***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Influenza A viruses are believed to spread between humans through contact , large respiratory droplets and small particle droplet nuclei ( aerosols ) , but the relative importance of each of these modes of transmission is unclear . Volunteer studies suggest that infections via aerosol transmission may have a higher risk of febrile illness . Here we apply a mathematical model to data from r and omized controlled trials of h and hygiene and surgical face masks in Hong Kong and Bangkok households . In these particular environments , inferences on the relative importance of modes of transmission are facilitated by information on the timing of secondary infections and apparent differences in clinical presentation of secondary infections result ing from aerosol transmission . We find that aerosol transmission accounts for approximately half of all transmission events . This implies that measures to reduce transmission by contact or large droplets may not be sufficient to control influenza A virus transmission in households Background H and hygiene is considered as an important means of infection control . We explored whether guided h and hygiene together with transmission-limiting behaviour reduces infection episodes and lost days of work in a common work environment in an open cluster-r and omized 3-arm intervention trial . Methods A total of 21 clusters ( 683 persons ) were r and omized to implement h and hygiene with soap and water ( 257 persons ) , with alcohol-based h and rub ( 202 persons ) , or to serve as a control ( 224 persons ) . Participants in both intervention arms also received st and ardized instructions on how to limit the transmission of infections . The intervention period ( 16 months ) included the emergence of the 2009 influenza p and emic and the subsequent national h and hygiene campaign influencing also the control arm . Results In the total follow-up period there was a 6.7 % reduction of infection episodes in the soap- and water arm ( p = 0.04 ) . Before the onset of the anti-p and emic campaign , a statistically significant ( p = 0.002 ) difference in the mean occurrence of infection episodes was observed between the control ( 6.0 per year ) and the soap- and -water arm ( 5.0 per year ) but not between the control and the alcohol-rub arm ( 5.6 per year ) . Neither intervention had a decreasing effect on absence from work . Conclusions We conclude that intensified h and hygiene using water and soap together with behavioural recommendations can reduce the occurrence of self-reported acute illnesses in common work environment . Surprisingly , the occurrence of reported sick leaves also increased in the soap- and water-arm . Trial Registration Clinical Trials.gov : NCT00981877 Source of funding The Finnish Work Environment Fund and the National Institute for Health and Welfare Elementary school-age children are particularly vulnerable to infections . While h and washing is the best method of preventing infections , many elementary schools are housed in buildings that have barriers to effective h and hygiene . The purpose of this study was to determine the effectiveness of an alcohol gel as an adjunct to h and washing in reducing absenteeism secondary to infectious illness .  Two-hundred and fifty-three elementary school children were r and omized by classroom into an experimental or control group . With a crossover design , all children participated in both groups , with a one-week washout period between phases . A 45-minute “ Germ Unit ” was taught to all children as they started the experimental phase and a st and ard unit on h and hygiene was taught as they started the control phase . Sixty-nine children were absent due to illness while in the control group . Thirty-nine children became ill while in the experimental group . Alcohol gel as an adjunct to h and washing was shown to be effective in reducing absenteeism due to infectious illness by 43 % Non-pharmaceutical interventions ( NPI ) such as facemasks and intensified h and hygiene may be effective in preventing influenza infections in households . It may be equally important that household members , especially children , can learn to use , maintain and tolerate these measures . We monitored adherence and tolerability of these NPI within a cluster-r and omized trial in households with influenza index patients . We recruited 147 participants in 41 households , 39 ( 95 % ) out of 41 index patients were children ( aged < 14 years ) . In households assigned to wear facemasks , their use peaked on day 4 after symptom onset of the index patient at 73 % and at 65 % for children and adults , respectively . Mean daily frequency of h and disinfection in households assigned to