Improving hand hygiene compliance in child daycare centres: a randomized controlled trial

Child Care Center Hand Hygiene Programs' Cost-Effectiveness in Preventing Respiratory Infections

BACKGROUND

We previously demonstrated that a hand hygiene program, including hand sanitizer and educational measures, for day care center (DCC) staff, children, and parents was more effective than a soap-and-water program, with initial observation, in preventing respiratory infections (RIs) in children attending DCCs. We analyzed the cost-effectiveness of these programs in preventing RIs.

METHODS

A cluster, randomized, controlled and open study of 911 children aged 0 to 3 years, attending 24 DCCs in Almeria. Two intervention groups of DCC-families performed educational measures and hand hygiene, one with soap-and-water (SWG) and another with hand sanitizer (HSG). The control group (CG) followed usual hand-washing procedures. RI episodes, including symptoms, treatments, medical contacts, complementary analyses, and DCC absenteeism days, were reported by parents. A Bayesian cost-effectiveness model was developed.

RESULTS

There were 5201 RI episodes registered. The adjusted mean societal costs of RIs per child per study period were CG: €522.25 (95% confidence interval [CI]: 437.10 to 622.46); HSG: €374.53 (95% CI: 314.90 to 443.07); SWG: €494.51 (95% CI: 419.21 to 585.27). The indirect costs constituted between 35.7% to 43.6% of the total costs. Children belonging to the HSG had an average of 1.39 fewer RI episodes than the CG and 0.93 less than the SWG. It represents a saving of societal cost mean per child per study period of €147.72 and €119.15, respectively. The HSG intervention was dominant versus SWG and CG.

CONCLUSIONS

Hand hygiene programs that include hand sanitizer and educational measures for DCC staff, children, and parents are more effective and cost less than a program with soap and water and initial observation in children attending DCCs.

Interventions to increase personal protective behaviours to limit the spread of respiratory viruses: A rapid evidence review and meta-analysis

PURPOSE

Increasing personal protective behaviours is critical for stopping the spread of respiratory viruses, including SARS-CoV-2: We need evidence to inform how to achieve this. We aimed to synthesize evidence on interventions to increase six personal protective behaviours (e.g., hand hygiene, face mask use, maintaining physical distancing) to limit the spread of respiratory viruses.

METHODS

We used best practice for rapid evidence reviews. We searched Ovid MEDLINE and Scopus. Studies conducted in adults or children with active or passive comparators were included. We extracted data on study design, intervention content, mode of delivery, population, setting, mechanism(s) of action, acceptability, practicability, effectiveness, affordability, spill-over effects, and equity impact. Study quality was assessed with Cochrane's risk-of-bias tool. A narrative synthesis and random-effects meta-analyses were conducted.

RESULTS

We identified 39 studies conducted across 15 countries. Interventions targeted hand hygiene (n = 30) and/or face mask use (n = 12) and used two- or three-arm study designs with passive comparators. Interventions were typically delivered face-to-face and included a median of three behaviour change techniques. The quality of included studies was low. Interventions to increase hand hygiene (k = 6) had a medium, positive effect (d = .62, 95% CI = 0.43-0.80, p < .001, I²  = 81.2%). Interventions targeting face mask use (k = 4) had mixed results, with an imprecise pooled estimate (OR = 4.14, 95% CI = 1.24-13.79, p < .001, I²  = 89.67%). Between-study heterogeneity was high.

CONCLUSIONS

We found low-quality evidence for positive effects of interventions targeting hand hygiene, with unclear results for interventions targeting face mask use. There was a lack of evidence for most behaviours of interest within this review.

