Handwashing Fact Sheet and Annotated Bibliography

Below is a fact sheet from a recent UNICEF literature review and an annotated bibliography of handwashing studies that we hope will be useful for Global Handwashing Day on Oct. 15, 2010.

Evidence Specific to Handwashing with Soap (Fact Sheet)– From: Evidence base: Water, Sanitation and Hygiene Interventions Literature Review: September 2010, Peter van Maanen, WASH Section, UNICEF.

  • Handwashing at critical times including before eating or preparing food and after using the toilet can reduce diarrhoea rates by almost 40 per cent (3IE 2009).
  • Handwashing with soap can reduce the incidence of acute respiratory infections (ARI’s) by around 23 per cent (WELL 2007).
  • One study assessed the effect of hand washing promotion with soap on the incidence of pneumonia and found that children younger than 5 years in households that received plain soap and hand washing promotion had a 50% lower incidence of pneumonia than controls.
  • Pneumonia (a lower respiratory infection) is the number one cause of mortality among children under five years old, taking the lives of an estimated 1.8 million children per year (SOWC 2008).
  • Handwashing can be a critical measure in controlling pandemic outbreaks of respiratory infections. Several studies carried out during the 2006 outbreak of severe acute respiratory syndrome (SARS) suggest that washing hands more than 10 times a day can cut the spread of the respiratory virus by 55 per cent (BMJ 2009).
  • Handwashing with soap is has been cited as one of the most cost effective interventions to prevent diarrhoeal related deaths and disease (Cairncross and Valdmanis 2006).
  • A review of several studies shows that handwashing in institutions such as primary schools and daycare centers reduce the incidence of diarrhoea by an average of 30 per cent (Cochrane 2008).
  • Rates of handwashing around the world are low. Observed rates of handwashing with soap at critical moments – i.e, before handling food and after using the toilet range from zero per cent to 34 per cent (Scott et al 2003).
  • A recent study shows that handwashing with soap by birth attendants and mothers significantly increased newborn survival rates by up to 44 per cent (Rhee et al 2008).
  • The lack of soap is not a significant barrier to handwashing – with the vast majority of even poor households having soap. Soap was present in 95 per cent of households in Uganda, 97 per cent of households in Kenya and 100 per cent of households in Peru (Curtis et al 2009).
  • Water alone is not enough, and soap is rarely used for handwashing. Laundry, bathing and washing dishes are seen as the priorities for soap use (GHD Planners Guide).
  • New studies suggest that handwashing promotion in schools can play a role in reducing absenteeism among primary school children. In China, for example, promotion and distribution of soap in primary schools resulted in 54 per cent fewer days of absence among students compared to schools without such an intervention (Bowen et al 2007)

An annotated bibliography of 12 peer-review handwashing studies published in 2010

1. BMC Public Health. 2010 Sep 9;10:545.

Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh.

Halder AK, Tronchet C, Akhter S, Bhuiya A, Johnston R, Luby SP.

International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh. amalk@icddrb.org

BACKGROUND: We analyzed data from the baseline assessment of a large intervention project to describe typical handwashing practices in rural Bangladesh, and compare measures of hand cleanliness with household characteristics.

METHODS: We randomly selected 100 villages from 36 districts in rural Bangladesh. Field workers identified 17 eligible households per village using systematic sampling. Field workers conducted 5-hour structured observations in 1000 households, and a cross-sectional assessment in 1692 households that included spot checks, an evaluation of hand cleanliness and a request that residents demonstrate their usual handwashing practices after defecation.

RESULTS: Although 47% of caregivers reported and 51% demonstrated washing both hands with soap after defecation, in structured observation, only 33% of caregivers and 14% of all persons observed washed both hands with soap after defecation. Less than 1% used soap and water for handwashing before eating and/or feeding a child. More commonly people washed their hands only with water, 23% after defecation and 5% before eating. Spot checks during the cross sectional survey classified 930 caregivers (55%) and 453children (28%) as having clean appearing hands. In multivariate analysis economic status and water available at handwashing locations were significantly associated with hand cleanliness among both caregivers and children.

