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SoleimanvandiAzar N, Aalaa M, Asadzandi S, Habibi H, Sanjari M, Malgard S. Effective protection methods against COVID-19: an umbrella review. jha 2025; 28 (1) :23-39
URL: http://jha.iums.ac.ir/article-1-4590-en.html
URL: http://jha.iums.ac.ir/article-1-4590-en.html
Neda SoleimanvandiAzar1 
, Maryam Aalaa2 , Shadi Asadzandi3 , Hengameh Habibi4 , Mahnaz Sanjari5 , Shiva Malgard6
, Maryam Aalaa2 , Shadi Asadzandi3 , Hengameh Habibi4 , Mahnaz Sanjari5 , Shiva Malgard6
1- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
2- Department of Medical Education, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
3- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran. ,Asadzandi.sh@iums.ac.ir
4- Emergency Department, Faculty of Nursing, Aja University of Medical Sciences, Tehran, Iran.
5- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. & Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
6- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
2- Department of Medical Education, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
3- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran. ,
4- Emergency Department, Faculty of Nursing, Aja University of Medical Sciences, Tehran, Iran.
5- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. & Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
6- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
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Introduction
Coronavirus disease 2019 (COVID-19) is an infectious disease caused by a coronavirus, SARS-CoV-2 (severe acute respiratory syndrome CoronaVirus-2) [1]. SARS-CoV-2 is transmitted through respiratory droplets, direct contact, and occasionally the airborne particles [2-5]. Since the outset of the pandemic, the most commonly globally implemented strategies to prevent the spread of COVID-19 have included advanced testing, contact tracing, isolation of infected cases, social distancing (SD), travel restriction, remote work, quarantine, lockdown, and school and business closure [6]. Systematic reviews have provided evidence on various respiratory viral infections, particularly seasonal influenza and COVID-19. However, an umbrella review is necessary due to the inconsistent and contradictory findings regarding the effectiveness, efficiency, and acceptability of preventive measures against SARS-CoV-2 and other beta viruses. Therefore, this umbrella review was conducted to assess the evidence on effective protective measures to prevent the transmission of COVID-19.
Methods
This umbrella review was conducted in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [7].
Search strategy: An advanced search was conducted in the Web of Science (WOS), Scopus, PubMed, Cochrane Library, Emerald, ProQuest, and Google Scholar. Reviews published in scientific journals up to the end of November 2021 were included. The search operators included Boolean operators (AND, OR and NOT), parenthesis, and truncation (see Supplement). After retrieving the articles, duplicates were eliminated using Endnote X8.2.
Inclusion criteria: The inclusion criteria for this review were as follows: 1) publications in English language; 2) systematic, systematized, or scoping reviews; 3) focus on face masks, personal protective equipment (PPE), or social distancing related to COVID-19; 4) availability of full text, and 5) review context encompassing the general population, patients, or healthcare workers (HCW).
The screening process, critical appraisal, and data extraction: Two independent researchers initially reviewed the titles and abstracts of all articles using a standardized checklist to exclude irrelevant studies. Subsequently, two researchers independently assessed the full texts to determine their eligibility. Any disagreements between the reviewers were resolved through discussion. The authors, then, extracted the following data from each eligible article: bibliographic information, objectives, research design, population, outcomes, and risk of bias.
Quality assessment: The AMSTAR 2 was utilized to critically appraise the included reviews. All 16 items of the AMSTAR 2 checklist were evaluated for each review. Most items have response options of Yes and No; however, some included a third option of Partial Yes. Four reviewers independently assessed the specified domains. Seven of 16 items were considered critical (Items 2, 4, 7, 9, 11, 13, and 15). The overall quality of each review was rated in four categories: high (no or one non-critical weakness), moderate (more than one non-critical weakness), low (one critical flaw, with or without non-critical weaknesses), and critically low (more than one critical flaw, with or without non-critical weaknesses [8].
Results
The study population of the included reviews comprised healthcare workers (HCWs) (n = 16), general population (n = 19), HCWs, the general population, and patients (n = 2), HCWs and the general population (n = 5), patients and general population (n = 2), and HCW along with college students (n = 1). The included reviews addressed three main protective methods: face masks (n = 40), PPE (n = 8), and social distancing (n = 2). Since six articles assessed more than one protective method, a fourth category was considered for studies, evaluation of more than one COVID-19 transmission protective methods (see Supplementary Tables).
