Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review

Disease Burden and Geographic Inequalities in 15 Types of Neonatal Infectious Diseases in 131 Low- and Middle-Income Countries and Territories

Background: The burden of neonatal infections in low- and middle-income countries and territories (LMICs) is a critical public health challenge, while our understanding of specific burden and secular trends remains limited. Methods: We gathered annual data on 15 types of neonatal infections in LMICs from 1990 to 2019 from the Global Burden of Disease 2019. Numbers, rates, percent changes, and estimated annual percentage changes of incidence and deaths were calculated. We also explored the association between disease burden, socio-demographic index (SDI), and universal health coverage index (UHCI). Results: Enteric infections and upper respiratory infections owned the top highest incidence rates for neonates in 2019. Neonatal sepsis and other neonatal infections, as well as otitis media, demonstrated an increasing trend of incidence across all 3 low- and middle-income regions. The top 3 causes of neonatal mortality in 2019 were neonatal sepsis and other neonatal infections, lower respiratory infections, and enteric infections. Between 1990 and 2019, all of the neonatal infection-related mortality rates suggested an overall decline. Sex differences could be found in the incidence and mortality of some neonatal infections, but most disease burdens decreased more rapidly in males. SDI and UHCI were both negatively associated with most of the disease burden, but there were exceptions. Conclusions: Our study serves as a vital exploration into the realities of neonatal infectious diseases in LMICs. The identified trends and disparities not only provide a foundation for future research but also underscore the critical need for targeted policy initiatives to alleviate on a global scale.

Childcare centre attendance and health, growth, and development among children aged 0-3 years in low- and middle-income countries: A systematic review

Background

Lack of childcare for children aged 0-3 years has emerged as a global crisis, accentuated by women's increasing workforce participation and recognition that young children require nurturing care. Through this systematic review, we sought to examine associations between childcare centre attendance in low- and middle-income countries (LMICs) and children's health, growth, and development, and to generate childcare centre programmatic and research recommendations for children aged 0-3 years.

Methods

We systematically searched PsycINFO, MEDLINE, PubMed, and Cochrane for articles on centre-based childcare for children aged 0-3 years in LMICs, published between 2000 and 2021 in English (or which were translated into English). We excluded articles on specialised subgroups or interventions. We imported the retrieved articles into Covidence for review and assessed them for bias using the National Institutes of Health (NIH) quality assessment tool.

Results

Twenty-two articles (24 studies) met the inclusion criteria, encompassing 36 927 children from 10 countries across Mexico and South America (n = 12), Africa (n = 5), and Asia (n = 5). Outcomes included health (n = 12), growth/nutrition (n = 6), and development (n = 6). Study quality assessments were low; 41% exceeded 50% of quality criteria and 45% adjusted for confounders. Associations between childcare attendance and outcome measures were primarily negative for health (n/N = 7/12) and positive for growth/nutrition (n/N = 5/6) and development (n/N = 4/6). Childcare centre programmatic recommendations for children aged 0-3 years included: age-specific policies; program quality, including safety, hygiene, nutrition, and curriculum; access and affordability; parent engagement; financial support; and workforce development. Research recommendations included: study design, including enrolment age, frequency, duration, childcare type, home and childcare sociodemographic and cultural environments, child and caregiver outcomes, and analytical approaches; longitudinal studies; and implementation research.

Conclusions

Rigorous primary research in global childcare for young children is urgently needed. Policies, programmes, and investments in high-quality childcare can promote nurturing care for young children, enabling mothers to participate in the workforce.

Registration

PROSPERO: CRD42018105576.

Synthesising the evidence for effective hand hygiene in community settings: an integrated protocol for multiple related systematic reviews

INTRODUCTION

Despite evidence for the efficacy and effectiveness of hand hygiene in reducing the transmission of infectious diseases, there are gaps in global normative guidance around hand hygiene in community settings. The goal of this review is to systematically retrieve and synthesise available evidence on hand hygiene in community settings across four areas: (1) effective hand hygiene; (2) minimum requirements; (3) behaviour change and (4) government measures.