intensified h and hygiene measures peaked at 7·7 ( day 6 ) for children and at 10·1 ( day 5 ) for adults . The majority of participants reported no problems with mask wearing . Data suggest that usage of NPI can be taught and that measures are well tolerated by adults and even sick children alike Please cite this paper as : Simmerman et al. ( 2011 ) Findings from a household r and omized controlled trial of h and washing and face masks to reduce influenza transmission in Bangkok , Thail and . Influenza and Other Respiratory Viruses 5(4 ) , 256–267 Background Evidence is needed on the effectiveness of non‐pharmaceutical interventions ( NPIs ) to reduce influenza transmission . Methodology We studied NPIs in households with a febrile , influenza‐positive child . Households were r and omized to control , h and washing ( HW ) , or h and washing plus paper surgical face masks ( HW + FM ) arms . Study nurses conducted home visits within 24 hours of enrollment and on days 3 , 7 , and 21 . Respiratory swabs and serum were collected from all household members and tested for influenza by RT‐PCR or serology . Principal Findings Between April 2008 and August 2009 , 991 ( 16·5 % ) of 5995 pediatric influenza‐like illness patients tested influenza positive . Four hundred and forty‐two index children with 1147 household members were enrolled , and 221 ( 50·0 % ) were aged < 6 years . Three hundred and ninety‐seven ( 89·8 % ) households reported that the index patient slept in the parents ’ bedroom . The secondary attack rate was 21·5 % , and 56/345 ( 16·3 % ; 95 % CI 12·4–20·2 % ) secondary cases were asymptomatic . H and ‐washing subjects reported 4·7 washing episodes/day , compared to 4·9 times/day in the HW + FM arm and 3·9 times/day in controls ( P = 0·001 ) . The odds ratios ( ORs ) for secondary influenza infection were not significantly different in the HW arm ( OR = 1·20 ; 95 % CI 0·76–1·88 ; P‐0.442 ) , or the HW + FM arm ( OR = 1·16 ; 95 % CI .0·74–1·82 ; P = 0.525 ) . Conclusions Influenza transmission was not reduced by interventions to promote h and washing and face mask use . This may be attributable to transmission that occurred before the intervention , poor facemask compliance , little difference in h and ‐washing frequency between study groups , and shared sleeping arrangements . A prospect i ve study design and a careful analysis of sociocultural factors could improve future NPI studies Background : Laboratory-based evidence is lacking regarding the efficacy of nonpharmaceutical interventions ( NPIs ) such as alcohol-based h and sanitizer and respiratory hygiene to reduce the spread of influenza . Methods : The Pittsburgh Influenza Prevention Project was a cluster-r and omized trial conducted in 10 elementary schools in Pittsburgh , PA , during the 2007 to 2008 influenza season . Children in 5 intervention schools received training in h and and respiratory hygiene , and were provided and encouraged to use h and sanitizer regularly .  Children in 5 schools acted as controls . Children with influenza-like illness were tested for influenza A and B by reverse-transcriptase polymerase chain reaction . Results : A total of 3360 children participated in this study . Using reverse-transcriptase polymerase chain reaction , 54 cases of influenza A and 50 cases of influenza B were detected . We found no significant effect of the intervention on the primary study outcome of all laboratory-confirmed influenza cases ( incidence rate ratio [ IRR ] : 0.81 ; 95 % confidence interval [ CI ] : 0.54 , 1.23 ) . However , we did find statistically significant differences in protocol -specified ancillary outcomes . Children in intervention schools had significantly fewer laboratory-confirmed influenza A infections than children in control schools , with an adjusted IRR of 0.48 ( 95 % CI : 0.26 , 0.87 ) . Total absent episodes were also significantly lower among the intervention group than among the control group ; adjusted IRR 0.74 ( 95 % CI : 0.56 , 0.97 ) . Conclusions : NPIs ( respiratory hygiene education and the regular use of h and sanitizer ) did not reduce total laboratory-confirmed influenza . However , the interventions did reduce school total absence episodes by 26 % and laboratory-confirmed influenza A infections by 52 % . Our results suggest that NPIs can be an important adjunct to influenza vaccination programs to reduce the number of influenza A infections among children INTRODUCTION The purpose was to determine the effectiveness of an instructional program on h and washing . The hypothesis stated that an instructional program on germs and h and washing in child care could significantly reduce the spread of infectious diseases in the test center . METHOD A longitudinal study was conducted in a field setting