Masks as a COVID-19 transmission protective method :Most of the reviews suggested that mask-wearing would be effective in preventing COVID-19 transmission [1,9-29]). According to the AMSTAR 2, 12 studies were critically low (CL), eight were high (H), and two were medium (M). Nevertheless, some studies did not report any protective effect of masks [30-33] (2 H, 2 CL), and one review concluded that there were inadequate data to assess t face mask effectiveness [34] (H). Some studies reported the effect of mask type on COVID-19 transmission prevention. N95 masks were found to be more effective than surgical [35] (H) or medical masks [18] (H), while surgical [36] (H) or medical masks [25,37] (1 M, 1 CL) were more effective than cloth masks. Cloth masks were the least effective among the mask types [38,39] (H, CL), whereas N95 masks were the most effective in preventing COVID-19 transmission [27,28] (H, M). Standard non-woven face masks were also found to be effective [14] (CL). Masks-wearing showed higher effectiveness among HCWs compared to general population [13,35] (1 CL, 1 H). However, one rapid systematic review found mask-wearing effective among healthy individuals in the community, HCWs, and patients [2] (L).
PPE as a COVID-19 transmission protective method :The combined use of masks, hand hygiene, and disinfectants revealed the increased effectiveness of these protections [17,40-42] (2 L, 2 H). Furthermore, masks used in combination with face shields [43-45] (2CL, 1 L) or eyewear [44] (L) were found to be effective. Gowns, gloves, and eye protection were also recommended for use in healthcare settings [40,43] (2 CL).
Social distancing as a COVID-19 transmission protective method: One systematic review did not clearly report the level of evidence supporting social distancing but still recommended its implementation [40] (CL). Another review supported physical distancing of at least 1 meter and, preferably, 2 meters or more [46] (H).
Discussion
This umbrella review assessed the evidence from reviews on the effectiveness of eye protection equipment, face masks, and physical and social distancing in preventing COVID-19 transmission among the general population, HCWs, and patients. Forty studies examined the effectiveness of various masks (cloth, surgical, N95, etc.) in preventing COVID-19 transmission. The findings of 21 studies confirmed the positive effect of masks in preventing transmission; three studies found medical masks more effective than cloth masks; and five studies reported N95 masks as the most effective type of mask. Two studies reported on protective effect of cloth masks, and four studies found no significant association between the use of surgical, medical, or N95 masks and infection transmission. Additional studies investigated the preventive effects of N95, surgical, and medical masks. Many studies confirmed the effectiveness of these types of masks, which is consistent with the results of the present study [10,12-15,25,42,44,47-49]. According to Abboah [50], regardless of the environment, mask type, or who is wearing it, masks serve two preventive purposes: to protect the wearer from infection, and to protect others from transmission. Therefore, mask-wearing wears face masks in public, a double barrier against COVID-19 transmission will be provided.
Although some studies did not support the effectiveness of masks [27,32], their conclusion may have been influenced by insufficient statistical power or confounding factors. Based on these studies, N95 masks may offer greater protection for HCWs [50]; medical and surgical masks may be effective for the general public; while cloth masks are likely ineffective in preventing transmission. Personal protective equipment (PPE) was another protective method against COVID-19 transmission. Some studies reported that masks, hand hygiene, gowns, gloves, and face shields decrease the risk of transmission, which is in line with WHO recommendations. WHO mentioned that masks alone are insufficient for full protection, and should be combined with other measures such as hand hygiene to prevent human-to-human COVID-19 transmission [44,45,51]. Although there is still little evidence regarding the effectiveness of hand hygiene in preventing COVID-19 infections, it is recognized as one of the most effective interventions in preventing infectious diseases [52].
