history [ 9 , 10 ] Fig. 1 .

Timeline of hand sanitizer’s history [ 9 , 10 ]

3 Relation between COVID-19 and hand sanitizer

3.1 mechanism of action of hand sanitizers against viruses.

Viruses are structural infectious agents that contain genetic material like DNA or RNA. Viruses are encapsulated and protected by a protein envelope known as capsid. Viruses are further categorized as “enveloped” or “unenveloped.” Apart from the structural elements, it also contains a host cell which helps in propagation of viruses [ 11 ]. A common compound in virucides is N-Propanol. It is believed that it damages the membrane of the virus and it affects its decoupling and protein synthesis. For effective virucidal efficacy concentrations of not less than 60% and not more than 90% is enough. Alcohol that contains not more than 1% water is less virucidal than alcohol in the ranges mentioned above. Therefore, water is essential in the process of protein denaturation. Regardless of what processes alcohol affects, if not many, it eventually results in primary metabolic pathways, damage to the cell membrane, and loss of cell integrity. Alcohol-based hand sanitizers target the cover that protects the components of the virus. All the components are very critical for the virus. Therefore, it is assumed that after one of the components is targeted it may lose its ability to transfer from one host to another. This mechanism is compared to bacteria; it is observed that ethanol’s virucidal effect when compared to propanol is more effective against viruses of clinical relevance. It is also worth noting that in cases where only ethanol is not as effective against the viruses, adding acids can improve ethanol’s performance [ 12 ].

The SARS-CoV-2 virus was named because its genome sequence is similar to that of the SARS coronavirus (SARS-CoV) [ 13 , 14 ]. CoV is related to the same gene beta coronavirus and has the same morphology as the single-stranded RNA virus [ 15 , 16 ]. Ethyl alcohol at a concentration of 60 to 80% is a potent agent that inactivates all lipophilic viruses (such as influenza virus, herpes, and vaccinia and many hydrophilic viruses (e.g., polio) [ 17 ].

The WHO in 2015 recommended 80% concentration of ethanol and 75% concentration of isopropyl alcohol for “disinfectant: alcohol-based hand sanitizer” [ 18 ]. Ethanol seems to be more effective against bacteria than isopropanol and N-propanol. WHO also recommended that alcohol-based disinfectants showed results against emerging viruses too for example Zika, Ebola, and MERS [ 19 , 20 ]. Another study showed that a little over 42.5% concentration of ethanol was able to destroy coronavirus in about thirty seconds [ 21 ].

3.2 Efficacy of hand sanitizers on viruses

It is harder to study viruses than bacteria. Many studies have tried to test the efficacy of hand sanitizers on viruses. Use of alcohol-based hand sanitizers are recommended by WHO for protection against multiple viruses including the coronavirus as it has proven effective in quantitative suspension testing [ 19 ]. Other sterile sources containing isopropyl alcohol as the main ingredient also have proven effective against multiple enveloped viruses [ 17 ].

Studies have been conducted in which viruses have been externally applied or put-on fingers and hand sanitizers have successfully reduced the viral particles [ 22 , 23 ]. Ethanol have been shown to be highly effectual against germs and most hospital-related viruses [ 24 , 25 ]. Seventy to 80% alcohol concentration was enough for reliable inactivation in multiple viruses. Adequate activities can be attained with prolonged contact with the concentration of alcohol over time and prolonged contact with undiscovered virus.

A review of the literature on the effectiveness of handwashing against severe acute respiratory syndrome (SARS) transmission found that nine out of 10 small case-control studies showed that hand washing reduced the risk of social contamination [ 26 ]. Vivo evidence of viral inactivity after the use of hand sanitizers is not available by standard methods. Vitro studies have established that alcohol-based disinfectants can be effectual in reducing viral load [ 8 ].