A Systematic Review for Effective Preventive Public Education of Respiratory Infection

The present study aimed to systematically review to find the best available evidence on the efficacy of non-pharmaceutical interventions that have been used in the community so far. Through eight electronic journal database, 9 articles met our inclusion Participants, Intervention, Control, Outcomes, and Study Design (PICOS) criteria based on medical symptoms, interventions, and improvements. In general, interventions included hand hygiene, mask use, health education such as cough etiquette, hand washing and sanitizer methods. In addition, exercise and meditation were performed to improve immunity. As a result, the number of incidents and absences related to respiratory infections were reduced, the frequency and method of handwashing improved, and there were also positive effects in knowledge, attitude/perception, and performance. We concluded that it is necessary to create an environment and systematic support so that organizations or governments can determine healthy behavior at the same time as an individual approach. Furthermore, the follow-up for evaluating the effectiveness of interventions and the monitoring period should be included during the study, consequently resulting in having an opportunity to continuously remind people about health behavior. The community provides information on various types of non-pharmaceutical intervention to maintain healthy management and lifestyles in the public.

A kindergarten-based, family-involved intervention to improve children's hand hygiene behavior: A cluster-randomized controlled trial

OBJECTIVE

The present study determined the feasibility and initial efficacy of a kindergarten-based, family-involved intervention in improving children's hand hygiene (HH) behaviors.

DESIGN

A cluster-randomized controlled trial was performed, with a cluster defined as a kindergarten class.

SAMPLE

Participants were recruited from 20 classes in six kindergartens. A total of 289 children and their families were enrolled in the intervention group, and 293 children and their families were enrolled in the control group.

MEASUREMENTS

HH behavior and a related knowledge survey, as well as data on absences due to infection, were collected.

INTERVENTION

An 8-week training session on HH for children and an education program combining a seminar and WeChat groups for parents were provided to participants in the intervention group.

RESULTS

Two HH behaviors of children, namely, HH after playing outside and 7-stage HH compliance, were significantly different between the two groups after the intervention. The two HH behaviors and knowledge of infections of parents/legal guardians in the intervention group were better than those in the control group after the intervention. The number of absences due to infections in children was lower in the intervention group than in the control group.

CONCLUSIONS

Kindergarten-based, family-involved interventions effectively improved the HH behavior of kindergarten children and decreased absences due to infections.

Impact of social isolation due to COVID-19 on the seasonality of pediatric respiratory diseases

Introduction

Respiratory tract diseases are the major cause of morbidity and mortality in children under the age of 5 years, constituting the highest rate of hospitalization in this age group.

Objectives

To determine the prevalence of hospitalizations for respiratory diseases in childhood in the last 5 years and to assess the impact of social isolation due to COVID-19 on the seasonal behavior of these diseases.

Methods

A cross-sectional clinical study was carried out, with a survey of all patients aged 0 to 17 years who were admitted with a diagnosis of respiratory diseases between January 2015 and July 2020. The database was delivered to the researchers anonymized. The variables used for analysis were date of admission, date of discharge, length of stay, age, sex and diagnosis. In order to make the analysis possible, the diagnoses were grouped into upper respiratory infection (URI), asthma / bronchitis, bronchiolitis and pneumonia.

Results

2236 admissions were included in the study. Children under 5 years old account for 81% of hospitalizations for respiratory disease in our population. In the adjusted model, an average reduction of 38 hospitalizations was observed in the period of social isolation (coefficient: -37.66; 95% CI (- 68.17; -7.15); p = 0.016).

Conclusion

The social isolation measures adopted during the COVID-19 pandemic dramatically interfered with the seasonality of childhood respiratory diseases. This was reflected in the unexpected reduction in the number of hospitalizations in the pediatric population during this period.

