Editor's Choice

Next to cleanliness

BMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39455.595255.47 (Published 10 January 2008) Cite this as: BMJ 2008;336:0

This article has a correction. Please see:

  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}bmj.com

    Whether or not pandemic flu is on its way, it’s likely we’ll see an increase in flu cases this winter, with all their attendant misery and cost. We have vaccines and antiviral drugs, but how effective are simple hygiene measures—hand washing and face masks?

    Tom Jefferson and colleagues have looked at the evidence, sifting through 2300 articles to find 51 studies worth considering (doi: 10.1136/bmj.39393.510347.BE). They conclude that these simple and low cost interventions can reduce spread, with the most impressive reductions in respiratory illness coming from high quality cluster randomised trials of hand washing in younger children. They extrapolate from case-control studies from the SARS outbreaks in Asia to derive numbers needed to treat and estimate that washing hands between patients or wearing masks, gloves, or gowns in four to six hospital or community initiatives would contain one epidemic. Combining the individual measures brings the number needed to treat down to three.

    But the evidence is thin, and most studies were of poor quality. Why has there been so little good research in this area? In his editorial (doi: 10.1136/bmj.39406.511817.BE), Martin Dawes points out that of the 336 trials on influenza registered on WHO’s international clinical trials registry, only three are about reducing transmission through physical distancing or barrier methods. Is this another manifestation of drug industry dominance over clinical trials (see last week’s editor’s choice, doi: 10.1136/bmj.39444.472708.47), or does it run deeper than that? In a rapid response Peter Doshi comments that the US Centers for Disease Control and Prevention’s recommendations on influenza are 25 000 words long but contain only one dismissive sentence on non-pharmaceutical interventions (www.bmj.com/cgi/eletters/bmj.39393.510347.BEv1). He asks why the response to Jefferson et al’s review has been muted: “The evidence indicates that these methods are effective, relatively easy to employ, and cheap? Is this not cause for celebration?” If it’s not a drug or a vaccine, it seems we’re not interested.

    Jefferson and colleagues call for more and better research, a plea echoed in a response from Joshua Jacob and colleagues in Tokyo, who suggest that stockpiling face masks against pandemic influenza is premature (www.bmj.com/cgi/eletters/bmj.39393.510347.BEv1), who also say randomised controlled trials will be hampered either by strong cultural beliefs in the efficacy of face masks (as in Japan) or by strong resistance among healthcare providers to wearing them (as in America).

    Which leads me to the main subject of discussion among UK doctors I’ve met this week (apart from the Tooke report on the future of specialist training (doi: 10.1136/bmj.39455.401817.80 and doi: 10.1136/bmj.39455.498600.4E) and Gordon Brown’s shock announcement about the need for more prevention (doi: 10.1136/bmj.39455.385868.80 and doi: 10.1136/bmj.39454.738912.4E): the government’s recent directive that doctors should be “bare below the elbows”—short sleeved shirts, no ties, no white coats, no wrist watches. The evidence for this new policy is sadly lacking, as the government admits (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078433). I am semi-reliably informed that the policy emerged from a conversation with doctors at one tertiary referral hospital. No one wants to be grouped in years to come among those who laughed at Lister or sneered at Semmelweiss. But I’m with Michael Moses, a plastic surgeon, who asks in his rapid response (www.bmj.com/cgi/eletters/336/7634/10) how the risk of infection from wrist watches stacks up against the risk from 100% bed occupancy.

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