The SARS-CoV-2 transmission has an incubation time of 10 days, which makes it easy to propagate through drops, contaminated hands or surfaces. Therefore, the effect of viral inactivity on all broadcasts should be considered [ 27 ]. Alcoholic disinfectants have been able to deactivate SARS-CoV-2 and MERS-CoV (also pre-activated coronaviruses) on living surfaces like plastic, glass, and metal [ 28 ]. A key limitation in analyzing the actual performance of hand disinfection is the recurring process of self-reported data gathering, which may not be the same and objective in terms of the frequency and method of hand washing [ 26 ].

4 Hand sanitizer types [ 29 ]

Hand sanitizers can usually be divided into two types: alcoholic or non-alcoholic. Alcohol-based hand sanitizer (ABHS) can contain alcohol, additives, and humectants to inhibit the growth and to kill the germs Fig. 2 .

Hand sanitizer types (alcoholic compounds, non-alcoholic compounds, and commonly used excipients)

5 Composition of hand sanitizers (Table 1 ) [ 30 , 31 ]

6 different preparation methods for alcohol-based hand sanitizer gels [ 32 ], 6.1 direct addition method.

Direct addition method as the name suggests is a method where in all the ingredients are added and mixed simultaneously but before the thickening agent. After the ingredients are mixed in the required compositions, the thickening agent is added. After the thickening agents are added, there are cases where there is a requirement of adding a neutralizing agent to maintain the pH level of the sanitizer to make it pH neutral. Modifications in the process is dependent on specific chemical compositions of ingredients in cases were the thickening agents not compatible with neutralizing agents.

6.2 Inverse addition method

In this procedure, the thickener is pre-wetted usually with glycerol. Once this is done, the sanitizer ingredients are added gradually and mixed thoroughly. The name itself suggests that this is opposite to the above method. The addition and requirements of neutralizing agents is similar to the above method. This method is suitable for small scale productions of sanitizers.

6.3 Other methods

High-viscosity solutions have the tendency to form lumps. We can use “hot/cold” technique to avoid this problem. This method is not suitable for components containing ethanol. Ethanol and other volatile components are added after a gel is prepared via hot cold technique during the cool down phase of the technique.

To avoid disadvantages of the above methods, like caking, a combination of the above methods can also be used for preparation of sanitizers. This means after preparation of a wet slurry, other ingredients are added using mechanisms used in addition method.

7 Various dosage forms of hand sanitizer

The United States Centres for Disease Control and Prevention (CDC) promoted washing hands and use of disinfectants [ 33 ]. Hand sanitizers are commercially available in a variety of forms, such as alcohol or water-based hand sanitizers, which are commonly utilised in a hospital setting. Various types of distribution structure have also been developed, such as gel, spray, wipe, cream, or foam. Alcoholic hand sanitizer is recommended by the World Health Organization (WHO) on the basis of the proven benefits of its rapid work and the proven spectrum of bacterial activity that protects against germs [ 34 , 35 , 36 , 37 , 38 ].

8 Marketed hand sanitizers

There are several hand sanitizers of well-known brands that are available in the market as shown in Fig. 3 .

Well-known marketed hand sanitizers

9 COVID-19 and the global hand sanitizer market

As COVID-19 has been exponentially spreading, the demand for hand sanitizers has also increased with the pharma companies and others producing hand sanitizers in huge quantities. People started buying them as a personal prevention tactic against the virus. This has suddenly led to a huge demand for raw materials for hand sanitizers. Raw materials like isopropanol were sold at higher prices as there was not enough stock due to sudden increase in demand. The demand has been met by innovations by the producers in the hand sanitizer industry and hand sanitizers have been produced in record numbers [ 39 ]. The hand sanitizer market has grown both in terms of revenue and sales in 2020 [ 40 ].

10 Innovation in production of hand sanitizer during outbreak of SARS-COV-2

10.1 production of alcohol-based sanitizer from sweet potato residue in the covid-19 emergency [ 41 ].