CONCLUSIONS: A minority of rural Bangladeshi residents washed both hands with soap at key handwashing times, though rinsing hands with only water was more common. To realize the health benefits of handwashing, efforts to improve handwashing in these communities should target adding soap to current hand rinsing practices.

2. Nurs Times. 2010 Sep 7-13;106(35):18-20.

The awkward feeling campaign: confronting poor hand hygiene to improve handwashing.

Holyoake D. University of Wolverhampton.

This article describes how a group of third year child branch student nurses at the University of Wolverhampton examined the way they perceived handwashing. During a three day workshop aimed at focusing on healthcare improvement, the students moved from regarding handwashing as a simple act of hygiene, to seeing it as a social behaviour, which is part of a larger organisational system. Through analysing cultural messages, themes and the idea of organisational power, the students developed a new way of thinking about what health professionals do with their hands. All the anecdotes featured in this article are reflections from the students (whose names have been changed to protect their anonymity). During the Handwashing Experiment, the students challenged traditional health promotion messages–which focus on how the individual can make a difference–and explored how organisations allow cross infection to persist. The result was a collection of reflective accounts and socially orientated, hard hitting posters.

3. Am J Infect Control. 2010 Sep;38(7):562-4.

Spreading the handwashing message: an alternative to traditional media campaigns.

Rosen L, Brody D, Zucker D, Manor O, Meier M, Rosen B, Lev E, Engelhard D.

Department of Health Promotion, Tel Aviv University, Tel Aviv, Israel. rosenl@post.tau.ac.il

Schools are a natural place from which to disseminate health messages to the community. Sending an entertaining handwashing video home with preschoolers as a component of a school-based program yielded impressive degrees of penetration and reach among families; consequently, this strategy offers a promising alternative to traditional media campaigns.

4. J Appl Microbiol. 2010 Jul 2.

Virus transfer between fingerpads and fomites.

Julian TR, Leckie JO, Boehm AB. Department of Civil and Environmental Engineering, Environmental and Water Studies, Stanford University, Stanford, CA, USA.

Aims: Virus transfer between individuals and fomites is an important route of transmission for both gastrointestinal and respiratory illness. The present study examines how direction of transfer, virus species, time since last handwashing, gender, and titre affect viral transfer between fingerpads and glass.

Methods and Results: Six hundred fifty-six total transfer events, performed by 20 volunteers using MS2, varphiX174, and fr indicated 0.23 +/- 0.22 (mean and standard deviation) of virus is readily transferred on contact. Virus transfer is significantly influenced by virus species and time since last handwashing. Transfer of fr bacteriophage is significantly higher than both MS2 and varphiX174. Virus transfer between surfaces is reduced for recently washed hands.

Conclusions: Viruses are readily transferred between skin and surfaces on contact. The fraction of virus transferred is dependent on multiple factors including virus species, recently washing hands, and direction of transfer likely because of surface physicochemical interactions.

Significance and Impact of the Study: The study is the first to provide a large data set of virus transfer events describing the central tendency and distribution of fraction virus transferred between fingers and glass. The data set from the study, along with the quantified effect sizes of the factors explored, inform studies examining role of fomites in disease transmission.

5. Trop Med Int Health. 2010 Jun;15(6):762-71.

Prevalent high-risk respiratory hygiene practices in urban and rural Bangladesh.

Nasreen S, Azziz-Baumgartner E, Gurley ES, Winch PJ, Unicomb L, Sharker MA, Southern D, Luby SP.

International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh.

OBJECTIVES: To identify existing respiratory hygiene risk practices, and guide the development of interventions for improving respiratory hygiene.

METHODS: We selected a convenience sample of 80 households and 20 schools in two densely populated communities in Bangladesh, one urban and one rural. We observed and recorded respiratory hygiene events with potential to spread viruses such as coughing, sneezing, spitting and nasal cleaning using a standardized assessment tool.