with a test group and a control group of 3- to 5-year-old children and their teachers in two similar child care setting s. For 21 weeks illnesses and symptoms of infectious diseases were assessed with a health assessment checklist . The test group received a developmentally appropriate instructional program on germs and h and washing . The teachers in the test group attended workshops on infectious diseases and h and washing . The control group maintained their usual h and washing procedures . RESULT At weeks 1 through 11 benchmark data were collected . At weeks 12 through 21 , peak cold and flu season , the test group had significantly fewer colds than the control group ( chi-squared analysis , 4.338 , 1 df , p < .05 ) ; thus the hypothesis was confirmed . DISCUSSION H and washing has been recognized as one way to manage the spread of infectious diseases in child care centers . H and washing helped to reduce colds at the test center where frequent and proper h and washing practice s were incorporated into the curriculum through an intervention program Background H and -washing is regarded as a potentially important behavior for preventing transmission of respiratory infection , particularly during a p and emic . Objective The objective of our study was to evaluate whether a Web-based intervention can encourage more frequent h and -washing in the home , and to examine potential mediators and moderators of outcomes , as a necessary first step before testing effects of the intervention on infection rates in the PRIMIT trial ( PRimary care trial of a website based Infection control intervention to Modify Influenza-like illness and respiratory infection Transmission ) . Methods In a parallel-group pragmatic exploratory trial design , 517 nonblinded adults recruited through primary care were automatically r and omly assigned to a fully automated intervention comprising 4 sessions of tailored motivational messages and self-regulation support ( n = 324 ) or to a no-intervention control group ( n = 179 ; ratio 2:1 ) . H and -washing frequency and theory of planned behavior cognitions relating to h and -washing were assessed by online question naires at baseline ( in only half of the control participants , to permit evaluation of effects of baseline assessment on effect sizes ) , at 4 weeks ( postintervention ; all participants ) , and at 12 weeks . Results H and -washing rates in the intervention group were higher at 4 weeks than in the control group ( mean 4.40 , n = 285 and mean 4.04 , n = 157 , respectively ; P < .001 , Cohen d = 0.42 ) and remained higher at 12 weeks ( mean 4.45 , n = 282 and mean 4.12 , n = 154 , respectively ; P < .001 , Cohen d = 0.34 ) . H and -washing intentions and positive attitudes toward h and -washing increased more from baseline to 4 weeks in the intervention group than in the control group . Mediation analyses revealed positive indirect effects of the intervention on change in h and -washing via intentions ( coefficient = .15 , 95 % confidence interval [ CI ] , .08–.26 ) and attitudes ( coefficient = 0.16 , 95 % CI , .09–.26 ) . Moderator analyses confirmed that the intervention was similarly effective for men and women , those of higher and lower socioeconomic status , and those with higher and lower levels of perceived risk . Conclusions This study provides promising evidence that Web-based interventions could potentially provide an effective method of promoting h and hygiene in the home . Data were collected during the 2010 influenza p and emic , when participants in both groups had already been exposed to extensive publicity about the need for h and hygiene , suggesting that our intervention could add to existing public health campaigns . However , further research is required to determine the effects of the intervention on actual infection rates . Trial International St and ard R and omized Controlled Trial Number ( IS RCT N ) : 75058295 ; http://www.controlled-trials.com/IS RCT N75058295 ( Archived by WebCite at http://www.webcitation.org/62KSbkNmm Background The economical impact of absenteeism and reduced productivity due to acute 
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The combination of h and hygiene with facemasks was found to have statistically significant efficacy against laboratory-confirmed influenza while h and hygiene alone did not .
Our meta-regression model did not identify statistically significant effects of latitude , temperature or humidity on the efficacy of h and hygiene .
Our findings highlight the potential importance of interventions that protect against multiple modes of influenza transmission , and the modest efficacy of h and hygiene suggests that additional measures besides h and hygiene may also be important to control influenza