METHODS AND ANALYSIS

This protocol entails a two-phased approach to identify relevant studies for multiple related systematic reviews. Phase 1 involves a broad search to capture all studies on hand hygiene in community settings. Databases, trial registries, expert consultations and hand searches of reference lists will be used to ensure an exhaustive search. A comprehensive, electronic search strategy will be used to identify studies indexed in PubMed, Web of Science, EMBASE, CINAHL, Global Health, Cochrane Library, Global Index Medicus, Scopus, PAIS Index, WHO IRIS, UN Digital Library and World Bank eLibrary published in English from January 1980 to March 2023. The outcome of phase 1 will be a reduced sample of studies from which further screening, specific to research questions across the four key areas can be performed. Two reviewers will independently assess each study for inclusion and disagreements will be resolved by a third reviewer. Quantitative and qualitative data will be extracted following best practices. We will assess all studies using the Mixed Method Appraisal Tool. All effect measures pertaining to review outcomes will be reported and a narrative synthesis of all studies will be presented including 'data-driven' descriptive themes and 'theory-driven' analytical themes as applicable.

ETHICS AND DISSEMINATION

This systematic review is exempt from ethics approval because the work is carried out on published documents. The findings of the reviews will be disseminated in related peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42023429145.

Effect of COVID-19 pandemic on the incidence of acute diarrheal disease and pneumonia among under 5 children in Ethiopia- A database study

COVID-19 has had a devastating impact on preventable and treatable pediatric diseases in Ethiopia. This study looks at the impact of COVID-19 on pneumonia and acute diarrheal diseases in the country, as well as the differences between administrative regions. In Ethiopia, we conducted a retrospective pre-post study to assess the impact of COVID-19 on children under the age of five who had acute diarrhea and pneumonia and were treated in health facilities during the pre-COVID-19 era (March 2019 to February 2020) and the COVID-19 era (March 2020 to February 2021). From the National Health Management District Health Information System (DHIS2, HMIS), we retrieved data on total acute diarrheal disease and pneumonia, along with their regional and monthly distribution. We calculated incidence rate ratios comparing the rates of acute diarrhea and pneumonia during the pre-and post-COVID-19 eras and adjusted for the year, using Poisson regression. The number of under-five children treated for acute pneumonia decreased from 2,448,882 before COVID-19 to 2,089,542 ((14.7% reduction (95%CI;8.72-21.28), p<0.001)) during COVID-19. Similarly, the number of under-five children treated for acute diarrheal disease decreased from 3,287,850 in pre-COVID-19 to, 2,961,771((9.91% reduction (95%CI;6.3-17.6%),p<0.001)) during COVID-19. In the majority of the administrative regions studied, pneumonia and acute diarrhea diseases decreased during COVID-19, but they increased in Gambella, Somalia, and Afar. During the COVID-19 period, the greatest reduction of children with pneumonia (54%) and diarrhea disease (37.3%) was found in Addis Ababa (p<0.001). The majority of administrative regions included in this study have seen a decrease in pneumonia and acute diarrheal diseases among children under the age of five, while three regions namely, Somalia, Gambela, and Afar saw an increase in cases during the pandemic. This emphasizes the importance of using tailored approaches in mitigating the impact of infectious diseases such as diarrhea and pneumonia during situations of a pandemic such as COVID-19.

Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Acute respiratory infection (ARI) is a leading cause of morbidity and mortality globally, with 83% of ARI mortality occurring in low-income and middle-income countries (LMICs) before the COVID-19 pandemic. We aimed to estimate the effect of interventions promoting handwashing with soap on ARI in LMICs.

METHODS

In our systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, Global Health, and Global Index Medicus for studies of handwashing with soap interventions in LMICs from inception to May 25, 2021. We included randomised and non-randomised controlled studies of interventions conducted in domestic, school, or childcare settings. Interventions promoting hand hygiene methods other than handwashing with soap were excluded, as were interventions in health-care facilities or the workplace. The primary outcome was ARI morbidity arising from any pathogen for participants of any age. Secondary outcomes were lower respiratory infection, upper respiratory infection, influenza confirmed by diagnostic test, COVID-19 confirmed by diagnostic test, and all-cause mortality. We extracted relative risks (RRs), using random-effects meta-analysis to analyse study results, and metaregression to evaluate heterogeneity. We assessed risk of bias in individual studies using an adapted Newcastle-Ottawa scale, and assessed the overall body of evidence using a Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The study is registered with PROSPERO, CRD42021231414.

