Journal of Preventive Medicine

Introduction
One of the most serious threats to human health throughout history has been the spread of various infectious diseases, the most recent of which is acute respiratory syndrome caused by a novel coronavirus first spread in Wuhan, China in late 2019. Due to the high spread of this virus, the number of infected people increased rapidly and it became a pandemic [4] such that on January 30, 2020, the World Health Organization (WHO) declared the outbreak of this virus a public health emergency and a global concern [5]. On February 12, 2020, WHO named this infectious disease “COVID-19” due to the existence of spikes on the surface of the virus that give the appearance of a crown. The WHO report on July 22, 2021, showed more than 1,917,3590 infected cases and 4,127,963 deaths in the world. The highest infection and death rates were related to the U.S. and European countries (1.8). According to the statistics of the Iranian Ministry of Health and Medical Education, 3,623,840 people had been infected and 88,063 people had died due to COVID-19 in Iran by July 22, 2021. Preventive measures to control and reduce the risks of infection recommended by the WHO include: Staying at home, avoiding going to crowded places, washing hands regularly for 20 seconds with soap and water, not touching the mouth, nose and eyes with dirty hands, having a social distance of at least 1-2 meters, and using a mask to cover mouth and nose [16]. Studies showed that the use of masks, home quarantine, and social distancing were associated with a reduction in the transmission and prevalence of COVID-19. In crowded places, the risk of virus transmission is high. Therefore, preventive measures and educational interventions are needed to reduce the rate of infection with COVID-19. The control of the COVID-19 pandemic is possible with the participation of community members in observing health protocols and preventive measures. This study aims to compare the probability of infection with COVID-19 in patients with positive and negative polymerase chain reaction (PCR) test results based on adherence to preventive measures (wearing masks, social distancing, and hand washing).

Methods
This is a case-control study. The case group included people with positive PCR test results and the control group included people with negative PCR test results. The participants were selected from among those referred to the Moein Health Center in Miandoab County, West Azerbaijan Province, Iran. The sample size was estimated to be 150 in each group (300 in total) using the formula and considering a 17% sample dropout. Adherence to preventive measures such as wearing masks, social distancing, and hand washing were considered as independent variables, and positive and negative PCR test results were considered as dependent variables. Data collection was done through face-to-face interviews using questionnaires. To describe the quantitative data of the case and control groups, Mean±SD were used. Logistic regression was used to determine risk factors and calculate the controlled odds ratio for confounding variables. Data analysis was done in STATA software, version 14. The significance level was set at 0.05.

Results
Regarding gender, 48.4% of participants in the case group and 51% of the controls were male (p=0.646). The mean age in the case and control groups was 42.5±15.28 and 41.97±15.65, respectively (P>0.05). Moreover, 27.97% of controls and 34.83% of cases had a university education (P>0.05), and 79% in the control group and 82.6% in the case group were married (P>0.05). Furthermore, 28.7% and 29.7% of the case and control groups were engaged in jobs with a high risk of COVID-19 infection, respectively. This difference was significant (P=0.049). In addition, 67.1% of controls and 80.6% of cases were from urban areas. This difference was significant (P=0.008). Based on the results of multiple regression analysis and after adjusting the effect of confounding variables, the probability of a positive PCR test in the case of non-adherence and partial adherence to social distancing guidelines was 37 times (OR=37.11, P=0.001, 95% CI, 14.15%, 97.26%) and 2 times (OR=2.68, P=0.003, 95% CI, 1.40%, 5.13%) higher than in people who adhered to social distancing guidelines, respectively. These odds ratios were statistically significant. The probability of a positive PCR test in people with university education was 5 times higher than in people with lower educational levels (OR= 4.90, P= 0.008, 95% CI, 1.52%, 15.83%). In case of non-adherence to social distancing guidelines, the probability of positive PCR test in Fars ethnicities was 2.5 times higher than in Turkish ethnicities (OR=2.52, P=0.002, 95% CI, 0.007%, 0.32%). Also, the probability of positive PCR test in people living in rural areas was higher by 0.44 compared to those living in urban areas (OR=0.44, P=0.04, 95% CI, 0.21%, 0.96%).

Conclusion
According to the results of the present study, the use of masks, adherence to social distancing guidelines, and hand washing have a negative relationship with COVID-19 infection. Therefore, the use of masks, adherence to social distancing guidelines, and washing hands can reduce the probability of positive PCR test results.

Ethical Considerations

Compliance with ethical guidelines
The present study was approved by the Ethics Committee of Urmia University of Medical Sciences (Code: IR.UMSU.REC.1400.077).