Assessment on Hand Hygiene Knowledge and Practices Among Pre-school Children in Klang Valley

Background. Pre-school children are at a higher risk to acquire infectious diseases such as hand, foot and mouth disease due to their immature immune system. Good hand hygiene prevents transmission of infectious diseases. This study aimed to determine the knowledge and practices of hand hygiene among pre-schoolers. Methods. In this prospective, multi-center study, the pre-schools were selected according to the selection criteria. A questionnaire consisting of socio-demographics, knowledge and practices of hand hygiene were administered via face-to-face interview during the pre- and post-intervention period. A total of 435 pre-schoolers aged 5 and 6 years old from 2 pre-schools within Klang Valley, School P (test group) and School C (control group) were involved in this study. The test group was provided with comprehensive hand hygiene education including video on proper handwashing technique during the 2 months intervention period, whereas the control group did not receive any form of intervention. The data were statistically analyzed using descriptive analysis and independent t-test. Results. Majority of pre-schoolers gained knowledge of handwashing from their parents. However, only 63% demonstrated good handwashing technique. Test group were significantly better (P < 0.05) in handwashing technique and hand hygiene routine score. Conclusion. A comprehensive hand hygiene education program should include proper handwashing facilities, resources, and awareness of the care-givers in instilling and sustaining good hand hygiene behavior.

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.

METHODS

A 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.

RESULTS

seven 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.

CONCLUSIONS

This 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.

Increased hand hygiene compliance in nursing homes after a multimodal intervention: A cluster randomized controlled trial (HANDSOME)

OBJECTIVE

To assess the effect of a multimodal intervention on hand hygiene compliance (HHC) in nursing homes.

DESIGN, SETTING, AND PARTICIPANTS

HHC was evaluated using direct, unobtrusive observation in a cluster randomized controlled trial at publicly funded nursing homes in the Netherlands. In total, 103 nursing home organizations were invited to participate; 18 organizations comprising 33 nursing homes (n = 66 nursing home units) participated in the study. Nursing homes were randomized into a control group (no intervention, n = 30) or an intervention group (multimodal intervention, n = 36). The primary outcome measure was HHC of nurses. HHC was appraised at baseline and at 4, 7, and 12 months after baseline. Observers and nurses were blinded.

INTERVENTION

Audits regarding hand hygiene (HH) materials and personal hygiene rules, 3 live lessons, an e-learning program, posters, and a photo contest. We used a new method to teach the nurses the WHO-defined 5 moments of HH: Room In, Room Out, Before Clean, and After Dirty.

RESULTS

HHC increased in both arms. The increase after 12 months was larger for units in the intervention arm (from 12% to 36%) than for control units (from 13% to 21%) (odds ratio [OR], 2.10; confidence interval [CI], 1.35-3.28). The intervention arm exhibited a statistically significant increase in HHC at 4 of the 5 WHO-defined HH moments. At follow-up, HHC in the intervention arm remained statistically significantly higher (OR, 1.93; 95% CI, 1.59-2.34) for indications after an activity (from 37% to 39%) than for indications before an activity (from 14% to 27%).

CONCLUSIONS

The HANDSOME intervention is successful in improving HHC in nursing homes.

[Infection control training for physicians to improve hand hygiene on surgical rounds : The more the better?]

BACKGROUND AND OBJECTIVE

A high level of hand hygiene compliance is the best way to prevent postoperative wound infections and is therefore an important starting point for interventions. Despite different campaigns the hand hygiene compliance of physicians remains to be improved. The aim was to analyze the effect of tailored and innovative interventions on the hand hygiene compliance of physicians.

METHODS

At first the hand hygiene compliance of physicians was monitored during their ward rounds at three different wards. Afterwards two different interventions were performed and 6 weeks after each intervention the hand hygiene compliance was monitored again.

RESULTS

The hand hygiene compliance of the control group (no intervention) did not change throughout the study. The ward where a small intervention was used showed an increase of hand hygiene compliance. Tailored intervention, however, resulted in a significant improvement of hand hygiene compliance in the ward where it was used.

DISCUSSION AND PROSPECTS

Training concerning hand hygiene has to be improved to increase the prevention of infections. Tailored interventions with a high amount of practical relevance are suited to increase the compliance with preventive procedures (e.g. hand hygiene compliance). To improve the infection prevention for physicians in the long term, a firm knowledge about the indications for hand hygiene procedures is needed. This can be ensured by infection control training with a practical focus, small memory aids and permanent support from infection prevention professionals.