RESULTS: In 907 (81%) of 1122 observed events, households’ participants coughed or sneezed into the air (i.e. uncovered), 119 (11%) into their hands and 83 (7%) into their clothing. Twenty-two per cent of women covered their coughs and sneezes compared to 13% of men (OR 2.6, 95% CI 1.6-4.3). Twenty-seven per cent of persons living in households with a reported monthly income of >72.6 US$ covered their coughs or sneezes compared to 13% of persons living in households with lower income (OR 3.2, 95% CI 1.6-6.2). In 956 (85%) of 1126 events, school participants coughed or sneezed into the air and 142 (13%) into their hands. Twenty-seven per cent of coughs/sneezes in rural schools were covered compared to 10% of coughs/sneezes in urban schools (OR 2.3, 95% CI 1.5-3.6). Hand washing was never observed after participants coughed or sneezed into their hands.

CONCLUSION: There is an urgent need to develop culturally appropriate, cost-effective and scalable interventions to improve respiratory hygiene practices and to assess their effectiveness in reducing respiratory pathogen transmission.

6 – Environ Sci Technol. 2010 May 1;44(9):3267-72.

Hands, water, and health: fecal contamination in Tanzanian communities with improved, non-networked water supplies.

Pickering AJ, Davis J, Walters SP, Horak HM, Keymer DP, Mushi D, Strickfaden R, Chynoweth JS, Liu J, Blum A, Rogers K, Boehm AB. Emmet Interdisciplinary Program in Environment and Resources, School of Earth Sciences, Stanford University, Stanford, California 94305, USA.

Comment in: Environ Sci Technol. 2010 May 1;44(9):3201.

Almost half of the world’s population relies on non-networked water supply services, which necessitates in-home water storage. It has been suggested that dirty hands play a role in microbial contamination of drinking water during collection, transport, and storage. However, little work has been done to evaluate quantitatively the association between hand contamination and stored water quality within households. This study measured levels of E. coli, fecal streptococci, and occurrence of the general Bacteroidales fecal DNA marker in source water, in stored water, and on hands in 334 households among communities in Dar es Salaam, Tanzania, where residents use non-networked water sources. Levels of fecal contamination on hands of mothers and children were positively correlated to fecal contamination in stored drinking water within households. Household characteristics associated with hand contamination included mother’s educational attainment, use of an improved toilet, an infant in the household, and dissatisfaction with the quantity of water available for hygiene. In addition, fecal contamination on hands was associated with the prevalence of gastrointestinal and respiratory symptoms within a household. The results suggest that reducing fecal contamination on hands should be investigated as a strategy for improving stored drinking water quality and health among households using non-networked water supplies.

7. Am J Trop Med Hyg. 2010 Apr;82(4):664-71.

Evaluation of the role of school children in the promotion of point-of-use water treatment and handwashing in schools and households–Nyanza Province, Western Kenya, 2007.

Blanton E, Ombeki S, Oluoch GO, Mwaki A, Wannemuehler K, Quick R.

Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention, 1600 Clifton Road, MS A-38, Atlanta, GA 30030, USA. eblanton@cdc.gov

We installed drinking water and handwashing stations in 17 rural schools and trained teachers to promote water treatment and hygiene to pupils. We gave schools flocculent-disinfectant powder and hypochlorite solution for water treatment. We conducted a baseline water handling survey of pupils’ parents from 17 schools and tested stored water for chlorine. We trained teachers and students about hygiene, installed water stations, and distributed instructional comic books to students. We conducted follow-up surveys and chlorine testing at 3 and 13 months. From baseline to 3-month follow-up, parental awareness of the flocculent-disinfectant increased (49-91%, P < 0.0001), awareness of hypochlorite remained high (93-92%), and household use of flocculent-disinfectant (1-7%, P < 0.0001) and hypochlorite (6-13%, P < 0.0001) increased, and were maintained after 13 months. Pupil absentee rates decreased after implementation by 26%. This school-based program resulted in pupil-to-parent knowledge transfer and significant increases in household water treatment practices that were sustained over 1 year.

8. Int J Epidemiol. 2010 Apr;39 Suppl 1:i193-205.

Water, sanitation and hygiene for the prevention of diarrhoea.

Cairncross S, Hunt C, Boisson S, Bostoen K, Curtis V, Fung IC, Schmidt WP.

