Combining drinking water treatment and hand washing for diarrhoea prevention, a cluster randomised controlled trial

OBJECTIVES: To evaluate the effectiveness of point of use water treatment with flocculent-disinfectant on reducing diarrhoea and the additional benefit of promoting hand washing with soap. METHODS: The study was conducted in squatter settlements of Karachi, Pakistan, where diarrhoea is a leading cause of childhood death. Interventions were randomly assigned to 47 neighbourhoods. Households in 10 neighbourhoods received diluted bleach and a water vessel; nine neighbourhoods received soap and were encouraged to wash hands; nine neighbourhoods received flocculent-disinfectant water treatment and a water vessel; 10 neighbourhoods received disinfectant-disinfectant water treatment and soap and were encouraged to wash hands; and nine neighbourhoods were followed as controls. Field workers visited households at least once a week from April to December 2003 to promote use of the interventions and to collect data on diarrhoea. RESULTS: Study participants in control neighbourhoods had diarrhoea on 5.2% of days. Compared to controls, participants living in intervention neighbourhoods had a lower prevalence of diarrhoea: 55% (95% CI 17%, 80%) lower in bleach and water vessel neighbourhoods, 51% (95% CI 12%, 76%) lower in hand washing promotion with soap neighbourhoods, 64% lower (95% CI 29%, 90%) in disinfectant-disinfectant neighbourhoods, and 55% (95% CI 18%, 80%) lower in disinfectant-disinfectant plus hand washing with soap neighbourhoods. CONCLUSIONS: With an intense community-based intervention and supplies provided free of cost, each of the home-based interventions significantly reduced diarrhoea. There was no benefit by combining hand washing promotion with water treatment.     

Increased hand washing reduces influenza virus surface contamination in Bangkok households, 2009–2010

Within a hand‐washing clinical trial, we evaluated factors associated with fomite contamination in households with an influenza‐infected child. Influenza virus RNA contamination was higher in households with low absolute humidity and in control households, suggesting that hand washing reduces surface contamination.     

Preventable and non‐preventable risk factors for influenza transmission and hygiene behavior in German influenza households,pandemic season (H1N1) 2009/2010

Background To date, little is known about the role of behavioral risk factors for influenza transmission as well as hygiene behavior in the household setting during the influenza pandemic (H1N1) 2009. In a household‐based study conducted during 2008/2009, we identified several behavioral risk factors for influenza transmission; 30% of index patients and 30% of household contacts reported increased hand cleaning frequency in the week after symptom onset of the index patient. We conducted another household‐based study during the pandemic season 2009/2010. Methods We identified index patients with laboratory confirmed influenza infection and interviewed household members after illness day 8 of the index patient. Outcome was influenza‐like illness (ILI) in a household contact. Results We included 108 households. Overall secondary attack rate was 10·1% (27/267) and decreased with increasing age. Apart from being in close daily proximity with the index patient for at least 9 hours, no other behavioral risk factor was associated with secondary ILI. Of all index patients and household contacts, 49% and 55%, respectively, cleaned their hands more often in the week after symptom onset of the index patient (in comparison with 2008/2009 P‐value for both <0·01). Conclusions While the study was hampered by its relatively limited size, data suggest that a significantly larger proportion of influenza households practiced good hand hygiene compared to the last pre‐pandemic season. This may have led to a different risk factor profile and a delay of the time threshold necessary for transmission among household members with close contact.     

The effect of a soap promotion and hygiene education campaign on handwashing behaviour in rural India: a cluster randomised trial

Objective  To investigate the effectiveness of a hygiene promotion intervention based on germ awareness in increasing handwashing with soap on key occasions (after faecal contact and before eating) in rural Indian households.
Methods  Cluster randomised trial of a hygiene promotion intervention in five intervention and five control villages. Handwashing was assessed through structured observation in a random sample of 30 households per village. Additionally, soap use was monitored in a sub-sample of 10 households per village using electronic motion detectors embedded in soap bars.
Results  The intervention reached 40% of the target population. Germ awareness increased as well as reported handwashing (a possible indicator of perceived social norms). Observed handwashing with soap on key occasions was rare (6%), especially after faecal contact (2%). Observed handwashing with soap on key occasions did not change 4 weeks after the intervention in either the intervention arm (−1%, 95% CI −2%/+0.3%), or the control arm (+0.4%, 95% CI −1%/+2%). Data from motion detectors indicated a significant but small increase in overall soap use in the intervention arm. We cannot confidently identify the nature of this increase except to say that there was no change in a key measure of handwashing after defecation.
Conclusion  The intervention proved scalable and effective in raising hygiene awareness. There was some evidence of an impact on soap use but not on the primary outcome of handwashing at key times. However, the results do not exclude that changes in knowledge and social norms may lay the foundations for behaviour change in the longer term.     