Improving Hand Hygiene Compliance in Nursing Homes: Protocol for a Cluster Randomized Controlled Trial (HANDSOME Study)

BACKGROUND

Hand hygiene compliance is considered the most (cost-)effective measure for preventing health care-associated infections. While hand hygiene interventions have frequently been implemented and assessed in hospitals, there is limited knowledge about hand hygiene compliance in other health care settings and which interventions and implementation methods are effective.

OBJECTIVE

This study aims to evaluate the effect of a multimodal intervention to increase hand hygiene compliance of nurses in nursing homes through a cluster randomized controlled trial (HANDSOME study).

METHODS

Nursing homes were randomly allocated to 1 of 3 trial arms: receiving the intervention at a predetermined date, receiving the identical intervention after an infectious disease outbreak, or serving as a control arm. Hand hygiene was evaluated in nursing homes by direct observation at 4 timepoints. We documented compliance with the World Health Organization's 5 moments of hand hygiene, specifically before touching a patient, before a clean/aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. The primary outcome is hand hygiene compliance of the nurses to the standards of the World Health Organization. The secondary outcome is infectious disease incidence among residents. Infectious disease incidence was documented by a staff member at each nursing home unit. Outcomes will be compared with the presence of norovirus, rhinovirus, and Escherichia coli on surfaces in the nursing homes, as measured using quantitative polymerase chain reaction.

RESULTS

The study was funded in September 2015. Data collection started in October 2016 and was completed in October 2017. Data analysis will be completed in 2020.

CONCLUSIONS

HANDSOME studies the effectiveness of a hand hygiene intervention specifically for the nursing home environment. Nurses were taught the World Health Organization's 5 moments of hand hygiene guidelines using the slogan "Room In, Room Out, Before Clean, After Dirty," which was developed for nursing staff to better understand and remember the hygiene guidelines. HANDSOME should contribute to improved hand hygiene practice and a reduction in infectious disease rates and related mortality.

TRIAL REGISTRATION

Netherlands Trial Register (NTR6188) NL6049; https://www.trialregister.nl/trial/6049.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17419.

Rinse-free hand wash for reducing absenteeism among preschool and school children

BACKGROUND

Illness-related absenteeism is an important problem among preschool and school children for low-, middle- and high- income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse-free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness-related absenteeism in preschool and school children.

OBJECTIVES

1. To assess the effectiveness of rinse-free hand washing for reducing absenteeism due to illness in preschool and school children compared to no hand washing, conventional hand washing with soap and water or other hand hygiene strategies. 2. To determine which rinse-free hand washing products are the most effective (if head-to-head comparisons exist), and what effect additional strategies in combination with rinse-free hand washing have on the outcomes of interest.

SEARCH METHODS

In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied.

SELECTION CRITERIA

Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse-free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions.

DATA COLLECTION AND ANALYSIS

Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings.

MAIN RESULTS

This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day-care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most-notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse-free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low-certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse-free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse-free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low-certainty evidence), which indicates rinse-free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse-free' group (eight days absent per 1000). There may be little to no difference between rinse-free hand washing and 'no rinse-free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low-certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very-low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse-free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very-low certainty evidence).

AUTHORS' CONCLUSIONS

The findings of this review may have identified a small yet potentially beneficial effect of rinse-free hand washing regimes on illness-related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse-free hand washing regimens in order to provide more conclusive, higher-certainty evidence regarding its impact. When considering the use of a rinse-free hand washing program in a local setting, there needs to be consideration of the current rates of illness-related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings.

Does a Playful Intervention Promote Hand Hygiene? Compliance and Educator's Beliefs about Hand Hygiene at a Daycare Center

PURPOSE

Our purpose was to analyze hand hygiene compliance before and after a playful intervention, and caregivers' beliefs, perception of self-efficacy, and barriers to hand hygiene at a daycare center in Brazil.