As coronavirus cases increased worldwide, hand sanitizer demand increased. So, to fulfil this demand, development of other new methods of producing alcohol-based hand sanitizer was the only way. Conversion of raw material from agriculture and food residue gives valuable bioproducts.

Sweet potato (Ipomoea batatas) is a source for manufacturing of bioethanol, as it has high amount of starch. This innovation technique was used in Brazil as Brazil is the 16th highest producer of sweet potato in the world and it produces 350,000 tons of sweet potato waste. Here, they develop the method of ethanol production from sweet potato waste. Greenhouse emissions also get reduced as the production of bioethanol from biowaste. Also, it increases new business opportunities in the food and agriculture field. Production of alcohol-based hand sanitizer from sweet potato residue was achieved as it showed favorable results and produced 1342 L of hand sanitizer per day.

10.2 Benzalkonium chloride (BZK) for hand disinfection during COVID-19 [ 42 ]

Benzalkonium chloride hand cleaner, manufactured in an FDA-registered facility to cGMP requirements is readily available. The CDC’s inclusion of benzalkonium chloride for hand sanitizer in its current COVID-19 hand hygiene recommendation, which is clearly supported by the available literature would immediately ease some of the extreme pressures already strained on ABHR’s (alcohol-based hand rub) supply chains. Products containing benzalkonium chloride that comply with the current FDA OTC monograph may offer another option for hand disinfection. Extending the recommendations would also allow the immediate implementation of a viable alternative to hand washing in situations where the use of alcohol-based products is restricted due to concerns about alcohol abuse and the potential arming of ABHR (alcohol-based hand rub) products [ 42 ].

Benzalkonium chloride hand sanitizer was compared with 70% ethanolic hand sanitizer for a week and the results show that benzalkonium chloride hand sanitizer was more effective to decrease Staphylococcus aureus on the fingertips of healthcare workers [ 43 ].

10.3 Production of ethanol-based hand sanitizer in breweries during COVID-19 emergency [ 44 ]

Due to increase in corona cases, disruption occurs in management of supply chain around the world. So, to solve this problem, many distilleries and breweries come to one conclusion that their facilities could help to produce hand sanitizer which follows the World Health Organization (WHO)-recommended formula and by considering all precautionary parameters they produced hand sanitizer safely and efficiently.

11 Alcohol and soaps

Keeping hands clean so as not to get sick while reducing the spread of germs to others is an important and necessary step. The CDC has also emphasized that keeping hands clean can prevent a lot of diseases from spreading by removing dirt and microbes from the surface of the skin [ 45 ]. Both soap and alcohol disinfectant work on microbial lipid membranes by dissolving and thus disabling them. If water is not available, then a very good alternative is alcoholic disinfectants, and the alcoholic content should be nearly about 60% in the disinfectant.

Compared to soap, alcohol-based disinfectants do not kill all types of bacteria, such as noroviruses and clostridium difficile, which can cause common diseases [ 46 , 47 ]. One major downside of sanitizers is that the liquid can evaporate before wiping evenly on all hands, thereby reducing the effect of disinfectants [ 48 , 49 ]. Moreover, disinfectants are also ineffective when hands are covered by some chemicals or have dirt on them [ 50 ].

12 Hand sanitizer versus soap

CDC has recommended washing hands with soap and water. It has multiple benefits like removal of pathogens and unwanted chemicals from hands. A 2016 systematic review showed that washing hands with soap is more effective than sanitizers to remove dirt and microorganisms [ 51 ]. However, when the effectiveness of soaps and disinfectants on bacterial inactivation were compared to different ethanol-based hand sanitizers, the vitro quantitative suspension test showed a 4 log 10% reduction (> 99.99%) in the tested envelope virus [ 52 ]. There are not enough studies on direct comparisons between soap and disinfectants. However, in some particular viruses and bacteria, soap and water is effective in comparisons with alcoholic disinfectants [ 19 , 53 ].

