Beyond Personal Protective Equipment

Adjunctive Methods for Control of Healthcare-Associated Respiratory Viral Infections

Zachary M. Most


Curr Opin Infect Dis. 2020;33(4):312-318. 

In This Article

Abstract and Introduction


Purpose of review: Prevention of nosocomial transmission of respiratory viruses is a priority in all healthcare settings and often achieved with the use of personal protective equipment. Several adjunctive infection prevention methods are in common use but their effectiveness in reducing healthcare-associated respiratory viral infections is unclear. In this review, recent advances regarding the effectiveness of several adjunctive infection prevention methods to reduce healthcare-associated respiratory viral infections are discussed.

Recent findings: Training and education on hand hygiene guidelines, mandatory influenza vaccination for healthcare personnel, access to paid sick leave to reduce ill presenteeism, cohorting of patients with the same infection or clinical syndrome, neuraminidase inhibitor chemoprophylaxis during influenza outbreaks, and enhanced visitor restrictions in pediatric hospitals all have shown some degree of effectiveness in observational or quasi-experimental studies.

Summary: Most of the studies evaluating the effect of adjunctive infection prevention methods on healthcare-associated respiratory viral infections are observational or quasi-experimental and are often combined with other interventions. Therefore, it is difficult to determine the precise effectiveness or efficacy of these interventions and more controlled trials are needed. Multimodal infection prevention policies are likely to be most effective in reducing healthcare-associated respiratory viral infections.


Respiratory viruses comprise a substantial proportion of healthcare-associated infections. Because of their spread via respiratory droplets and contact with contaminated fomites, the risk for nosocomial transmission is very high. Healthcare-associated respiratory viral infections (HARVI) have long been identified and recognized as a source of morbidity in hospitalized patients,[1,2] but with recent advances in viral diagnostic testing the importance of respiratory viruses other than influenza and respiratory syncytial virus (RSV) is becoming more clear.[3–10]

In order to prevent HARVI in hospitals and long-term care facilities (LTCF), isolation precautions are often implemented. These precautions involve healthcare personnel (HCP) donning personal protective equipment (PPE). Some controversies still exist over the appropriate methods and situations for PPE use, but overall PPE is widely accepted as an essential method to prevent HARVI.[11–15]

There is less evidence to support the use of adjunctive methods beyond PPE to reduce nosocomial respiratory viral transmission (Table 1). It has been difficult to study the effects of these adjunctive methods for several reasons. Randomized controlled trials may be unethical and difficult to power because of small marginal benefits. It is also very difficult to differentiate the specific effects of one intervention because multiple interventions are often bundled together or are implemented stepwise over time.[16] Because of these challenges most of the evidence to support the use of adjunctive methods is observational. Nevertheless, there have been many recent advances in our understanding of HARVI prevention. The present review will discuss the most recent evidence regarding the use of several adjunctive methods to reduce nosocomial respiratory virus transmission. Conclusions from these studies cannot reliably be generalized to viruses that were not investigated, such as SARS-CoV-2, but the same infection prevention methods are the ones most likely to be effective against any virus that transmits via respiratory droplets.