DESIGN AND METHODS

This a quasi-experimental study was conducted from January to July 2017 in a daycare center that provides full-time education for children aged zero to four years from low-income families. The playful intervention with 24 caregivers included an emoji card game to address their beliefs and perception of self-efficacy and a product that reveals dirty areas on washed hands. For 126 children aged two to four years we used a story told through puppets, card games, songs, and a practice of washing hands colored with tempera paint.

RESULTS

The results showed that the playful intervention with children and caregivers increased hand hygiene compliance from 13.3% to 41.4% with a significant statistical difference (p < 0.001) after the intervention. The caregiver's perception of self-efficacy for hand hygiene was higher after bathroom use (59.8%) and lower after playing outdoors (28.6%).

CONCLUSIONS

Playful interventions performed by nurses promote hand hygiene compliance among children and caregivers at daycare centers.

PRACTICE IMPLICATIONS

Practice implications include that health education provided by pediatric nurses is essential in promoting health and preventing the dissemination of infectious diseases to children and caregivers at daycare centers.

A multimodal intervention to improve hand hygiene compliance via social cognitive influences among kindergarten teachers in China

Children attending kindergarten are at high risk for contracting infections, for which hand hygiene (HH) has been recognized as the most cost-effective prevention measure globally. Kindergarten teachers’ HH behavior plays a vital role in encouraging favorable hygiene techniques and environment. This study aims to evaluate the effectiveness of a multimodal intervention at changing kindergarten teachers’ HH behavior and social cognitive factors that influences HH behavior in China. The intervention named “Clean Hands, Happy Life” includes HH products with refills, reminders and cues for action, a kick-off event with awards, and training programs. We evaluated the intervention using a self-administrative questionnaire with a stratified random sample of 12 kindergartens. Two surveys was completed by 176 teachers at baseline and 185 after the 6-month intervention. Compared with the baseline scores, there was a significant improvement in the overall self-reported HH compliance of teachers (9.38 vs. 9.68 out of 10, p = 0.006), as well as teachers’ perceived disease susceptibility, disease severity and behavioral control after the intervention (p<0.05). We found that teachers’ HH compliance was likely to be higher among those who have better HH guideline awareness (β = 0.48, p<0.01) and perceived behavioral control (β = 0.26, p = 0.01), which explained 24.2% of the variance of self-reported compliance of teachers at baseline. The assessed intervention may provide Chinese kindergarten teachers with behavioral skills and cognitions that associated with the compliance of HH behavior. We thus recommend future intervention studies consider our HH behavior change techniques, address multiple social cognitive determinants of HH behavior and include the change of targeted influences in the impact evaluation.

Effectiveness of a Hand Hygiene Program at Child Care Centers: A Cluster Randomized Trial

OBJECTIVES

Respiratory infections (RIs) are an important cause of morbidity and excessive antibiotic prescriptions in children attending day care centers (DCCs). We aimed to assess the effectiveness of an educational and hand hygiene program in DCCs and homes in reducing RI incidence and antibiotic prescriptions in children.

METHODS

A cluster, randomized, controlled, and open study of 911 children aged 0 to 3 years attending 24 DCCs in Almería (Spain) with an 8-month follow-up. Two intervention groups of DCC families performed educational and hand hygiene measures, 1 with soap and water (SWG; n = 274), another with hand sanitizer (HSG; n = 339), and the control group (CG; n = 298) followed usual hand-washing procedures. RI episode rates were compared through multilevel Poisson regression models. The percentage of days missed were compared with Poisson exact tests.

