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Policy Review
Nonpharmaceutical Interventions
for Pandemic Influenza, National and Community Measures
World Health Organization Writing Group*1
Appendix 2. Controlled
studies of the effect of handwashing on transmitting respiratory
infections
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First author
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Nature of study
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Pertinent results
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Pertinent conclusions
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Carabin (1)
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Randomized, controlled trial in 47 daycare centers
(for children <5 years of age) in Quebec, Canada. Randomization
was by center after stratification by incident rate of respiratory
infection. Intervention was increased handwashing in children and
staff by a single staff training session. Outcomes were upper respiratory
tract infections and diarrheal disease in children (measured coliform
contamination but no viral microbiology, winters of 1996 and 1997).
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Outcome measures were recorded in intervention and
control groups in each center in the autumn of 1996 (before intervention)
and 1997 (after intervention). Compliance was measured and showed
that the intervention had been carried out. Both groups had a decrease
in respiratory infections and diarrheal disease; however, intervention
groups experienced greater and significantly reduced rates after
intervention than control centers. The reduction in upper respiratory
infections was 25%, but little effect on diarrheal illnesses was
seen. Environmental contamination (with coliforms) was reduced in
both groups during the intervention, which suggests spillover of
the intervention.
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Handwashing reduced the incidence of upper respiratory
infections in children <5 years of age.
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Dyer (2)
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10-week cross-over intervention study among 420
schoolchildren (5–12 years of age) in California compared handwashing
and enhanced supervised handwashing and use of a hand sanitizer.
Outcome measures were absences due to infectious diseases (no microbiology,
early spring 1998).
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School absences due to infectious diseases during
the enhanced handwashing period were 42% lower than in the ordinary
period. For absences due to gastrointestinal disease and respiratory
infections, the reductions were 29% and 50%, respectively. The effect
was consistent in both periods of the trial, and all reductions
were significant.
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Enhancing handwashing and use of hand sanitizers
among children in school reduces infection.
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Falsey (3)
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US intervention study in 3 eldercare homes with
a historical control period. Intervention was to get staff to wash
their hands between clients (residents) (virologic studies, winter
1995/1996).
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In 3 preintervention years, rates of respiratory
infection in the elderly were 14.5, 12.8, and 10.4, respectively,
per 100 person-months, and rates declined significantly (to 5.7)
in the intervention year. The equivalent rates for staff were 21.0,
13.9, 11.3, and 9.5, respectively, with no significant decline.
Virologic testing indicated only 37 influenza isolations among 392
illness episodes during the 4 years. No change in specific viruses
could account for the decline in year 4.
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Staff handwashing seemed to be associated with reduced
incidence of respiratory infection in the elderly but not in staff;
however, the use of a historical control period can be misleading.
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Larson (4)
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Randomized, double-blind, controlled trial in 238
families in an American city compared the effect of antibacterial
and conventional soaps and other products. Outcomes were self-reported
symptoms (no microbiology, 48 weeks in an unstated year).
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Most symptoms were respiratory. No significant differences
were seen in runny noses, fever, cough, or sore throat between intervention
and control families.
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No advantage to using antibacterial versus conventional
washing materials was found in this industrialized country setting.
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Luby (5)
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Community-cluster, randomized, controlled trial
in urban setting (Karachi, Pakistan) compared handwashing promotion
in all family members with outcomes of diarrheal disease and lower
respiratory tract infections (no microbiology, 12 months, 2002–2003).
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Children <15 years of age in intervention clusters
had lower incidences of cough and breathing difficulty compared
with a control (no intervention) group. Children <5 years of
age had lower rates of pneumonia, diarrhea, and impetigo in the
intervention versus control groups. No advantage of using antibacterial
versus ordinary soap was seen.
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In this study in a developing country, handwashing
had a significant effect in protecting children against respiratory
infections of unknown cause. Although most infections would be viral,
only a small proportion might be expected to be due to influenza
virus.
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Ponka (6)
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Open-clustered, unrandomized intervention study
in daycare centers in urban setting (Helsinki, Finland) involved
60 centers with 228 controls. The intervention involved training
in increased handwashing among children and staff plus other hygiene
measures, including cleaning surfaces and toys, toileting hygiene,
excluding ill persons, and some instruction of parents. Outcomes
were effect on absences due to infections (no microbiology, winter
and spring 1999–2000).
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For children <3 years of age, intervention centers
had significantly fewer absences due to all infections and respiratory
infections in the intervention period compared with a baseline period.
The crude percentage reduction in absences due to upper respiratory
infections was 39% and that due to all infections was 32%. No such
effect was seen in the control centers, and no effect was seen in
children 3–6 years of age in either intervention or control centers.
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An effect of a combination of hygiene measures was
seen but only in young children, and handwashing was only 1 measure.
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Roberts (7)
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Randomized, controlled trial in 23 of 26 daycare
centers in an Australian city involved 11 intervention centers and
12 control centers. Compliance (handwashing and wiping children's
noses) was measured (no microbiology, 1996).
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A significantly lower number of episodes of illness
was seen in children <2 years of age, with no significant effect
in older children or all children. Rates of absence were lower in
the intervention centers, but the difference was not significant.
Where compliance was measured against illness rates, a 17% reduction
in colds was seen in younger (<24 months) children with no effect
in older children.