FINDINGS

26 studies with 161 659 participants met inclusion criteria, providing 27 comparisons (21 randomised). Interventions promoting handwashing with soap reduced any ARI compared with no handwashing intervention (RR 0·83 [95% CI 0·76-0·90], I2 88%; 27 comparisons). Interventions also reduced lower respiratory infections (0·78 [0·64-0·94], I2 64%; 12 comparisons) and upper respiratory infections (0·74 [0·59-0·93], I2 91%; seven comparisons), but not test-confirmed influenza (0·94 [0·42-2·11], I2 90%; three comparisons), test-confirmed COVID-19 (no comparisons), or all-cause mortality (prevalence ratio 0·95 [95% CI 0·71-1·27]; one comparison). For ARI, no heterogeneity covariates were significant at p<0·1 and the GRADE rating was moderate certainty evidence.

INTERPRETATION

Interventions promoting handwashing with soap can reduce ARI in LMICs, and could help to prevent the large burden of respiratory disease.

FUNDING

Bill & Melinda Gates Foundation, Reckitt Global Hygiene Institute, and UK FCDO.

Spatial epidemiology of acute respiratory infections in children under 5 years and associated risk factors in India: District-level analysis of health, household, and environmental datasets

Background

In India, acute respiratory infections (ARIs) are a leading cause of mortality in children under 5 years. Mapping the hotspots of ARIs and the associated risk factors can help understand their association at the district level across India.

Methods

Data on ARIs in children under 5 years and household variables (unclean fuel, improved sanitation, mean maternal BMI, mean household size, mean number of children, median months of breastfeeding the children, percentage of poor households, diarrhea in children, low birth weight, tobacco use, and immunization status of children) were obtained from the National Family Health Survey-4. Surface and ground-monitored PM_2.5 and PM₁₀ datasets were collected from the Global Estimates and National Ambient Air Quality Monitoring Programme. Population density and illiteracy data were extracted from the Census of India. The geographic information system was used for mapping, and ARI hotspots were identified using the Getis-Ord Gi^* spatial statistic. The quasi-Poisson regression model was used to estimate the association between ARI and household, children, maternal, environmental, and demographic factors.

Results

Acute respiratory infections hotspots were predominantly seen in the north Indian states/UTs of Uttar Pradesh, Bihar, Delhi, Haryana, Punjab, and Chandigarh, and also in the border districts of Uttarakhand, Himachal Pradesh, and Jammu and Kashmir. There is a substantial overlap among PM_2.5, PM₁₀, population density, tobacco smoking, and unclean fuel use with hotspots of ARI. The quasi-Poisson regression analysis showed that PM_2.5, illiteracy levels, diarrhea in children, and maternal body mass index were associated with ARI.

Conclusion

To decrease ARI in children, urgent interventions are required to reduce the levels of PM_2.5 and PM₁₀ (major environmental pollutants) in the hotspot districts. Furthermore, improving sanitation, literacy levels, using clean cooking fuel, and curbing indoor smoking may minimize the risk of ARI in children.

Nonpharmaceutical interventions to prevent viral respiratory infection in community settings: an umbrella review

Background

Respiratory viruses pose an important public health threat to most communities. Nonpharmaceutical interventions (NPIs) such as masks, hand hygiene or physical distancing, among others, are believed to play an important role in reducing transmission of respiratory viruses. In this umbrella review, we summarise the evidence of the effectiveness of NPIs for the prevention of respiratory virus transmission in the community setting.

Observations

A systematic search of PubMed, Embase, Medline and Cochrane reviews resulted in a total of 24 studies consisting of 11 systematic reviews and meta-analyses, 12 systematic reviews without meta-analyses and one standalone meta-analysis. The current evidence from these data suggests that hand hygiene is protective against respiratory viral infection. The use of hand hygiene and facemasks, facemasks alone and physical distancing were interventions with inconsistent evidence. Interventions such as school closures, oral hygiene or nasal saline rinses were shown to be effective in reducing the risk of influenza; however, the evidence is sparse and mostly of low and critically low quality.

Conclusions

Studies on the effectiveness of NPIs for the prevention of respiratory viral transmission in the community vary in study design, quality and reported effectiveness. Evidence for the use of hand hygiene or facemasks is the strongest; therefore, the most reasonable suggestion is to use hand hygiene and facemasks in the community setting.