RESULTS

There were 5211 RI episodes registered. Children in the HSG had less risk of RI episodes (incidence rate ratio [IRR]: 0.77; 95% confidence interval [CI]: 0.68-0.88) and antibiotic prescriptions (IRR: 0.69; 95% CI: 0.57-0.84) compared with the those in the CG. Children in the SWG had a higher risk of RI episodes (IRR: 1.21; 95% CI: 1.06-1.39) and antibiotic prescriptions (IRR: 1.31; 95% CI: 1.08-1.56) than those in the HSG. Pupils missed 5186 DCC days because of RIs, and the percentage of days absent was significantly lower in the HSG compared with the CG (P < .001) and the SWG (P < .001).

CONCLUSIONS

Hand hygiene programs that include hand sanitizer and educational measures for DCC staff, children, and parents, reduce absent days, RIs, and antibiotic prescriptions for these infections in children at DCCs.

A hand hygiene intervention to decrease hand, foot and mouth disease and absence due to sickness among kindergarteners in China: A cluster-randomized controlled trial

OBJECTIVES

To evaluate the effect of the "Clean Hands, Happy Life" intervention on the incidence of hand, food and mouth disease (HFMD) and on school absences due to sickness in kindergarten students.

METHODS

The intervention consisted of four hand hygiene (HH) promotion components and was evaluated in a cluster-randomized controlled trial among 8275 children and 18 kindergartens from May to October, 2015 in Shenzhen, China. We compared two intervention arms - received the intervention in kindergartens only and in both kindergartens and families, respectively - to the control arm in multilevel analyses.

RESULTS

During the follow-up, the incidence of HFMD in both intervention arms was significantly lower than in the control arm (IRR₁: 0.39, 95%CI: 0.26-0.59; IRR₂: 0.30, 95%CI: 0.19-0.49); the duration of absence due to sickness (in days) in both intervention arms was significantly shorter than in the control arm (β₁ = 0.58, 95%CI: 0.41-0.74; β₂ = 0.34, 95%CI: 0.17-0.50), controlling for the area type of kindergarten and grade level of children. Furthermore, during the follow-up we found that there were fewer episodes of absence due to respiratory, skin and eye infections (P < 0.05).

CONCLUSIONS

Our intervention is effective at reducing HFMD infections and absence due to sickness in children attending kindergartens in China.

Behavioral Interventions to Reduce Infections in Pediatric Long-term Care Facilities: The Keep It Clean for Kids Trial

Children in pediatric long-term care facilities (pLTCF) represent a highly vulnerable population and infectious outbreaks occur frequently, resulting in significant morbidity, mortality, and resource use. The purpose of this quasi-experimental trial using time series analysis was to assess the impact of a 4-year theoretically based behavioral intervention on infection prevention practices and clinical outcomes in three pLTCF (288 beds) in New York metropolitan area including 720 residents, ages 1 day to 26 years with mean lengths of stay: 7.9-33.6 months. The 5-pronged behavioral intervention included explicit leadership commitment, active staff participation, work flow assessments, training staff in the World Health Organization "'five moments of hand hygiene (HH)," and electronic monitoring and feedback of HH frequency. Major outcomes were HH frequency, rates of infections, number of hospitalizations associated with infections, and outbreaks. Mean infection rates/1000 patient days ranged from 4.1-10.4 pre-intervention and 2.9-10.0 post-intervention. Mean hospitalizations/1000 patient days ranged from 2.3-9.7 before and 6.4-9.8 after intervention. Number of outbreaks/1000 patient days per study site ranged from 9-24 pre- and 9-18 post-intervention (total = 95); number of cases/outbreak ranged from 97-324 (total cases pre-intervention = 591 and post-intervention = 401). Post-intervention, statistically significant increases in HH trends occurred in one of three sites, reductions in infections in two sites, fewer hospitalizations in all sites, and significant but varied changes in the numbers of outbreaks and cases/outbreak. Modest but inconsistent improvements occurred in clinically relevant outcomes. Sustainable improvements in infection prevention in pLTCF will require culture change; increased staff involvement; explicit administrative support; and meaningful, timely behavioral feedback.