Social distancing has been a hot topic during the pandemic. Reducing interpersonal contact is a widely used and cost-effective strategy for controlling COVID-19. One study mentioned social distancing; however, the finding was based only on author's suggestion and lacked conclusive evidence. Therefore, the combined use of multiple prevention methods will be more effective [39-41, 43,45]. Two reviews reported social distancing as a protective method against COVID-19 transmission [39,41]. Maintaining a distance of at least one meter has been shown to effectively decrease infection transmission [46]. Social distancing measures, such as travel restrictions, school closure, avoiding mass gatherings, closure of non-essential commercial operations, and lack of presence in animal shelters aim to decrease transmission by minimizing interpersonal contact [53]. Many studies have confirmed the role of social distancing in COVID-19 prevention [54-56]. Meanwhile, some studies have questioned the effect of social distancing [57,58]. The public health outcomes of limited social relationships may include domestic violence and mental health problems, such as anxiety and depression. Despite challenges to community health services, social distancing is preferred [57].
Limitations
Due to the rapid spread of COVID-19 and the sensitive nature of the situation, the study protocol was not registered in any databases. In addition, only systematic reviews, rapid reviews, and scoping reviews were considered, while other types of reviews such as overviews, literature reviews, and status reviews were excluded. Moreover, full text access was unavailable for some studies, which were excluded from the review. It should be noted that the absence of meta-analysis is another limitation.
Conclusion
The study revealed that combining several protective methods, such as hand hygiene, mask-wearing, and physical or social distancing of at least
Coronavirus disease 2019 (COVID-19) is an infectious disease caused by a coronavirus, SARS-CoV-2 (severe acute respiratory syndrome CoronaVirus-2) [1]. SARS-CoV-2 is transmitted through respiratory droplets, direct contact, and occasionally the airborne particles [2-5]. Since the outset of the pandemic, the most commonly globally implemented strategies to prevent the spread of COVID-19 have included advanced testing, contact tracing, isolation of infected cases, social distancing (SD), travel restriction, remote work, quarantine, lockdown, and school and business closure [6]. Systematic reviews have provided evidence on various respiratory viral infections, particularly seasonal influenza and COVID-19. However, an umbrella review is necessary due to the inconsistent and contradictory findings regarding the effectiveness, efficiency, and acceptability of preventive measures against SARS-CoV-2 and other beta viruses. Therefore, this umbrella review was conducted to assess the evidence on effective protective measures to prevent the transmission of COVID-19.
Methods
This umbrella review was conducted in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [7].
Search strategy: An advanced search was conducted in the Web of Science (WOS), Scopus, PubMed, Cochrane Library, Emerald, ProQuest, and Google Scholar. Reviews published in scientific journals up to the end of November 2021 were included. The search operators included Boolean operators (AND, OR and NOT), parenthesis, and truncation (see Supplement). After retrieving the articles, duplicates were eliminated using Endnote X8.2.
Inclusion criteria: The inclusion criteria for this review were as follows: 1) publications in English language; 2) systematic, systematized, or scoping reviews; 3) focus on face masks, personal protective equipment (PPE), or social distancing related to COVID-19; 4) availability of full text, and 5) review context encompassing the general population, patients, or healthcare workers (HCW).
The screening process, critical appraisal, and data extraction: Two independent researchers initially reviewed the titles and abstracts of all articles using a standardized checklist to exclude irrelevant studies. Subsequently, two researchers independently assessed the full texts to determine their eligibility. Any disagreements between the reviewers were resolved through discussion. The authors, then, extracted the following data from each eligible article: bibliographic information, objectives, research design, population, outcomes, and risk of bias.
Quality assessment: The AMSTAR 2 was utilized to critically appraise the included reviews. All 16 items of the AMSTAR 2 checklist were evaluated for each review. Most items have response options of Yes and No; however, some included a third option of Partial Yes. Four reviewers independently assessed the specified domains. Seven of 16 items were considered critical (Items 2, 4, 7, 9, 11, 13, and 15). The overall quality of each review was rated in four categories: high (no or one non-critical weakness), moderate (more than one non-critical weakness), low (one critical flaw, with or without non-critical weaknesses), and critically low (more than one critical flaw, with or without non-critical weaknesses [8].