Impact of community masking on COVID-19: A cluster-randomized trial in Bangladesh

We conducted a cluster-randomized trial to measure the effect of community-level mask distribution and promotion on symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in rural Bangladesh from November 2020 to April 2021 (N = 600 villages, N = 342,183 adults). We cross-randomized mask type (cloth versus surgical) and promotion strategies at the village and household level. Proper mask-wearing increased from 13.3% in the control group to 42.3% in the intervention arm (adjusted percentage point difference = 0.29; 95% confidence interval = [0.26, 0.31]). The intervention reduced symptomatic seroprevalence (adjusted prevalence ratio = 0.91 [0.82, 1.00]), especially among adults ≥60 years old in villages where surgical masks were distributed (adjusted prevalence ratio = 0.65 [0.45, 0.85]). Mask distribution with promotion was a scalable and effective method to reduce symptomatic SARS-CoV-2 infections.

Personal care formulations demonstrate virucidal efficacy against multiple SARS-CoV-2 variants of concern: Implications for hand hygiene and public health

Despite considerable progress being made on vaccine roll out, practicing proper hand hygiene has been advocated as a consistent precautionary intervention against the circulating and emerging variants of SARS-CoV-2. Two variants of concern, namely beta and delta, have been shown to exhibit enhanced transmissibility, high viral load, and ability to escape antibody-mediated neutralization. In this report we have empirically determined the efficacy of selected personal care formulations from Unilever in inactivating the beta and delta variants of SARS-CoV-2 under simulated real-life conditions. All the formulations demonstrated greater than 99.9% reduction in viral infective titres which is comparable to inactivation of the original strain of SARS-CoV-2 virus tested under the same conditions. Therefore, it can be concluded that well-designed personal care formulations when tested under consumer-centric conditions, and with proven efficacy against the parent strain of SARS-CoV-2 will continue to be effective against extant and emerging variants of SARS-CoV-2.

Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries

INTRODUCTION

Domestic hand hygiene could prevent over 500 000 attributable deaths per year, but 6 in 10 people in least developed countries (LDCs) do not have a handwashing facility (HWF) with soap and water available at home. We estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs.

METHODS

Our model combines quantities of households with no HWF and prices of promotion campaigns, HWFs, soap and water. For quantities, we used estimates from the WHO/UNICEF Joint Monitoring Programme. For prices, we collated data from recent impact evaluations and electronic searches. Accounting for inflation and purchasing power, we calculated costs over 2021-2030, and estimated total cost probabilistically using Monte Carlo simulation.

RESULTS

An estimated US$12.2-US$15.3 billion over 10 years is needed for universal hand hygiene in household settings in 46 LDCs. The average annual cost of hand hygiene promotion is US$334 million (24% of annual total), with a further US$233 million for 'top-up' promotion (17%). Together, these promotion costs represent US$0.47 annually per head of LDC population. The annual cost of HWFs, a purpose-built drum with tap and stand, is US$174 million (13%). The annual cost of soap is US$497 million (36%) and water US$127 million (9%).

CONCLUSION

The annual cost of behavioural change promotion to those with no HWF represents 4.7% of median government health expenditure in LDCs, and 1% of their annual aid receipts. These costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behavioural change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households.

The indirect impact of COVID-19 pandemic on inpatient admissions in 204 Kenyan hospitals: An interrupted time series analysis