Funding
This study was funded by the Student Research Committee of Urmia University of Medical Sciences. 

Authors' contributions
Conceptualization and study design: Fatemeh Shahi and Ghasem Yadegarfar; Data collection, data analysis, and data interpretation: Fatemeh Shahi, Elham Davtalab Esmaeili, Hosein Azizi, and Hadi Farid Soltani; Writing: Fatemeh Shahi, Ghasem Yadegarfar, and Hamid Reza Farrokh Islamlo; Final approval: All authors.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgements
The authors would like to thank the Urmia University of Medical Sciences for their financial support.


 

1. Sachs JD, Horton R, Bagenal J, Ben Amor Y, Karadag Caman O, Lafortune G. The lancet COVID-19 commission. Lancet. 2020; 396(10249):454-5. [DOI:10.1016/S0140-6736(20)31494-X] [PMID] [PMCID]
2. Kassema JJ. COVID-19 outbreak: Is it a health crisis or economic crisis or both? Case of african counties. Dev Econ. 2020; 9(51):1-15. [DOI:10.2139/ssrn.3559200]
3. Hui DS, I Azhar E, Madani TA, Ntoumi F, Kock R, Dar O, et al. The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health - The latest 2019 novel coronavirus outbreak in Wuhan, China. Int J Infect Dis. 2020; 91:264-6. [DOI:10.1016/j.ijid.2020.01.009] [PMID] [PMCID]
4. World Health Organization (WHO). Transmission of SARS-CoV-2: Implications for infection prevention precautions: Scientific brief [Internet]. 2020 [Updated 2020 July 9]. Available from: [Link]
5. Jin YH, Cai L, Cheng ZS, Cheng H, Deng T, Fan YP, et al. A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version). Mil Med Res. 2020; 7(1):4. [DOI:10.1186/s40779-020-0233-6] [PMID] [PMCID]
6. World Health Organization (WHO). WHO director-general’s remarks at the media briefing on 2019-nCoV on 11 February 2020 [Internet]. 2020 [Updated 2020 February 11]. Available from: [Link]
7. Wei Q, Wang Y, Ma J, Han J, Jiang M, Zhao L, et al. Description of the first strain of 2019-nCoV, C-Tan-nCoV Wuhan strain - national pathogen resource center, China, 2020. China CDC Wkly. 2020; 2(6):81-2. [DOI:10.46234/ccdcw2020.023] [PMID] [PMCID]
8. Caron B, Arondel Y, Reimund JM. COVID-19 and inflammatory bowel disease: Questions on incidence, severity, and impact of treatment? Clin Gastroenterol Hepatol. 2020; 18(11):2637-8. [DOI:10.1016/j.cgh.2020.06.002] [PMID] [PMCID]
9. World Health Organization (WHO). Coronavirus disease (COVID-19). Geneva: World Health Organization; 2020. [Link]
10. Tomasi D. Coronavirus disease (COVID-19). A socioepidemiological review. Vt Acad Arts Sci. 2020; 1:1-7. [Link]
11. Adhikari SP, Meng S, Wu YJ, Mao YP, Ye RX, Wang QZ, et al. Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: A scoping review. Infect Dis Poverty. 2020; 9(1):29. [DOI:10.1186/s40249-020-00646-x] [PMID] [PMCID]
12. Hendrix MJ, Walde C, Findley K, Trotman R. Absence of apparent transmission of SARS-CoV-2 from two stylists after exposure at a hair salon with a universal face covering policy - Springfield, Missouri, May 2020. MMWR Morb Mortal Wkly Rep. 2020; 69(28):930-2. [DOI:10.15585/mmwr.mm6928e2] [PMID]
13. Zou L, Ruan F, Huang M, Liang L, Huang H, Hong Z, et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med. 2020; 382(12):1177-9. [DOI:10.1056/NEJMc2001737] [PMID] [PMCID]
14. Smith EC, Blanc H, Surdel MC, Vignuzzi M, Denison MR. Coronaviruses lacking exoribonuclease activity are susceptible to lethal mutagenesis: Evidence for proofreading and potential therapeutics. Plos Pathog. 2013; 9(8):e1003565. [DOI:10.1371/journal.ppat.1003565] [PMID] [PMCID]
15. Alimohamadi Y, Taghdir M, Sepandi M. Estimate of the basic reproduction number for COVID-19: A systematic review and meta-analysis. J Prev Med Public Health. 2020; 53(3):151-7. [DOI:10.3961/jpmph.20.076] [PMID] [PMCID]
