Handwashing in averting infectious diseases: Relevance to COVID-19

Main Article Content

Mainul Haque https://orcid.org/0000-0002-6124-7993


acute respiratory tract infection, hand hygiene, decontamination, influenza, behavior change, handwashing, hygiene, community, hand sanitizer, influenza infection, influenza transmission, acute gastroenteritis, children, health education, respiratory illness, low- and middle-income countries


After officially declared as a pandemic by the World Health Organization (WHO), drastic measures to restrict human movements to contain the COVID-19 infection are employed by most of the countries. Maintaining high personal hygiene by frequent handwashing and be vigilant of clinical signs are widely recommended to reduce the disease burden. The national and international health agencies, including the Centers for Disease Control and Prevention (CDC) and the WHO, have provided guidelines for prevention and treatment suggestions. Here, in this brief article, based on available clinical information, the author discusses why handwashing could be protective of COVID-19 infections. Although a detailed and in-depth discussion of various preventive and protective measures is beyond the scope of this article, this review will focus on the utility of frequent handwashing in minimizing the risk of spreading COVID-19 infection.
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1. Labarraque AG. Instructions and Observations Concerning the Use of the Chlorides Soda and Lime. Translated by Porter J. New Haven, CT: Baldwin and Treadway; 1829, 1–42. [Internet]. [cited 2020 July 11]. Available from: https:// ia800309.us.archive.org/31/items/62980020R.nlm. nih.gov/62980020R.pdf

2. Rotter ML. 150 years of hand disinfection— Semmelweis’ heritage. Hyg Med. 1997;22:332–9. https://doi.org/10.1136/bmj.319.7208.518

3. Rotter ML. Semmelweis’ sesquicentennial: A little-noted anniversary of handwashing. Curr Opin Infect Dis. 1998;11(4):457–60. https://doi. org/10.1097/00001432-199808000-00011

4. Noakes TD, Borresen J, Hew-Butler T, Lambert MI, Jordaan E. Semmelweis, and the etiology of puerperal sepsis 160 years on a historical review. Epidemiol Infect. 2008;136(1):1–9. https://doi. org/10.1017/S0950268807008746

5. Semmelweis I. Classics in Social Medicine. The Etiology, Concept and Prophylaxis of Childbed Fever (Excerpts). Translated by Carter C. 1983. 4–12. The University of Wisconsin Press. [Internet]. [cited 2020 July 11]. Available from: https://www. socialmedicine.info/socialmedicine/index.php/ socialmedicine/article/viewFile/178/353

6. Haque M, Sartelli M, McKimm J, Abu Bakar M. Healthcare-associated infections—An overview. Infect Drug Resist. 2018;2018(11):2321–33. https://doi.org/10.2147/IDR.S177247

7. Aiello AE, Coulborn RM, Perez V, Larson EL. Effect of hand hygiene on infectious disease risk in the community setting: A meta-analysis. Am J Public Health. 2008;98(8):1372–81. https://doi. org/10.2105/AJPH.2007.124610

8. McGuinness SL, Barker SF, O’Toole J, et al. Effect of hygiene interventions on acute respiratory infections in childcare, school, and domestic settings in low- and middle-income countries: A systematic review. Trop Med Int Health. 2018;23(8):816–33. https://doi.org/10.1111/tmi.13080

9. Wang Z, Lapinski M, Quilliam E, Jaykus LA, Fraser A. The effect of hand-hygiene interventions on infectious disease-associated absenteeism in elementary schools: A systematic literature review. Am J Infect Control. 2017;45(6):682–9. https://doi.org/10.1016/j.ajic.2017.01.018

10. Warren-Gash C, Fragaszy E, Hayward AC. Hand hygiene to reduce community transmission of influenza and acute respiratory tract infection: A systematic review. Influenza Other Respir Viruses. 2013;7(5):738–49. https://doi.org/10.1111/irv.12015

