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Home Eurosurveillance Weekly Release  2006: Volume 11/ Issue 41 Article 1
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Eurosurveillance, Volume 11, Issue 41, 12 October 2006

Citation style for this article: Nicoll A. Personal (non-pharmaceutical) protective measures for reducing transmission of influenza – ECDC interim recommendations. Euro Surveill. 2006;11(41):pii=3061. Available online:

Personal (non-pharmaceutical) protective measures for reducing transmission of influenza – ECDC interim recommendations

A Nicoll, (
European Centre for Disease Prevention and Control, Stockholm, Sweden

Epidemics of seasonal human influenza occur every winter in Europe and people naturally wish to protect themselves and their families from infection. At present there is particular interest in developing guidance on personal protective measures (hand-washing, respiratory hygiene, early self-isolation, mask-wearing etc). The same measures are likely to be effective in reducing transmission of both human seasonal and pandemic influenza and so this approach is also part of preparations for the next influenza pandemic [1]. Knowledge and awareness of these personal measures among the European public needs to be improved [2].

Box. How influenza transmits – infection parameters [1,3]

  • A viral respiratory infection mainly spread from person to person by:
  1. large droplets from an infected person coughing and sneezing*
  2. by direct or indirect contact (eg, when an infected person coughs or sneezes into her/his hand, and then shakes hands with another person).
  • Those most at risk:
  1. People in close proximity (within 1 metre*) to infected people who are coughing and sneezing.
  2. People who have contact with fomites contaminated with respiratory secretions (eg, those handling tissues recently used by others or touching the hands of infectious persons who have handled tissues or touched their nose).
  • Incubation period (from exposure to first symptoms) is most typically 48 to 72 hours with a range of from 24 hours to 7 days
  • Infected people are most infectious soon after they develop symptoms, and although they continue to excrete virus for up to five days after the onset of symptoms (7 days in children), the amount of virus, and hence the infection risk, drops steadily.
  • Spread from a person before they develop symptoms has only rarely been recorded and therefore it is presumed that infections from people before they have symptoms represent only a small minority of all transmissions.

*Fine droplet and aerosol spread may occur, but this is considered a possible transmission mode in only a minority of infections. This may occur in some healthcare settings where medical procedures (such as intubation) artificially generate aerosols containing virus.

There is indirect evidence that personal protective measures and other broader community public health measures (social distancing measures, school closures) can be quite effective [1,3]. For example, during the severe acute respiratory syndrome (SARS) outbreaks in Hong Kong in spring 2003, which coincided with the latter part of influenza season there, it was observed that as extensive personal and community public health measures took place, reported influenza case numbers fell significantly, more so than usual for that time of year [4].

Earlier this year, the European Centre for Disease Prevention and Control (ECDC) was asked by European Union member state authorities to make recommendations on personal (non-phamaceutical) protective measures that could be taken to reduce the risks of transmission of epidemic and pandemic influenza, either to themselves or from themselves if they are infectious. This work is in addition to that on community-based actions and pharmaceutical measures (vaccination and use of antivirals).

The ECDC recommendations on personal protective measures are based on what is known of the transmission characteristics of influenza and the evidence of effectiveness of measures which have been summarised in extensive reviews in 2005 [3,5,6] They are compatible with those recommendations already put forward by the World Health Organization in its Global Influenza Pandemic Preparedness Plan (Annex 1) [1]

The personal protective measures which are supported by the ECDC are listed below:

  • Regular handwashing (strongly supported)
  • Good respiratory hygiene (covering mouth and nose when coughing or sneezing, using tissues and disposing of them appropriately)
  • Mask wearing in healthcare settings (by those with symptoms of acute respiratory infections)
  • When influenza is circulating, early isolation at home of people feeling unwell and feverish

An evidence-based approach poses problems because this area has long been neglected by researchers and those who fund research. There is suprisingly little evidence and almost no experimental studies to show whether personal protective measures work. Indeed, the ECDC’s strongest recommendation is that this topic should receive urgent research attention [5].

Like WHO, the ECDC is neutral but permissive on general mask wearing by everyone during the influenza season as there is no firm evidence as to whether or not this has an impact on transmission [1,5].

Quarantine, which is the separation or restriction of movement or activity of well people who are thought to have been exposed to influenza and may become infectious to others, is not generally recommended by ECDC for influenza patients, because of practical implications and because infections transmitted by pre-symptomatic people are so rare [3]. However, ECDC would support quarantine if it were recommended by local risk assessments, for example when trying to stop spread in a healthcare setting, or if a person known to be exposed to diagnosed influenza, is nearing the end of the incubation period and has planned to embark on a long journey where self-isolation would be impossible. In the latter case, the person probaby should be advised not to travel. During a severe pandemic voluntary household quarantine (asking families to isolate themselves) following diagnosis of a case of influenza in the family might be considered.

With some caveats mentioned above, these recommendations would generally apply both to human seasonal influenza and during an influenza pandemic. They are interim and are subject to continuous review. Further questions and answers are available at the ECDC website ( Comments on the recommendations, details of pertinent studies that have been published and not covered in the WHO Reviews, and details of experimental studies that are underway or planned are all welcomed and should be sent to

Paula Vasconcelos for scientific review of this article

*Erratum. The original article stated that people at risk were those within a 3 metre radius of infected people who are coughing and sneezing. In fact, this should have been 1 metre. Corrected 18 October 2006.  


  1. World Health Organization. WHO Global Influenza Preparedness Plan. 2005 Annex One. Recommendations for non-pharmaceutical public health measures (pages 42-46) (
  2. Gupta RK, Toby M, Bandopadhyay G, Cooke M, Gelb D, Nguyen-Van-Tam JS. Public understanding of pandemic influenza, United Kingdom [letter]. Emerg Infect Dis [serial on the Internet]. 2006 Oct. (
  3. WHO Writing Group Non-pharmaceutical Interventions for Pandemic Influenza, Review - National and Community Measures Emerging Infectious Disease Journal 2006 Vol 12, January (
  4. Lo JYC, Tsang THF, Leung Y-H, Yeung EYH, Wu T, Lim WWL. Respiratory infections during SARS outbreak, Hong Kong, 2003. Emerg Infect Dis [serial on the Internet]. 2005 Nov (
  5. European Centre for Disease Prevention and Control (
  6. World Health Organization Writing Group. Nonpharmaceutical interventions for pandemic influenza, international measures. Emerging Infectious Disease Journal . 2006 Vol 12 Jan (

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