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The study did not support the hypothesis that infection
rates could be reduced by handwashing, although this finding could
be due to poor compliance with the intervention.
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Ryan (8)
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Large observational study using a historical control
period was undertaken before, during, an after a handwashing intervention
among military recruits in the United States. Outcome measures were
compliance rates, reported illness, and outpatient and hospitalization
rates (limited microbiology, streptococcal cultures; 1996–1998).
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A 45% reduction in reported outpatient (primary
care) consultations was seen for respiratory infections, with no
effect on hospitalization. Those complying with the intervention
had a significantly lower rate of reported respiratory infections
than those not complying (3.2 vs. 4.7 episodes per recruit).
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Although the intervention had statistically significant
effects, this finding must be interpreted cautiously because of
the use of a historical control period.
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Uhari (9)
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Randomized, controlled trial in daycare centers
in Helsinki, Finland, compared handwashing promotion in staff, children
(<5 years of age), siblings (outside the nursery), and parents.
Outcomes were all infections and absences (no microbiology, 15 months
in 1991 and 1992).
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A small but significant difference was seen in all
infections and symptoms attributable to respiratory infections (rhinitis
and cough) in children (lower in the intervention group). Infection
rates were also lower in the staff, but the article does not mention
respiratory versus other infections. Parents of children in the
intervention groups missed less time from work because of less illness
among their children, but no difference was seen in parental or
sibling illnesses.
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In this study in a well-resourced country, handwashing
had a significant effect on protecting children against respiratory
infections of unknown cause. No measurable benefit was seen in protecting
families against background-level infectious disease by intervening
with their children in nurseries. That finding does not exclude
an effect during an outbreak or pandemic.
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White (10)
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Randomized, controlled trial in 4 university residence
halls (430 students total) in the United States compared handwashing
promotion based around an alcohol-based hand sanitizer (2 halls)
versus no intervention. Hand sanitizers were available in both groups
but not promoted in the control group (no microbiology, autumn 2001).
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Somewhat greater handwashing and far greater use
of hand sanitizers were seen in intervention than control residences.
Intervention groups had 20% less illness overall and lower rates
of all respiratory symptoms (including sore throats, stuffy noses,
fever, cough).
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In this small study, handwashing and use of a hand
sanitizer seemed to protect against respiratory illnesses. No conclusion
could be drawn about the additional value of the sanitizer.
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Appendix
2 References
- Carabin H, Gyorkos TW, Soto JC, Joseph L, Payment
P, Collet JP. Effectiveness
of a training program in reducing infections in toddlers attending day
care centers. Epidemiology. 1999;10:219–27.
- Dyer DL, Shinder A, Shinder F. Alcohol-free
instant hand sanitizer reduces elementary school illness absenteeism.
Fam Med. 2000;32:633–8.
- Falsey AR, Criddle MM, Kolassa JE, McCann RM, Brower CA, Hall WJ.
Evaluation
of a handwashing intervention to reduce respiratory illness rates in
senior day-care centers. Infect Control Hosp Epidemiol. 1999;20:200–2.
- Larson EL, Lin SX, Gomez-Pichardo C, Della-Latta P. Effect
of antibacterial home cleaning and handwashing products on infectious
disease symptoms: a randomized, double-blind trial. Ann Intern Med.
2004;140:321–9.
- Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, Altaf A,
et al. Effect
of handwashing on child health: a randomised controlled trial. Lancet.
2005;366:225–33.
- Ponka A, Poussa T, Laosmaa M. The
effect of enhanced hygiene practices on absences due to infectious diseases
among children in day care centers in Helsinki. Infection. 2004;32:2–7.
- Roberts L, Smith W, Jorm L, Patel M, Douglas RM, McGilchrist C. Effect
of infection control measures on the frequency of upper respiratory
infection in child care: a randomized, controlled trial. Pediatrics.
2000;105:738–42.
- Ryan MA, Christian RS, Wohlrabe J. Handwashing
and respiratory illness among young adults in military training.
Am J Prev Med. 2001;21:79–83.
- Uhari M, Mottonen M. An
open randomized controlled trial of infection prevention in child day-care
centers. Pediatr Infect Dis J. 1999;18:672–7.
- White C, Kolble R, Carlson R, Lipson N, Dolan M, Ali Y, et al. The
effect of hand hygiene on illness rate among students in university
residence halls. Am J Infect Control. 2003;31:364–70.
1The writing group was established by request
of the WHO Global Influenza Programme. It consisted of the following persons:
David Bell,
Centers for Disease Control and Prevention, Atlanta, Georgia, USA (coordinator);
Angus Nicoll, European Centre for Disease Prevention and Control, Stockholm,
Sweden, and Health Protection Agency, London, United Kingdom (working
group chair); Keiji Fukuda, WHO, Geneva, Switzerland; Peter Horby, WHO,
Hanoi, Vietnam; and Arnold Monto, University of Michigan, Ann Arbor, Michigan,
USA. In addition, the following persons made substantial contributions:
Frederick Hayden, University of Virginia, Charlottesville, Virginia, USA;
Clare Wylks and Lance Sanders, Australian Government Department of Health
and Ageing, Canberra, Australian Capital Territory, Australia; and Jonathan
Van Tam, Health Protection Agency, London, United Kingdom.
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