11. Moncion K, Young K, Tunis M, Rempel S, Stirling R, Zhao L. Effectiveness of hand hygiene practices in preventing influenza virus infection in the community setting: A systematic review. Can Commun Dis Rep. 2019;45(1):12–23. https://doi. org/10.14745/ccdr.v45i01a02

12. Mbakaya BC, Lee PH, Lee RL. Hand hygiene intervention strategies to reduce diarrhoea and respiratory infections among schoolchildren in  developing countries: A systematic review. Int J Environ Res Public Health. 2017;14(4): 371. https://doi.org/10.3390/ijerph14040371

13. Petersen E, Wasserman S, Lee SS, et al. COVID-19 —We urgently need to start developing an exit strategy. Int J Infect Dis. 2020;96:233–9. https:// doi.org/10.1016/j.ijid.2020.04.035

14. Commission on a Global Health Risk Framework for the Future; National Academy of Medicine, Secretariat. The neglected dimension of global security: A framework to counter infectious disease crises, 3, strengthening public health as the foundation of the health system and first line of defense. [Internet]. Washington, DC: National Academies Press (US); 2016. [cited 2020 June 5]. Available from: https://www.ncbi.nlm.nih.gov/ books/NBK368392/

15. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Board on Global Health; Committee on Clinical Trials during the 2014-2015 Ebola outbreak. In: Busta ER, Mancher M, Cuff PA, et al., editors. Integrating clinical research into epidemic response: The Ebola experience. Strengthening capacity for response and research [Internet]. Washington, DC: National Academies Press; 2017 [cited 2020 June 05]. Available from: https:// www.ncbi.nlm.nih.gov/books/NBK441672/

16. Haque M, Islam T, Rahman NAA, et al. Strengthening primary health-care services to help prevent and control long-term (chronic) non-communicable diseases in low- and middle-income countries. Risk Manag Healthc Policy. 2020; 2020(13):409–26. https://doi.org/10.2147/RMHP. S241399

17. World Health Organization. WHO guidelines on hand hygiene in health care: First global patient safety challenge clean care is safer care. Chapter 7. Transmission of pathogens by hands [Internet]. Geneva: World Health Organization; 2009. [cited 2020 June 5]. Available from: https://www.ncbi. nlm.nih.gov/books/NBK144014/

18. Burton M, Cobb E, Donachie P, Judah G, Curtis V, Schmidt WP. The effect of handwashing with water or soap on bacterial contamination of hands. Int J Environ Res Public Health. 2011;8(1):97–104. https://doi.org/10.3390/ijerph8010097

19. Freeman MC, Stocks ME, Cumming O, et al. Hygiene and health: A systematic review of hand-washing practices worldwide and update of health effects. Trop Med Int Health. 2014;19(8):906–16. https://doi.org/10.1111/tmi.12339

20. Lau JT, Yang X, Pang E, Tsui HY, Wong E, Wing YK. SARS-related perceptions in Hong Kong. Emerg Infect Dis. 2005;11(3):417–24. https://doi. org/10.3201/eid1103.040675
21. Lau JT, Yang X, Tsui H, Kim JH. Monitoring community responses to the SARS epidemic in Hong Kong: From day 10 to day 62. J Epidemiol Community Health. 2003;57(11):864–70. https:// doi.org/10.1136/jech.57.11.864

22. Lau JT, Tsui H, Lau M, Yang X. SARS transmission, risk factors, and prevention in Hong Kong. Emerg Infect Dis. 2004;10(4):587–92. https://doi. org/10.3201/eid1004.030628

23. Tang CS, Wong CY. Factors influencing the wearing of face masks to prevent severe acute respiratory syndrome among adult Chinese in Hong Kong. Prev Med. 2004;39(6):1187–93. https://doi. org/10.1016/j.ypmed.2004.04.032

24. Rabie T, Curtis V. Handwashing and risk of respiratory infections: A quantitative systematic review. Trop Med Int Health. 2006;11(3):258–67. https:// doi.org/10.1111/j.1365-3156.2006. 01568.x

25. Mehta Y, Gupta A, Todi S, et al. Guidelines for prevention of hospital-acquired infections. Indian J Crit Care Med. 2014;18(3):149–63. https://doi. org/10.4103/0972-5229.128705

26. Carroll A. Hand washing for health-care workers in domestic care settings. Br J Community Nurs. 2001;6(5):217–23. https://doi.org/10.12968/bjcn. 2001.6.5.7081

27. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/ SHEA/ APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1–CE4.