The first case of severe acute respiratory coronavirus 2 (SARS-CoV-2) was identified in March 2020 in Kenya resulting in the implementation of public health measures (PHM) to prevent large-scale epidemics. We aimed to quantify the impact of COVID-19 confinement measures on access to inpatient services using data from 204 Kenyan hospitals. Data on monthly admissions and deliveries from the District Health Information Software version 2 (DHIS 2) were extracted for the period January 2018 to March 2021 stratified by hospital ownership (public or private) and adjusting for missing data using multiple imputation (MI). We used the COVID-19 event as a natural experiment to examine the impact of COVID-19 and associated PHM on use of health services by hospital ownership. We estimated the impact of COVID-19 using two approaches; Statistical process control (SPC) charts to visualize and detect changes and Interrupted time series (ITS) analysis using negative-binomial segmented regression models to quantify the changes after March 2020. Sensitivity analysis was undertaken to test robustness of estimates using Generalised Estimating Equations (GEE) and impact of national health workers strike on observed trends. SPC charts showed reductions in most inpatient services starting April 2020. ITS modelling showed significant drops in April 2020 in monthly volumes of live-births (11%), over-fives admissions for medical (29%) and surgical care (25%) with the greatest declines in the under-five's admissions (59%) in public hospitals. Similar declines were apparent in private hospitals. Health worker strikes had a significant impact on post-COVID-19 trends for total deliveries, live-births and caesarean section rate in private hospitals. COVID-19 has disrupted utilization of inpatient services in Kenyan hospitals. This might have increased avoidable morbidity and mortality due to non-COVID-19-related illnesses. The declines have been sustained. Recent data suggests a reversal in trends with services appearing to be going back to pre- COVID levels.

Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low- and middle-income countries (LMICs): An umbrella review

Despite significant progress in the last few decades, infectious diseases remain a major threat to child health in low- and middle-income countries (LMICs)-particularly amongst more disadvantaged groups. It is imperative to understand the best available evidence concerning which public health interventions reduce morbidity, mortality and health inequalities in children aged under five years. To address this gap, we carried out an umbrella review (a systematic reviews of reviews) to identify evidence on the effects of public health interventions (promotion, protection, prevention) on morbidity, mortality and/or health inequalities due to infectious diseases amongst children in LMICs. Ten databases were searched for records published between 2014-2021 alongside a manual search of gray literature. Articles were quality-assessed using the Assessment of Multiple Systematic Reviews tool (AMSTAR 2). A narrative synthesis was conducted. We identified 60 systematic reviews synthesizing 453 individual primary studies. A majority of the reviews reported on preventive interventions (n = 48), with a minority on promotion (n = 17) and almost no reviews covering health protection interventions (n = 2). Effective interventions for improving child health across the whole population, as well as the most disadvantaged included communication, education and social mobilization for specific preventive services or tools, such as immunization or bed nets. For all other interventions, the effects were either unclear, unknown or detrimental, either at the overall population level or regarding health inequalities. We found few reviews reporting health inequalities information and the quality of the evidence base was generally low. Our umbrella review identified some prevention interventions that might be useful in reducing under five mortality from infectious diseases in LMICs, particularly amongst the most disadvantaged groups.

Nonpharmacological interventions to reduce respiratory viral transmission: an evidence-based review with recommendations

BACKGROUND

Viral respiratory infections are a leading cause of worldwide mortality and exert the potential to cause global socioeconomic crises. However, inexpensive, efficacious, and rapidly deployable strategies to reduce viral transmission are increasingly important in the setting of an ongoing pandemic, though not entirely understood. This article provides a comprehensive review of commonly employed nonpharmacological interventions to interrupt viral spread and provides evidence-based recommendations for their use.

METHODOLOGY

A systematic review of three databases was performed. Studies with defined endpoints of subjects receiving one of five interventions (nasal washing, gargling, personal protective equipment (PPE), social distancing, and hand hygiene) were included. An evidence-based review of the highest level of evidence, with recommendations, was created in accordance with a previously described, rigorous, iterative process.

RESULTS

Fifty-four primary studies were included. The most commonly studied intervention was hand hygiene, followed by PPE, gargling, saline nasal washing, and social distancing.

CONCLUSIONS

Mask use and hand hygiene are strong recommendations for prevention of viral transmission. Donning gloves, gowns, and eye protection are a recommendation in healthcare settings. Saline nasal washing and gargling are options in selected populations. Although an aggregate level of evidence is not provided, the authors recommend social distancing.

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.

Availability and factors influencing community level handwashing facility in Ethiopia: Implication for prevention of infectious diseases

Background

Handwashing is one of the most effective ways to prevent transmission of infectious diseases. A substantial body of research has examined the status and determinants of handwashing facilities in healthcare settings and schools. However, its status at home in the community, especially in developing countries, remains unclear. This study aimed to examine the availability and factors influencing basic handwashing facilities at households in Ethiopia.