Findings from a household randomized controlled trial of hand washing and face masks to reduce influenza transmission in Bangkok, Thailand

Please cite this paper as: Simmerman et al. (2011) Findings from a household randomized controlled trial of hand washing and face masks to reduce influenza transmission in Bangkok, Thailand. Influenza and Other Respiratory Viruses 5(4), 256–267 Background Evidence is needed on the effectiveness of non‐pharmaceutical interventions (NPIs) to reduce influenza transmission. Methodology We studied NPIs in households with a febrile, influenza‐positive child. Households were randomized to control, hand washing (HW), or hand washing plus paper surgical face masks (HW + FM) arms. Study nurses conducted home visits within 24 hours of enrollment and on days 3, 7, and 21. Respiratory swabs and serum were collected from all household members and tested for influenza by RT‐PCR or serology. Principal Findings Between April 2008 and August 2009, 991 (16·5%) of 5995 pediatric influenza‐like illness patients tested influenza positive. Four hundred and forty‐two index children with 1147 household members were enrolled, and 221 (50·0%) were aged <6 years. Three hundred and ninety‐seven (89·8%) households reported that the index patient slept in the parents’ bedroom. The secondary attack rate was 21·5%, and 56/345 (16·3%; 95% CI 12·4–20·2%) secondary cases were asymptomatic. Hand‐washing subjects reported 4·7 washing episodes/day, compared to 4·9 times/day in the HW + FM arm and 3·9 times/day in controls (P = 0·001). The odds ratios (ORs) for secondary influenza infection were not significantly different in the HW arm (OR = 1·20; 95% CI 0·76–1·88; P‐0.442), or the HW + FM arm (OR = 1·16; 95% CI .0·74–1·82; P = 0.525). Conclusions Influenza transmission was not reduced by interventions to promote hand washing and face mask use. This may be attributable to transmission that occurred before the intervention, poor facemask compliance, little difference in hand‐washing frequency between study groups, and shared sleeping arrangements. A prospective study design and a careful analysis of sociocultural factors could improve future NPI studies.     

Impact of a school-based hygiene promotion and sanitation intervention on pupil hand contamination in Western kenya: a cluster randomized trial

Abstract. Handwashing with soap effectively reduces exposure to diarrhea-causing pathogens. Interventions to improve hygiene and sanitation conditions in schools within low-income countries have gained increased attention; however, their impact on schoolchildren's exposure to fecal pathogens has not been established. Our trial examined whether a school-based water, sanitation, and hygiene intervention reduced Escherichia coli contamination on pupils' hands in western Kenya. A hygiene promotion and water treatment intervention did not reduce risk of E. coli presence (relative risk [RR] = 0.92, 95% confidence interval [CI] = 0.54-1.56); the addition of new latrines to intervention schools significantly increased risk among girls (RR = 2.63, 95% CI = 1.29-5.34), with a non-significant increase among boys (RR = 1.36, 95% CI = 0.74-2.49). Efforts to increase usage of school latrines by constructing new facilities may pose a risk to children in the absence of sufficient hygiene behavior change, daily provision of soap and water, and anal cleansing materials.     

Effectiveness of a hand hygiene program to reduce acute gastroenteritis at child care centers: A cluster randomized trial

We aimed to assess the effectiveness of an educational and hand hygiene program in daycare centers (DCCs) and homes on acute gastroenteritis (AGE) incidence in children attending DCCs.METHODSA randomized, controlled, and open study of 911 children aged 0-3 years attending 24 DCCs in Almería (Spain) with an 8-month follow-up was employed. Two intervention groups of DCCs families performed educational and hand hygiene measures, 1 with soap and water (soap and water group; n = 274), another with hand sanitizer (hand sanitizer group [HSG]; n = 339), and the control group (CG; n = 298) followed usual handwashing procedures. We compared AGE episode rates with Poisson regression model.RESULTSseven hundred fourteen AGE episodes were registered, significant differences between HSG and CG children were found during December and January. A multivariate model was applied and the adjusted incidence rate ratios by rotavirus vaccination found significant differences when children were previously vaccinated, the children in the soap and water group had a higher risk of AGE episodes (incidence rate ratio: 1.28, 95% confidence interval:1.0-1.64), compared with those in the HSG.CONCLUSIONSThis study demonstrated that hand hygiene programs that included hand sanitizer were most effective in the winter months. Further, the largest reduction of AGE episodes occurred in the children that followed hand hygiene programs including hand sanitizer and educational measures for DCC staff, parents, and children, and were vaccinated for rotavirus.     

Fall prevention in residential care: a cluster, randomized, controlled trial

OBJECTIVES: To establish the effectiveness of a fall-prevention program in reducing falls and injurious falls in older residential care residents. DESIGN: Cluster, randomized, controlled trial. SETTING: Fourteen randomly selected residential care homes in Auckland, New Zealand. PARTICIPANTS: All older residents (n=628, 95% participation rate). INTERVENTION: Residential care staff, using existing resources, implemented systematic individualized fall-risk management for all residents using a fall-risk assessment tool, high-risk logo, and strategies to address identified risks. MEASUREMENTS: Number of residents sustaining a fall, falls, and injurious-falls incidence rates. RESULTS: During 12 months of follow-up, 103 (43%) residents in the control group and 173 (56%) residents in the intervention group fell (P<.018). There was a significantly higher incidence rate of falls in intervention homes than in control homes (incident rate ratio=1.34, 95% confidence interval=1.06-1.72) during the intervention period after adjusting for dependency level (type of home), baseline fall rate, and clustering. There was no difference in the injurious fall incidence rate or incidence of serious injuries. CONCLUSION: This fall-prevention intervention did not reduce falls or injury from falls. Low-intensity intervention may be worse than usual care.