28. Ariza-Heredia EJ, Chemaly RF. Update on infection control practices in cancer hospitals. CA Cancer J Clin. 2018;68(5):340–55. https://doi.org/ 10.3322/caac.21462

29. World Health Organization. World alliance for patient safety. Global patient safety challenge: 2005–2006 [Internet]. World Health Organization, Geneva, 2005 [cited 2020 June 06]. Available from: https://www.who.int/patientsafety/events/05/ GPSC_Launch_ENGLISH_FINAL.pdf?ua=1

30. Mathur P. Hand hygiene: Back to the basics of  infection control. Indian J Med Res. 2011;134(5):611–20. https://doi.org/10.4103/0971-5916.90985

31. Pittet D, Allegranzi B, Storr J. The WHO clean care is safer care program: Field-testing to enhance sustainability and spread of hand hygiene improvements. J Infect Public Health. 2008;1(1):4–10. https://doi.org/10.1016/j.jiph.2008. 08.006

32. Magiorakos AP, Leens E, Drouvot V, et al. Pathways to clean hands: Highlights of successful hand hygiene implementation strategies in Europe. Euro Surveill. 2010;15(18):19560.

33. Singhal T. A review of Coronavirus disease-2019 (COVID-19). Indian J Pediatr. 2020;87(4):281–6. https://doi.org/10.1007/s12098-020-03263-6

34. Mackenzie JS, Smith DW. COVID-19: A novel zoonotic disease caused by a coronavirus from China: What we know and what we don’t. Microbiol Aust. 2020;41(1):45–50. https://doi. org/10.1071/MA20013

35. Harvard Medical School. COVID-19 basics. Symptoms spread and other essential information about the new coronavirus and COVID-19 [Internet]. Harvard Health Publishing 2020 [cited 2020 Apr 22]. Available from: https://www. health.harvard.edu/diseases-and-conditions/ covid-19-basics

36. National Jewish Health. Coronavirus (COVID-19): Symptoms [Internet]. 2020 [cited 2020 Apr 20]. Available from: https://www.nationaljewish.org/ conditions/coronavirus-covid-19/symptoms

37. Park SE. Epidemiology, virology, and clinical features of severe acute respiratory syndrome— Coronavirus-2 (SARS-CoV-2; Coronavirus Disease-19). Clin Exp Pediatr. 2020;63(4):119–24. https://doi.org/10.3345/cep.2020.00493

38. World Health Organization. WHO director-general’s opening remarks at the media briefing on COVID-19—11 March 2020 [Internet]. WHO 2020 [cited 2020 Apr 22]. Available from: https:// www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020

39. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;323(13):1239–42. https://doi.org/10.1001/jama. 2020.2648

40. Khadka S, Hashmi FK, Usman M. Preventing COVID-19 in low- and middle-income countries. Drugs Ther Perspect. 2020 Apr;13:1–3. https://doi. org/10.1007/s40267-020-00728-8

41. Imperial College London. WHO collaborating Centre for Infectious Disease Modelling. The global impact of COVID-19 and strategies for mitigation and suppression [Internet]. MRC Centre for Global Infectious Disease analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics, Imperial College London; 2020 [cited 2020 Apr 22]. Available from: https:// www.imperial.ac.uk/media/imperial-college/med-icine/sph/ide/gida-fellowships/Imperial-College-COVID19-Global-Impact-26-03-2020v2.pdf