16. Hadaway A. COVID-19: Prevent the spread a review of www. cdc. gov/coronavirus. Journal of Consumer Health on the Internet. 2020; 24(4):407-15. [DOI:10.1080/15398285.2020.1831353]
17. Kanu FA, Smith EE, Offutt-Powell T, Hong R; Delaware Case Investigation and Contact Tracing Teams3; Dinh TH, et al. Declines in SARS-CoV-2 transmission, hospitalizations, and mortality after implementation of mitigation measures- Delaware, March-June 2020. MMWR Morb Mortal Wkly Rep. 2020; 69(45):1691-4. [DOI:10.15585/mmwr.mm6945e1] [PMID] [PMCID]
18. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19) 2023 Case Definition. Atlanta: Centers for Disease Control and Prevention; 2023. [Link]
19. MacIntyre CR, Chughtai AA. A rapid systematic review of the efficacy of face masks and respirators against coronaviruses and other respiratory transmissible viruses for the community, healthcare workers and sick patients. Int J Nurs Stud. 2020; 108:103629. [DOI:10.1016/j.ijnurstu.2020.103629] [PMID] [PMCID]
20. Leung NHL, Chu DKW, Shiu EYC, Chan KH, McDevitt JJ, Hau BJP, et al. Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med. 2020; 26(5):676-80. [DOI:10.1038/s41591-020-0843-2] [PMID] [PMCID]
21. 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. [DOI:10.3201/eid1004.030628] [PMID] [PMCID]
22. Davies A, Thompson KA, Giri K, Kafatos G, Walker J, Bennett A. Testing the efficacy of homemade masks: Would they protect in an influenza pandemic? Disaster Med Public Health Prep. 2013; 7(4):413-8. [DOI:10.1017/dmp.2013.43] [PMID] [PMCID]
23. Stockwell RE, Wood ME, He C, Sherrard LJ, Ballard EL, Kidd TJ, et al. Face masks reduce the release of pseudomonas aeruginosa cough aerosols when worn for clinically relevant periods. Am J Respir Crit Care Med. 2018; 198(10):1339-42. [DOI:10.1164/rccm.201805-0823LE] [PMID]
24. Tracht SM, Del Valle SY, Hyman JM. Mathematical modeling of the effectiveness of facemasks in reducing the spread of novel influenza A (H1N1). Plos One. 2010; 5(2):e9018. [DOI:10.1371/journal.pone.0009018] [PMID] [PMCID]
25. Brienen NC, Timen A, Wallinga J, van Steenbergen JE, Teunis PF. The effect of mask use on the spread of influenza during a pandemic. Risk Anal. 2010; 30(8):1210-8. [DOI:10.1111/j.1539-6924.2010.01428.x] [PMID] [PMCID]
26. Aiello AE, Perez V, Coulborn RM, Davis BM, Uddin M, Monto AS. Facemasks, hand hygiene, and influenza among young adults: A randomized intervention trial. Plos One. 2012; 7(1):e29744. [DOI:10.1371/journal.pone.0029744] [PMID] [PMCID]
27. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: Big data analytics, new technology, and proactive testing. JAMA. 2020; 323(14):1341-2. [DOI:10.1001/jama.2020.3151] [PMID]
28. Chan KH, Yuen KY. COVID-19 epidemic: Disentangling the re-emerging controversy about medical facemasks from an epidemiological perspective. Int J Epidemiol. 2020; 49(4):1063-6. [DOI:10.1093/ije/dyaa044] [PMID] [PMCID]
29. Wu J, Xu F, Zhou W, Feikin DR, Lin CY, He X, et al. Risk factors for SARS among persons without known contact with SARS patients, Beijing, China. Emerg Infect Dis. 2004 10(2):210-6. [DOI:10.3201/eid1002.030730] [PMID] [PMCID]
30. MacIntyre CR, Seale H, Dung TC, Hien NT, Nga PT, Chughtai AA, et al. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open. 2015; 5(4):e006577. [DOI:10.1136/bmjopen-2014-006577] [PMID] [PMCID]
31. van der Sande M, Teunis P, Sabel R. Professional and home-made face masks reduce exposure to respiratory infections among the general population. Plos One. 2008; 3(7):e2618. [DOI:10.1371/journal.pone.0002618] [PMID] [PMCID]
32. Chin A, Chu J, Perera MRA, Hui KPY, Yen HL, Chan MCW, et al. Stability of SARS-CoV-2 in different environmental conditions. Lancet Microbe. 2020; 1(1):30003-3. [DOI:10.1016/S2666-5247(20)30003-3]