London School of Hygiene & Tropical Medicine, Department of Infectious & Tropical Diseases, London, UK. sandy.cairncross@lshtm.ac.uk

BACKGROUND: Ever since John Snow’s intervention on the Broad St pump, the effect of water quality, hygiene and sanitation in preventing diarrhoea deaths has always been debated. The evidence identified in previous reviews is of variable quality, and mostly relates to morbidity rather than mortality.

METHODS: We drew on three systematic reviews, two of them for the Cochrane Collaboration, focussed on the effect of handwashing with soap on diarrhoea, of water quality improvement and of excreta disposal, respectively. The estimated effect on diarrhoea mortality was determined by applying the rules adopted for this supplement, where appropriate.

RESULTS: The striking effect of handwashing with soap is consistent across various study designs and pathogens, though it depends on access to water. The effect of water treatment appears similarly large, but is not found in few blinded studies, suggesting that it may be partly due to the placebo effect. There is very little rigorous evidence for the health benefit of sanitation; four intervention studies were eventually identified, though they were all quasi-randomized, had morbidity as the outcome, and were in Chinese.

CONCLUSION: We propose diarrhoea risk reductions of 48, 17 and 36%, associated respectively, with handwashing with soap, improved water quality and excreta disposal as the estimates of effect for the LiST model. Most of the evidence is of poor quality. More trials are needed, but the evidence is nonetheless strong enough to support the provision of water supply, sanitation and hygiene for all.

9. Epidemiol Infect. 2010 Mar;138(3):409-14.

Dirty hands: bacteria of faecal origin on commuters’ hands.

Judah G, Donachie P, Cobb E, Schmidt W, Holland M, Curtis V.

Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. Gaby.judah@lshtm.ac.uk

Although many studies have investigated bacteria on the hands of health-care workers and caregivers, few have looked at microbiological contamination on the hands of the general adult public. This study investigated faecal bacteria on the hands of commuters in five UK cities. Of the 404 people sampled 28% were found to have bacteria of faecal origin on their hands. A breakdown by city showed that the proportion of people with contaminated hands increased the further north the city of investigation (P<0.001), an effect which was due in large part to a significant trend in men but not in women. Bus users were more contaminated than train users. The results of this exploratory study indicate that hand hygiene practices in the UK may be inadequate and that faecal indicator bacteria on hands may be used to monitor the effect of hand-washing promotion campaigns.

10. Am J Trop Med Hyg. 2010 Feb;82(2):270-8.

Efficacy of waterless hand hygiene compared with handwashing with soap: a field study in Dar es Salaam, Tanzania.

Pickering AJ, Boehm AB, Mwanjali M, Davis J. Emmett Interdisciplinary Program in Environment and Resources, School of Earth Sciences and Civil and Environmental Engineering, and Woods Institute for the Environment, Stanford University, Stanford, CA 94305, USA. amyjanel@stanford.edu

Effective handwashing with soap requires reliable access to water supplies. However, more than three billion persons do not have household-level access to piped water. This research addresses the challenge of improving hand hygiene within water-constrained environments. The antimicrobial efficacy of alcohol-based hand sanitizer, a waterless hand hygiene product, was evaluated and compared with handwashing with soap and water in field conditions in Dar es Salaam, Tanzania. Hand sanitizer use by mothers resulted in 0.66 and 0.64 log reductions per hand of Escherichia coli and fecal streptococci, respectively. In comparison, handwashing with soap resulted in 0.50 and 0.25 log reductions per hand of E. coli and fecal streptococci, respectively. Hand sanitizer was significantly better than handwashing with respect to reduction in levels of fecal streptococci (P = 0.01). The feasibility and health impacts of promoting hand sanitizer as an alternative hand hygiene option for water-constrained environments should be assessed.

11. Soc Sci Med. 2010 Feb;70(3):383-91.

Three kinds of psychological determinants for hand-washing behaviour in Kenya.

Aunger R, Schmidt WP, Ranpura A, Coombes Y, Maina PM, Matiko CN, Curtis V.