42. Bruinen de Bruin Y, Lequarre AS, McCourt J, et al. Initial impacts of global risk mitigation measures taken during the combatting of the COVID-19 pandemic. Saf Sci. 2020;14(3):104773. https:// doi.org/10.1016/j.ssci.2020.104773

43. Contini C, Di Nuzzo M, Barp N, et al. The novel zoonotic COVID-19 pandemic: An expected global health concern. J Infect Dev Ctries. 2020;14(3):254–64. https://doi.org/10.3855/jidc. 12671

44. Institute of Medicine (US) Forum on Microbial Threats. A world in motion: The global movement of people, products, pathogens, and power. In: Knobler S, Mahmoud A, Lemon S, et al., editors. The impact of globalization on infectious disease emergence and control. Exploring the consequences and opportunities: Workshop summary. Proceedings [Internet]. National Academies Press, Washington, DC: 2006 [cited]. Available from: https://www.ncbi.nlm.nih.gov/ books/NBK56593/

45. Chakraborty I, Maity P. COVID-19 outbreak: Migration, effects on society, global environment, and prevention. Sci Total Environ. 2020;728:138882. https://doi.org/10.1016/j.scitotenv.2020.138882

46. Schwalbe N, Hupert N. Models, math, and COVID-19: A public health response [Internet]. International Institute for Global Health, United Nations University; 2020 [cited 2020 June 05]. Available from: https://iigh.unu.edu/publications/ articles/models-math-and-covid-19-a-public-health-response.htmlA

47. Rothwell DR. Good government, bad government: The politics of public health. US break with WHO: Where does it leave the rest of the world? [Internet]. The Lowy Institute. 2020 [cited 2020 June 05]. Available from: https://www.lowyinsti-tute.org/the-interpreter/debate/good-government-bad-government-politics-public-health

48. Demaio AR, Kragelund Nielsen K, Pinkowski Tersbøl B, Kallestrup P, Meyrowitsch DW. Primary health care: A strategic framework for the prevention and control of chronic non-communicable disease. Glob Health Action. 2014;7(1):24504. https://doi.org/10.3402/gha.v7.24504

49. UN News. Workers and COVID-19: Access to healthcare, now ‘a matter of life and death.’ Global perspective Human stories [Internet]. 2020 [cited 2020 June 05]. Available from: https://news.un.org/ en/story/2020/05/1064112

50. International Labor Organization. Informal economy. More than 60 percent of the world’s employed population are in the informal economy Social protection responses to the COVID-19 pandemic in developing countries: Strengthening resilience by  building universal social protection [Internet]. Social Protection Spotlight. 2018 [cited 2020 June 05]. Available from: https://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_627189/ lang--en/index.html

51. International Labor Organization. Social protection responses to the COVID-19 pandemic in developing countries: Strengthening resilience by building universal social protection [Internet]. Social Protection Spotlight. 2020 [cited 2020 June 05]. Available from: https:// www.ilo.org/wcmsp5/groups/public/---ed_pro-t e c t / - - - s o c _ s e c / d o c u m e n t s / p u bl i c at i o n / wcms_744612.pdf

52. Pell MB, Lesser B. The COVID-19 lockdown will take its own toll on health, researchers warn [Internet]. World Economic Forum. 2020 [cited 2020 Apr 22]. Available from: https://www.wefo-rum.org/agenda/2020/04/how-the-covid-19-lockdown-will-take-its-own-toll-on-health/

53. Nortajuddin A. COVID-19: Debunking myths [Internet]. The ASEAN Post. [cited 2020 Apr 22]. Available from: https://theaseanpost.com/article/ covid-19-debunking-myths

54. Financial Times. Coronavirus: Trump orders the US to halt funding to WHO—as it happened [Internet]. 2020 [cited 2020 Apr 22]. Available from: https://www.ft.com/content/59ff62ae-3f66-3ec2-b269-e94e9a72f198

55. Yulisman L. Coronavirus pandemic. Compulsory for Indonesians to wear masks in public [Internet]. The Straits Times. 2020 [cited 2020 Apr 22]. Available from: https://www.straitstimes.com/asia/ se-asia/compulsory-for-indonesians-to-wear-masks-in-public