Method

We analysed the 2016 Ethiopian Demographic and Health Survey (EDHS) data. EDHS employed a two-stage stratified cluster sampling technique. Data were collected from the lowest administrative unit (kebele). A multivariable logistic regression model that allowed cluster-level random effects was employed to examine factors that affect the availability of basic handwashing facilities (water plus soap) at households. Estimates from the regression model are reported as odds ratios (ORs) with standard errors clustered at the DHS cluster level to account for a sampling methodology.

Results

In our sample, only 1292 (8% [95% CI, 7.6%–8.4%]) of the households had basic handwashing facilities. Compared with head of household who had no formal education, the odds of having basic handwashing facilities was higher among head of household who completed secondary level of education (adjusted odds ratio [AOR] = 1.83; 95% CI: 1.35–2.49) and higher level of education (AOR = 2.35; 95% CI: 1.63–3.39). Odds of having basic handwashing facilities was increased with having radio (AOR = 1.32; 95% CI: 1.10–1.63) and television (AOR = 1.49; 95% CI: 1.10–2.02) at home. Households that had improved latrine were two times more likely to have basic handwashing facilities (AOR = 2.09; 95% CI: 1.56–2.80). Being at higher household wealth quintiles was associated with increased odds of having basic handwashing facilities.

Conclusion

Very low basic handwashing facilities was demonstrated by this study, whereas, awareness and socio-economic related factors were identified as a determinants for its availability in the household. Greater efforts are needed to increase the coverage of community-level handwashing facilities.

Impact of a school-based water, sanitation and hygiene programme on children's independent handwashing and toothbrushing habits: a cluster-randomised trial

Objectives

To explore whether a school-based water, sanitation and hygiene programme, which includes group hygiene activities, contributes to the formation of independent handwashing and toothbrushing habits among Filipino children.

Methods

In this cluster-randomised trial, twenty primary schools were randomly allocated to the intervention or control arm. Intervention schools received group handwashing facilities and implemented daily group handwashing and toothbrushing activities. A soap use to toilet event ratio was calculated to measure children’s independent handwashing behaviour after toilet use, and dental plaque accumulation on Monday morning was measured as a proxy indicator for children’s independent toothbrushing behaviour at home.

Results

Four months after implementation, handwashing and toothbrushing behaviours did not significantly differ between intervention and control schools. The mean soap use in intervention schools and control schools was 0.41 g and 0.30 g per toilet event, respectively (p = 0.637). Compared to baseline, mean plaque scores reduced by 4.2% and 3.5% in intervention and control schools, respectively (p = 0.857).

Conclusions

Although health benefits have been established, school-based group handwashing and toothbrushing may not be sufficient to increase children’s uptake of independent hygiene behaviours.

Electronic supplementary material

The online version of this article (10.1007/s00038-020-01514-z) contains supplementary material, which is available to authorized users.

Handwashing in averting infectious diseases: Relevance to COVID-19

After officially declared as a pandemic by the World Health Organization (WHO), drastic measures to restrict human movements to contain the COVID-19 infection are employed by most of the countries. Maintaining high personal hygiene by frequent handwashing and be vigilant of clinical signs are widely recommended to reduce the disease burden. The national and international health agencies, including the Centers for Disease Control and Prevention (CDC) and the WHO, have provided guidelines for prevention and treatment suggestions. Here, in this brief article, based on available clinical information, the author discusses why handwashing could be protective of COVID-19 infections. Although a detailed and in-depth discussion of various preventive and protective measures is beyond the scope of this article, this review will focus on the utility of frequent handwashing in minimizing the risk of spreading COVID-19 infection.

Effects of Individual and Combined Water, Sanitation, Handwashing, and Nutritional Interventions on Child Respiratory Infections in Rural Kenya: A Cluster-Randomized Controlled Trial