Results
The study population of the included reviews comprised healthcare workers (HCWs) (n = 16), general population (n = 19), HCWs, the general population, and patients (n = 2), HCWs and the general population (n = 5), patients and general population (n = 2), and HCW along with college students (n = 1). The included reviews addressed three main protective methods: face masks (n = 40), PPE (n = 8), and social distancing (n = 2). Since six articles assessed more than one protective method, a fourth category was considered for studies, evaluation of more than one COVID-19 transmission protective methods (see Supplementary Tables).
Masks as a COVID-19 transmission protective method :Most of the reviews suggested that mask-wearing would be effective in preventing COVID-19 transmission [1,9-29]). According to the AMSTAR 2, 12 studies were critically low (CL), eight were high (H), and two were medium (M). Nevertheless, some studies did not report any protective effect of masks [30-33] (2 H, 2 CL), and one review concluded that there were inadequate data to assess t face mask effectiveness [34] (H). Some studies reported the effect of mask type on COVID-19 transmission prevention. N95 masks were found to be more effective than surgical [35] (H) or medical masks [18] (H), while surgical [36] (H) or medical masks [25,37] (1 M, 1 CL) were more effective than cloth masks. Cloth masks were the least effective among the mask types [38,39] (H, CL), whereas N95 masks were the most effective in preventing COVID-19 transmission [27,28] (H, M). Standard non-woven face masks were also found to be effective [14] (CL). Masks-wearing showed higher effectiveness among HCWs compared to general population [13,35] (1 CL, 1 H). However, one rapid systematic review found mask-wearing effective among healthy individuals in the community, HCWs, and patients [2] (L).
PPE as a COVID-19 transmission protective method :The combined use of masks, hand hygiene, and disinfectants revealed the increased effectiveness of these protections [17,40-42] (2 L, 2 H). Furthermore, masks used in combination with face shields [43-45] (2CL, 1 L) or eyewear [44] (L) were found to be effective. Gowns, gloves, and eye protection were also recommended for use in healthcare settings [40,43] (2 CL).
Social distancing as a COVID-19 transmission protective method: One systematic review did not clearly report the level of evidence supporting social distancing but still recommended its implementation [40] (CL). Another review supported physical distancing of at least 1 meter and, preferably, 2 meters or more [46] (H).
Discussion
This umbrella review assessed the evidence from reviews on the effectiveness of eye protection equipment, face masks, and physical and social distancing in preventing COVID-19 transmission among the general population, HCWs, and patients. Forty studies examined the effectiveness of various masks (cloth, surgical, N95, etc.) in preventing COVID-19 transmission. The findings of 21 studies confirmed the positive effect of masks in preventing transmission; three studies found medical masks more effective than cloth masks; and five studies reported N95 masks as the most effective type of mask. Two studies reported on protective effect of cloth masks, and four studies found no significant association between the use of surgical, medical, or N95 masks and infection transmission. Additional studies investigated the preventive effects of N95, surgical, and medical masks. Many studies confirmed the effectiveness of these types of masks, which is consistent with the results of the present study [10,12-15,25,42,44,47-49]. According to Abboah [50], regardless of the environment, mask type, or who is wearing it, masks serve two preventive purposes: to protect the wearer from infection, and to protect others from transmission. Therefore, mask-wearing wears face masks in public, a double barrier against COVID-19 transmission will be provided.
Although some studies did not support the effectiveness of masks [27,32], their conclusion may have been influenced by insufficient statistical power or confounding factors. Based on these studies, N95 masks may offer greater protection for HCWs [50]; medical and surgical masks may be effective for the general public; while cloth masks are likely ineffective in preventing transmission. Personal protective equipment (PPE) was another protective method against COVID-19 transmission. Some studies reported that masks, hand hygiene, gowns, gloves, and face shields decrease the risk of transmission, which is in line with WHO recommendations. WHO mentioned that masks alone are insufficient for full protection, and should be combined with other measures such as hand hygiene to prevent human-to-human COVID-19 transmission [44,45,51]. Although there is still little evidence regarding the effectiveness of hand hygiene in preventing COVID-19 infections, it is recognized as one of the most effective interventions in preventing infectious diseases [52].