56. The Guardian. How far? How soon? Czechs grapple with how to ease COVID-19 lockdown [Internet]. 2020 [cited 2020 Apr 22]. Available from: https://www.theguardian.com/world/2020/apr/19/ czechs-grapple-with-how-to-ease-covid-19-lockdown

57. Islam SM, Purnat TD, Phuong NT, Mwingira U, Schacht K, Fröschl G. Non-communicable diseases (NCDs) in developing countries: A symposium report. Global Health. 2014;10(81):81. https://doi.org/10.1186/s12992-014-0081-9

58. Rule J, Ngo DA, Oanh TT, et al. Strengthening primary health care in low- and middle-income countries: Generating evidence through evaluation. Asia Pac J Public Health. 2014;26(4):339–48. https://doi.org/10.1177/1010539513503869

59. Kruk ME, Nigenda G, Knaul FM. Redesigning primary care to tackle the global epidemic of noncommunicable disease. Am J Public Health. 2015;105(3):431–7. https://doi.org/10.2105/AJPH. 2014.302392

60. Bardossy AC, Zervos J, Zervos M. Preventing hospital-acquired infections in low-income and middle-income countries: Impact, gaps, and opportunities. Infect Dis Clin North Am. 2016;30(3):805–18. https://doi.org/10.1016/j.idc. 2016.04.006

61. Palagyi A, Marais BJ, Abimbola S, Topp SM, McBryde ES, Negin J. Health system preparedness for emerging infectious diseases: A synthesis  of the literature. Glob Public Health. 2019;14(12):1847–68. https://doi.org/10.1080/174 41692.2019.1614645

62. Alessi C. The effect of the COVID-19 epidemic on health and care—Is this a portent of the ‘new normal’? [Internet]. Healthcare IT News. Europe/ UK. Population Health. 2020 [cited 2020 Apr 22]. Available from: https://www.healthcareitnews. com/blog/europe/effect-covid-19-epidemic-health-and-care-portent-new-normal

63. The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)— China, 2020[J]. China CDC Weekly. 2020;2(8): 113–22.

64. World Health Organization. Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19) [Internet]. 2020 [cited 2020 Apr 22]. Available from: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf

65. Evans D, Over M. The economic impact of COVID-19 in low- and middle-income countries [Internet]. Center for Global Development; 2020 [cited 2020 Apr 22]. Available from: https://www. cgdev.org/blog/economic-impact-covid-19-low-and-middle-income-countries

66. Mckenzie B. Beyond COVID-19: Supply chain resilience holds the key to recovery [Internet]. Oxford Economics; 2020 [cited 2020 Apr 22]. Available from: https://www.bakermckenzie. com/-/media/files/insight/publications/2020/04/ covid19-global-economy.pdf

67. Neo P. COVID-19’s crop crisis: Pandemic poses a  major risk to Asia’s food supply and trade— Expert [Internet]. 2020 [cited 2020 Apr 22]. Available from: https://www.foodnavigator-asia. com/Article/2020/04/15/COVID-19-s-crop-crisis-Pandemic-poses-major-risk-to-Asia-s-food-supply-and-trade-expert?utm_source=copyright& utm_medium=OnSite&utm_campaign=copyright

68. Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings [Internet]. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. 2020 [cited 2020 Apr 23]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ infection-control-recommendations.html

69. Westcott B, Renton A. Live updates. Coronavirus pandemic: Updates from around the world [Internet]. 2020 [cited 2020 Apr 23]. Available from: https://edition.cnn.com/world/live-news/ coronavirus-pandemic-04-23-20-intl/index.html

70. The Lancet. COVID-19: Too little, too late? Lancet. 2020;395(10226):755. https://doi.org/10.1016/ S0140-6736(20)30522-5