33. Kelso JK, Milne GJ, Kelly H. Simulation suggests that rapid activation of social distancing can arrest epidemic development due to a novel strain of influenza. BMC Public Health. 2009; 9:117. [DOI:10.1186/1471-2458-9-117] [PMID] [PMCID]
34. Caley P, Philp DJ, McCracken K. Quantifying social distancing arising from pandemic influenza. J R Soc Interface. 2008; 5(23):631-9. [DOI:10.1098/rsif.2007.1197] [PMID] [PMCID]
35. Hatchett RJ, Mecher CE, Lipsitch M. Public health interventions and epidemic intensity during the 1918 influenza pandemic. Proc Natl Acad Sci USA. 2007; 104(18):7582-7. [DOI:10.1073/pnas.0610941104] [PMID] [PMCID]
36. Hou C, Chen J, Zhou Y, Hua L, Yuan J, He S, et al. The effectiveness of quarantine of Wuhan city against the corona virus disease 2019 (COVID-19): A well-mixed SEIR model analysis. J Med Virol. 2020; 92(7):841-8. [DOI:10.1002/jmv.25827] [PMID]
37. Chen TM, Rui J, Wang QP, Zhao ZY, Cui JA, Yin L. A mathematical model for simulating the phase-based transmissibility of a novel coronavirus. Infect Dis Poverty. 2020; 9(1):24. [DOI:10.1186/s40249-020-00640-3] [PMID] [PMCID]
38. Kretzschmar ME, Rozhnova G, van Boven M. Isolation and contact tracing can tip the scale to containment of COVID-19 in populations with social distancing. Front Phys. 2021; 8:677. [DOI:10.3389/fphy.2020.622485]
39. Lash RR, Donovan CV, Fleischauer AT, Moore ZS, Harris G, Hayes S, et al. COVID-19 contact tracing in two counties - North Carolina, June-July 2020. MMWR Morb Mortal Wkly Rep. 2020; 69(38):1360-3. [DOI:10.15585/mmwr.mm6938e3] [PMID] [PMCID]
40. Wang J, Tang K, Feng K, Lin X, Lv W, Chen K, et al. High temperature and high humidity reduce the transmission of COVID-19. BMJ Open. 2020; [Unpublished]. [Link]
41. Rashed EA, Kodera S, Gomez-Tames J, Hirata A. Influence of absolute humidity, temperature and population density on covid-19 spread and decay durations: Multi-prefecture study in Japan. Int J Environ Res Public Health. 2020; 17(15):5354. [PMID]
42. Hasheminik M, Parsaeimehr Z, Jamalinik M, Tajabadi A. [The challenge of transmission chain and effective hospital strategies in controlling the prevalence of Covid-19 (Persian)]. J Mil Med. 2022; 22(2):205-6. [DOI:10.30491/JMM.22.2.205]
43. Alfahan A, Alhabib S, Abdulmajeed I, Rahman S, Bamuhair S. In the era of corona virus: Health care professionals' knowledge, attitudes, and practice of hand hygiene in Saudi primary care centers: A cross-sectional study. J Community Hosp Intern Med Perspect. 2016; 6(4):32151. [DOI:10.3402/jchimp.v6.32151] [PMID] [PMCID]
44. Spinazzè A, Cattaneo A, Cavallo DM. COVID-19 outbreak in Italy: Protecting worker health and the response of the Italian industrial hygienists association. Ann Work Expo Health. 2020; 64(6):559-64. [DOI:10.1093/annweh/wxaa044] [PMID] [PMCID]
45. World Health Organization (WHO). Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: Interim guidance [Internet]. 2020 [Updated 2020 March 19]. Available from: [Link]
46. Islam MS, Rahman KM, Sun Y, Qureshi MO, Abdi I, Chughtai AA, et al. Current knowledge of COVID-19 and infection prevention and control strategies in healthcare settings: A global analysis. Infect Control Hosp Epidemiol. 2020; 41(10):1196-206. [DOI:10.1017/ice.2020.237] [PMID] [PMCID]
47. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect. 2020; 104(3):246-51. [DOI:10.1016/j.jhin.2020.01.022] [PMID] [PMCID]
48. To KK, Cheng VC, Cai JP, Chan KH, Chen LL, Wong LH, et al. Seroprevalence of SARS-CoV-2 in Hong Kong and in residents evacuated from Hubei province, China: A multicohort study. Lancet Microbe. 2020; 1(3):e111-8. [DOI:10.1016/S2666-5247(20)30053-7] [PMID] [PMCID]