London School of Hygiene and Tropical Medicine, ITD, Keppel Street, London, United Kingdom. robert.aunger@lshtm.ac.uk

Washing hands with soap at the right times – primarily after contact with faeces, but also before handling food or feeding an infant – can significantly reduce the incidence of childhood infectious disease. Here, we present empirical results which substantiate a recent claim that washing hands can be the consequence of different kinds of psychological causes. Such causes can be divided into three kinds of control over behaviour: automatic or habitual responses, motivated or goal-driven behaviour to satisfy needs, and cognitive causes which reflect conscious concerns. Empirical results are based on 3-h-long structured observations of hand-washing behaviour in 802 nationally representative Kenyan households with children under five, and structured interviews with the primary female caretaker in these households, collected in March 2007. Factor analysis of questionnaire responses identified three psychological factors which are also significant predictors of observed hand-washing behaviour: having the habit of hand-washing at particular junctures during the day, the motivated need for personal or household cleanliness, and a lack of cognitive concern about the cost of soap use. These factors each represent a different kind of psychological cause. A perceived link between clean hands and sexual attractiveness also appeared in the factor analysis, but was not a determinant of actual behaviour. We also report evidence that those who express concern about the cost of soap use are those with relatively few economic resources. We suggest that those developing hygiene promotion programmes should consider the possible existence of multiple types of strategies for increasing hand-washing behaviour.

12. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006207.

Physical interventions to interrupt or reduce the spread of respiratory viruses.

Jefferson T, Del Mar C, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, van Driel ML, Nair S, Foxlee R, Rivetti A.

Vaccines Field, The Cochrane Collaboration, Via Adige 28a, Anguillara Sabazia, Roma, Italy, 00061.

Update of: Cochrane Database Syst Rev. 2007;(4):CD006207.

BACKGROUND: Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a world-wide threat. Antiviral drugs and vaccinations may be insufficient to prevent catastrophe.

OBJECTIVES: To systematically review the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses.

SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 2); MEDLINE (1966 to May 2009); OLDMEDLINE (1950 to 1965); EMBASE (1990 to May 2009); and CINAHL (1982 to May 2009).

SELECTION CRITERIA: We scanned 2958 titles, excluded 2790 and retrieved the full papers of 168 trials, to include 59 papers of 60 studies. We included any physical interventions (isolation, quarantine, social distancing, barriers, personal protection and hygiene) to prevent transmission of respiratory viruses. We included the following study designs: randomised controlled trials (RCTs), cohorts, case controls, cross-over, before-after, and time series studies.

DATA COLLECTION AND ANALYSIS: We used a standardised form to assess trial eligibility. RCTs were assessed by: randomisation method; allocation generation; concealment; blinding; and follow up. Non-RCTs were assessed for the presence of potential confounders, and classified into low, medium, and high risks of bias.

MAIN RESULTS: The risk of bias for the four RCTs, and most cluster RCTs, was high. The observational studies were of mixed quality. Only case-control data were sufficiently homogeneous to allow meta-analysis.The highest quality cluster RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children. Additional benefit from reduced transmission from children to other household members is broadly supported in results of other study designs, where the potential for confounding is greater. Six case-control studies suggested that implementing barriers to transmission, isolation, and hygienic measures are effective at containing respiratory virus epidemics. We found limited evidence that N95 respirators were superior to simple surgical masks, but were more expensive, uncomfortable, and caused skin irritation. The incremental effect of adding virucidals or antiseptics to normal handwashing to decrease respiratory disease remains uncertain. Global measures, such as screening at entry ports, were not properly evaluated. There was limited evidence that social distancing was effective especially if related to the risk of exposure.

AUTHORS’ CONCLUSIONS: Many simple and probably low-cost interventions would be useful for reducing the transmission of epidemic respiratory viruses. Routine long-term implementation of some of the measures assessed might be difficult without the threat of a looming epidemic.

7 responses to “Handwashing Fact Sheet and Annotated Bibliography

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  6. the information here are very helpful to me.

  7. Nripendra Kumar Sarma, Guwahati, Assam (India )

    The STUDY on Evaluation of the role of school children in the promotion of point-of-use water treatment and handwashing in schools and households–Nyanza Province, Western Kenya, 2007, has proved the efficacy of the approach for Students – to – Parents Knowledge Transfer as well as Practice in Homes in a sustained manner. The sustainability of such students motivated practice is beyond doubt.

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