71. Yang X, Yu Y, Xu J, et al. Clinical course and out-comes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med. 2020;8:475–81. https://doi.org/10.1016/ S2213-2600(20)30079-5

72. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet. 2020;395(10223):470–3. https://doi. org/10.1016/S0140-6736(20)30185-9

73. Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020;382(8):727–33. https:// doi.org/10.1056/NEJMoa2001017

74. Bhutta ZA, Basnyat B, Saha S, Laxminarayan R. COVID-19 risks and response in South Asia. BMJ. 2020;368:m1190. https://doi.org/10.1136/ bmj.m1190

75. Brewster D. Why South Asia may come out of the COVID-19 crisis better than many expect [Internet]. 2020 [cited 2020 Apr 24]. Available from: https:// www.lowyinstitute.org/the-interpreter/why-south-asia-may-come-out-covid-19-crisis-better-many-expect

76. Sajid I. South Asia: Virus cases top 35,000, deaths pass 1,000 India is region’s hardest-hit country, followed by Pakistan, Bangladesh, and Afghanistan [Internet]. [cited 2020 Apr 24]. Available from: https://www.aa.com.tr/en/asia-pacific/south-asia-virus-cases-top-35-000-deaths-pass-1-000/ 1814760#

77. World Population Review. SAARC countries, 2020 [Internet]. 2020 [cited 2020 Apr 24]. Available from: https://worldpopulationreview.com/coun-tries/saarc-countries/

78. European Center for Disease Prevention and Control. Coronavirus disease 2019 (COVID-19) in the EU/EEA and the UK—Eighth update. Rapid Risk Assessment [Internet]. 2020 [cited 2020 Apr 24]. Available from: https://www.ecdc. europa.eu/sites/default/files/documents/covid-19-rapid-risk-assessment-coronavirus-disease-2019-eighth-update-8-april-2020.pdf

79. The World Bank. Population ages 65 and above (% of the total population) [Internet]. 2019 [cited 2020 Apr 24]. Available from: https://data.world-bank.org/indicator/SP.POP.65UP.TO.ZS? locations=US-IT-FR-ES-GB

80. Collins AS. Preventing health care-associated infections. In: Hughes RG, editor. Patient safety and quality: An evidence-based handbook for nurses. Chapter 41 [Internet]. Rockville, MD: Agency for Healthcare Research and Quality (US); 2008 [cited 2020 Apr 24].. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2683/

81. Zhou Q, Fan L, Lai X, Tan L, Zhang X. Estimating extra length of stay and risk factors of mortality attributable to healthcare-associated infection at a Chinese university hospital: A multi-state model. BMC Infect Dis. 2019;19(1):975. https:// doi.org/10.1186/s12879-019-4474-5
82. Anargh V, Singh H, Kulkarni A, Kotwal A, Mahen A. Hand hygiene practices among healthcare workers (HCWs) in a tertiary care facility in Pune. Med J Armed Forces India. 2013;69(1):54–6. https://doi.org/10.1016/j.mjafi.2012.08.011

83. Loftus MJ, Guitart C, Tartari E, et al. Hand hygiene in low- and middle-income countries. Int J Infect Dis. 2019;86:25–30. https://doi.org/10.1016/j. ijid.2019.06.002

84. Sax H, Allegranzi B, Chraïti MN, Boyce J, Larson E, Pittet D. The World Health Organization hand hygiene observation method. Am J Infect Control. 2009;37(10):827–34. https://doi.org/10.1016/j.ajic. 2009.07.003

85. Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. ‘My five moments for hand hygiene’: A user-centered design approach to understand, train, monitor and report hand hygiene. J Hosp Infect. 2007;67(1):9–21. https://doi.org/10.1016/j. jhin.2007.06.004

86. Atkinson J, Chartier Y, Pessoa-Silva CL, et al., editors. Natural ventilation for infection control in health-care settings. Annex C, Respiratory droplets [Internet]. Geneva: World Health Organization; 2009 [cited 2020 Apr 24]. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK143281/