In addition, washing the hands removes the skin’s own fatty acids that can lead to stressful skin, ultimately representing a potential gateway for germs [ 46 , 54 ]. To overcome the limit of simple hand washing, hand sanitizers have been introduced that are effective in combating pathogenic microorganisms and also improve the condition of the skin by adding emollients [ 55 , 56 ].

13 Harmful effects of hand sanitizers on human health

13.1 ethanol poisoning.

Ethanol is widely used as a disinfectant and alcoholic beverage. The possibility of skin absorption and skin cancer through carcinogenicity remains unclear due to the lack of current research [ 57 ]. There is no specific measure to assess toxic levels of ethanol disinfectants. Various studies have proven that acute exposures are not toxic. However, blood ethanol levels are affected with long-term exposures to ethanol-based hand sanitizers. In humans with 33% damaged skin, 70% ethanol is absorbed through the skin [ 58 ]. Moreover, exposure to ethanol-sensitive skin can cause systemic toxicity and reaction to the system. In cosmetics, it is also not suggested to use ethanol on injured skin. Eye irritation, skin dryness, cracking, redness, itching, and contact dermatitis can be caused by regular exposure to ethanol [ 59 ]. Studies have showed that ethanol sanitizers affect the concentration of ethyl glucuronide in urine. Acute alcohol poisoning can be caused by any daily home use items like alcoholic hand sanitizers (ABHS), mouthwash, cosmetics, and so on. Clinical symptoms appear at a certain concentration of alcohol in the blood. Lethal dose of ethanol can be life threatening. Symptoms begin 1 to 2 h after consuming ethanol-based hand sanitizers. Symptoms like vomiting, epigastric pain, and various depressions of the central nervous system are commonly seen. Ethanol poisoning has also been linked to hyperthermia, possible heart attacks, arrythmia, hypoglycaemia, ketoacidosis, and hypotension [ 60 ].

13.2 Isopropyl alcohol poisoning

Higher molecular weight of isopropyl alcohol tends to be more lethal than ethanol poisoning. Such poisoning is commonly seen due to accidental ingestions. Studies and data have shown that the lethal dose was about 250 ml [ 61 ]. Exposure to the minimum dose was not a serious health problem and consuming 50% concentration of more than 25 ml isopropanol caused minor symptoms. Isopropyl alcohol has major clinical effect on children. People can be at a risk of long-term depression, hypotension, and central nervous system dysfunction after prolonged exposure to isopropyl alcohol. Isopropyl alcohol also irritates the mucous membranes in the stomach and may result in gastritis associated with ketosis, hypoglycaemia, respiratory depression, and high serum creatinine. A high dose can weaken heart muscle and its long-term use is conducive to rhabdomyolysis, myoglobinuria, and acute renal failure. Seventy percent of the deaths were associated with ingestion of ≥ 400 mg/dL in concentrations of 70% isopropyl solution [ 62 , 63 ]. Isopropanol absorption through the skin can cause skin irritation, and prolonged and frequent exposure can cause blemishes, wrinkles, redness, and dryness [ 64 ].

13.3 Toxicity of hydrogen peroxide

Hydrogen peroxide is only risky when consumed in high concentration. In some cases, it causes portal vein obstruction, abnormalities in the stomach, slight irritability, and vomiting of sous vide [ 65 ]. It creates toxic gases which when it comes in contact with tissues, it breaks down in oxygen and water. The presence of oxygen and water can cause air embolism in many organs [ 66 ].

13.4 Child risk factor

Hand sanitizers come in colourful packaging with tempting flavors and children may lick it. Small doses are not harmful; however, young children are more likely to be poisoned by alcohol than adolescents [ 67 ]. Young children are more prone to liver issues when intoxicated with alcohol. Recent reports have shown that young children, including those with apnoea, acidosis, and coma, have been drinking alcohol-based hand sanitizers. A CDC research paper analysed data reported to the National Poison Data System (NPDS) on sanitizer exposures in the hands of children under 12–14 years of age [ 68 ]. In the first half of 2020, the U.S. reported that 9504 children under the age of 12 came in contact with a disinfectant and concluded that even a small amount of alcohol could harm children [ 69 ].