Social distancing has been a hot topic during the pandemic. Reducing interpersonal contact is a widely used and cost-effective strategy for controlling COVID-19. One study mentioned social distancing; however, the finding was based only on author's suggestion and lacked conclusive evidence. Therefore, the combined use of multiple prevention methods will be more effective [39-41, 43,45]. Two reviews reported social distancing as a protective method against COVID-19 transmission [39,41]. Maintaining a distance of at least one meter has been shown to effectively decrease infection transmission [46]. Social distancing measures, such as travel restrictions, school closure, avoiding mass gatherings, closure of non-essential commercial operations, and lack of presence in animal shelters aim to decrease transmission by minimizing interpersonal contact [53]. Many studies have confirmed the role of social distancing in COVID-19 prevention [54-56]. Meanwhile, some studies have questioned the effect of social distancing [57,58]. The public health outcomes of limited social relationships may include domestic violence and mental health problems, such as anxiety and depression. Despite challenges to community health services, social distancing is preferred [57].
Limitations
Due to the rapid spread of COVID-19 and the sensitive nature of the situation, the study protocol was not registered in any databases. In addition, only systematic reviews, rapid reviews, and scoping reviews were considered, while other types of reviews such as overviews, literature reviews, and status reviews were excluded. Moreover, full text access was unavailable for some studies, which were excluded from the review. It should be noted that the absence of meta-analysis is another limitation.
Conclusion
The study revealed that combining several protective methods, such as hand hygiene, mask-wearing, and physical or social distancing of at least
1 m can significantly reduce COVID-19 transmission. It is recommended that the general public use three-layer medical masks, while HCWs should wear N95, medical, or surgical masks, as along with other PPE. More quantitative studies are needed, and clinical trials should be conducted to address all aspects of this disease. Researchers are also suggested to pay more attention to social distancing and eye protection tools, so that in future pandemic, these methods can be implemented with greater confidence in their effectiveness.
Supplements: Search strategy and extracted data from studies.
Declarations
Ethical considerations: This document represents findings of a project at Iran University of Medical Sciences. The secured reference number of the code of ethics to conduct the project is IR.IUMS.REC.1400.676
Funding: This study was funded as a research project by Iran University of Medical Sciences. The funder had no role in data collection, analysis and manuscript preparation.
Conflicts of interests: The authors declare that they have no competing interest.
Authors’ contribution: SHA: Data analysis, writing– original draft, final approval; MA: Study design, data analysis, writing– original draft, final approval; SHM: Study design, data analysis, writing– original draft, final approval; NS: Data analysis, writing– original draft, final approval; MS: Study design; HH: Data curation; final approval. All authors read and approved the final manuscript.
Consent for publication: Not applicable.
Data availability: All data reported in text and supplements.
AI Declaration: None.
Acknowledgments: The present study is part of a research project entitled "Investigating the effect of masks, social distancing, and eye protection as a result of COVID-19: A systematic review study," approved by Iran University of Medical Sciences in 2021 with the 1400-21769-90-2.
Supplements: Search strategy and extracted data from studies.
Declarations
Ethical considerations: This document represents findings of a project at Iran University of Medical Sciences. The secured reference number of the code of ethics to conduct the project is IR.IUMS.REC.1400.676
Funding: This study was funded as a research project by Iran University of Medical Sciences. The funder had no role in data collection, analysis and manuscript preparation.
Conflicts of interests: The authors declare that they have no competing interest.
Authors’ contribution: SHA: Data analysis, writing– original draft, final approval; MA: Study design, data analysis, writing– original draft, final approval; SHM: Study design, data analysis, writing– original draft, final approval; NS: Data analysis, writing– original draft, final approval; MS: Study design; HH: Data curation; final approval. All authors read and approved the final manuscript.
Consent for publication: Not applicable.
Data availability: All data reported in text and supplements.
AI Declaration: None.
Acknowledgments: The present study is part of a research project entitled "Investigating the effect of masks, social distancing, and eye protection as a result of COVID-19: A systematic review study," approved by Iran University of Medical Sciences in 2021 with the 1400-21769-90-2.
Type of Study: Review |
Subject:
Health Services Management
Received: 2025/02/2 | Accepted: 2025/07/27 | Published: 2025/08/31
Received: 2025/02/2 | Accepted: 2025/07/27 | Published: 2025/08/31
Supplement [PDF 492 KB] (48 Download)
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