87. Tellier R, Li Y, Cowling BJ, Tang JW. Recognition of aerosol transmission of infectious agents: A commentary. BMC Infect Dis. 2019;19(1):101. https://doi.org/10.1186/s12879-019-3707-y

88. Kucharski AJ, Russell TW, Diamond C, et al. Early dynamics of transmission and control of COVID-19: A mathematical modeling study. Lancet Infect Dis. 2020;20:553–58. https://doi. org/10.1016/S1473-3099(20)30144-4

89. Wu JT, Leung K, Bushman M, et al. Estimating clinical severity of COVID-19 from the transmission dynamics in Wuhan, China. Nat Med. 2020;26(4): 506–10. https://doi.org/10.1038/s41591-020-0822-7

90. Liu J, Liao X, Qian S, et al. Community Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, Shenzhen, China, 2020. Emerg Infect Dis. 2020;26(6):1320–1323. https:// doi.org/10.3201/eid2606.200239

91. Chan J, Yuan S, Kok K, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: A study of a family cluster. Lancet. 2020;395:514–23. https://doi.org/10.1016/S0140-6736(20)30154-9

92. Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med. 2020; 382: 1199–207. https://doi.org/10.1056/NEJMoa 2001316.

93. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506. https://doi.org/10.1016/S0140-6736(20)30183-5

94. Burke RM, Midgley CM, Dratch A, et al. Active monitoring of persons exposed to patients with confirmed COVID-19—United States, January– February 2020. MMWR Morb Mortal Wkly Rep. 2020;69(9):245–6. https://doi.org/10.15585/mmwr. mm6909e1external icon

95. Marinella MA. COVID-19 pandemic and the stethoscope: Don’t forget to sanitize. Heart Lung. 2020;49:350. https://doi.org/10.1016/j.hrtlng. 2020.03.017

96. World Health Organization. Modes of transmission of the virus causing COVID-19: Implications for IPC precaution recommendations [Internet]. 2020 [cited 2020 Apr 24]. Available from: https:// www.who.int/news-room/commentaries/detail/ modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations

97. Wolfe MK, Gallandat K, Daniels K, Desmarais AM, Scheinman P, Lantagne D. Handwashing and Ebola virus disease outbreaks: A randomized comparison of soap, hand sanitizer, and 0.05% chlorine solutions on the inactivation and removal of model organisms Phi6 and E. coli from hands and persistence in rinse water. PLoS One. 2017;12(2):e0172734. https://doi.org/10.1371/jour-nal.pone.0172734

98. Tuladhar E, Hazeleger WC, Koopmans M, Zwietering MH, Duizer E, Beumer RR. Reducing viral contamination from finger pads: Handwashing is more effective than alcohol-based hand disinfectants. J Hosp Infect. 2015;90(3):226–34. https://doi.org/10.1016/j.jhin.2015.02.019

99. Thordarson P. The science of soap—Here’s how it kills the coronavirus [Internet]. The Guardian. 2020 [cited 2020 Apr 24]. Available from: https://www. theguardian.com/commentisfree/2020/mar/12/ science-soap-kills-coronavirus-alcohol-based-disinfectants

100. Centers for Disease Control and Prevention. Cleaning and disinfection for households. Interim recommendations for U.S. households with suspected or confirmed coronavirus disease 2019 (COVID-19) [Internet]. CDC 2020 [cited 2020 Apr  24]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/clean-ing-disinfection.html

101. Jha A, Kawoosa VM. Why social distancing is tough to implement. The first problem in implementing social distancing in India could be its population density itself [Internet]. Hindustan Times. 2020 [cited 2020 June 6]. Available from: https://www.hindustantimes.com/india-news/ why-social-distancing-is-tough-to-implement/sto-ry-iTp2VbV2GQxEvIeSwoOMCK.html

102. Hopman J, Allegranzi B, Mehtar S. Managing COVID-19 in low- and middle-income countries. JAMA. 2020;323(16):1549–50. https://doi.org/ 10.1001/jama.2020.4169