13.5 Skin effects due to exposure to hand sanitizers

Studies have shown that immoderate use of disinfectants to prevent against the coronavirus has resulted in damaging the skin which has resulted in reducing its capabilities to fight against another virus. The use of skin disinfectants deprives the skin from sebum and water hence causing skin dryness. Dry and damaged skin is the focal point of many bacterial diseases and increases the risk of germs on the skin. Increased use of hand sanitizers has shown in surveys and studies that it increases the chances of getting norovirus [ 54 , 70 ].

Hand sanitizers containing an alcohol can also dissolve the lipid levels of the skin and its lipid-dissolving effect is incompatible with the concentration of alcohol. Therefore, damaging lipid barriers and eventually it causes hand eczema [ 71 , 72 ].

Once the barrier is broken, it eventually causes dermatitis. Symptoms like dryness, acne, wrinkles, burning, swelling, erythema and cracking are very common for dermatitis [ 73 ]. Currently, a study done on health workers with COVID-19 in China reported skin damage to the skin due to hand hygiene. Workers who cleaned up hands frequently have reported skin damages [ 74 ].

Eczema can be clearly distinguished from the place of disinfection with swelling, wrinkles. The part of hand where eczema has been detected may also turn into ulcer when it is exposed to disinfectant. In severe cases, the wounds may be swollen, and even damaged, with secondary infections [ 56 , 71 ].

14 Conclusion

Given the exploding nature of the pandemic, the world health machinery suggested regular use of hand sanitizers as one of the protection measures against the coronavirus. Hand sanitizers helps fight against the virus by damaging the cell membrane and therefore damages the components of the virus making it futile. Hand sanitizers have been highly effective to inactivate multiple viruses. Studies showed that alcohol-based disinfectants were effective in deactivating SARS-CoV-2 and MERS-CoV. Alcohol-based hand sanitizers includes components like ethanol, isopropyl alcohol, glycerine, and water and are available in various forms. There are multiple methods of industrial preparation of hand sanitizers. Industry experts invented various innovative methods to meet the requirement of the hand sanitizers. However effective the hand sanitizers are, they come with various adversarial effects. Ethanol exposure causes skin irritation, eye irritation, cracking of the skin, and redness and can also cause contact dermatitis. Isopropyl poisoning is also a threat due to long term use of hand sanitizers. Hydrogen peroxide is an important content of hand sanitizers, and it has proven to be highly risky when consumed in high concentrations. Children are also at a high risk of getting affected by hand sanitizers. Drinking hand sanitizers can cause serious harm to children. Skin is the most exposed to hand sanitizers. Extensive use of hand sanitizers can likely lead to hand dermatitis and hand eczema. An alternative to hand sanitizers as suggested by experts is hand washing with soaps. Though its limitations of not being available at all places, it has been found that soaps are highly effective to fight the virus and, in some cases, even more effective than sanitizers. Therefore, to combat the current pandemic hand sanitizers are a very effective way to keep the virus from spreading and affect us but it is also seen that extensive use of hand sanitizers can be harmful.

Abbreviations

World Health Organization

Deoxyribonucleic acid

Ribonucleic acid

Centers for Disease Control and Prevention

Alcohol-based hand sanitizer

United States Pharmacopeia

Food and Drug Administration

Alcohol-based hand rub

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Prajapati, P., Desai, H. & Chandarana, C. Hand sanitizers as a preventive measure in COVID-19 pandemic, its characteristics, and harmful effects: a review. J. Egypt. Public. Health. Assoc. 97 , 6 (2022). https://doi.org/10.1186/s42506-021-00094-x

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DOI : https://doi.org/10.1186/s42506-021-00094-x

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