Poor nutrition and hand hygiene are risk factors for acute respiratory infections (ARIs). Safe drinking water and sanitation can reduce exposure to pathogens and encourage healthy immune responses, reducing the risk of ARIs. Within a trial assessing impacts of water, sanitation, and handwashing (WASH), and nutritional interventions, we evaluated effects on ARIs. The WASH Benefits cluster-randomized trial enrolled pregnant women from Kenyan villages and evaluated health outcomes in children born to enrolled mothers 1 and 2 years after intervention delivery. Geographically adjacent clusters were block-randomized into a passive control (no promotional visits), a double-sized active control (monthly visits to measure mid–upper arm circumference), and six intervention groups: chlorinated drinking water (W), improved sanitation (S), handwashing with soap (H), combined WSH, improved nutrition (N) through counseling and lipid-based nutrient supplementation (LNS), and combined WSHN. The main outcome was the prevalence of ARI symptoms (cough, panting, wheezing, or difficulty breathing) in children younger than 3 years. Masking participants was not possible. Analyses were intention-to-treat. Between November 2012 and May 2014, 702 clusters were enrolled, including 6,960 (year 1) and 7,088 (year 2) children with ARI data. The cluster-level intra-cluster correlation coefficient for ARIs was 0.026 across both years. Water, sanitation, and handwashing interventions with behavior change messaging did not reduce ARIs. Nutrition counseling and LNS modestly reduced ARI symptoms compared with controls in year 1 [prevalence ratio (PR): 0.87, 95% confidence interval (CI): 0.77–0.99], but no effect in the combined WSHN group weakens this finding.

Integrating Face Washing into a School-Based, Handwashing Behavior Change Program to Prevent Trachoma in Turkana, Kenya

Trachoma is the leading infectious cause of blindness, and facial cleanliness is associated with reduced odds of trachomatous inflammation and Chlamydia trachomatis infection, but there is little evidence of how to drive this behavior change at scale. We report the results of a program integrating face washing into a school-based handwashing promotion program in Turkana County, Kenya. Children aged 5–15 years participated in an intervention delivered to schools in two phases, along with a third phase receiving the intervention after the evaluation, which served as a control. The primary outcome was the number of face washing events that took place when handwashing occurred, which was measured by a 3-hour structured observation at all 67 schools, and a total of 3,871 handwashing events were observed. Differences in observed in face washing behavior between each phase and the control schools were calculated using log-binomial regression with clustering at the school level, whereas survey responses on knowledge of trachoma transmission and prevention were compared using χ² tests adjusted for clustering at the school level. Face washing during handwashing events was higher in schools after 12 months (59.3%) and 20 months (44.2%) than in control schools (18.7%, P < 0.001). Trachoma knowledge was higher in schools evaluated after 12 months (80%) and 20 months (70%) than in control schools (42%, P < 0.001), and knowledge of some of key preventive behaviors was higher in intervention schools. Integrating face washing messages into school-based handwashing promotion programs increased face washing, which may help to prevent trachoma when combined with other interventions.

Impact of a teacher-led school handwashing program on children's handwashing with soap at school and home in Bihar, India

Handwashing with soap is an important preventive health behavior, and yet promoting this behavior has proven challenging. We report the results of a program that trained teachers to deliver a handwashing with soap behavior change program to children in primary schools in Bihar, India. Ten intervention schools selected along with ten nearby control schools, and intervention schools received the “School of Five” program promoting handwashing with soap using interactive stories, games, and songs, behavioral diaries to encourage habit formation, and public commitment. Households with children aged 8–13 attending the nearby school were enrolled in the study. Handwashing with soap was measured using sticker diaries before eating and after defecation 4 weeks after the intervention was completed. Children in the treatment reported 15.1% more handwashing with soap on key occasions (35.2%) than those in the control group (20.1%) (RR: 1.77, CI: (1.22, 2.58), p = .003). There was no evidence that handwashing with soap after defecation was higher in the treatment group than the control group (RR: 1.18, CI: (0.88, 1.57), p = .265), but there was strong evidence that handwashing with soap was greater in the treatment than in the control before eating (RR: 2.68, 95% CI: (1.43, 5.03), p = .002). Rates of handwashing increased both at home (RR: 1.63, CI: 1.14, 2.32), p = .007) and at school (RR: 4.76, 95% CI: (1.65, 17.9), p = .004), though the impact on handwashing with soap at key occasions in schools was much higher than at home. Promoting handwashing with soap through teachers in schools may be an effective way to achieve behavior change at scale.

Effect of Two Complementary Mass-Scale Media Interventions on Handwashing with Soap among Mothers

Poor handwashing behavior is a major cause of morbidity and mortality globally. We evaluated two complementary mass-scale media interventions targeting mothers to increase the frequency of handwashing with soap; one using TV advertising, and the other mobile phone messaging. Television Commercials (TVCs): Mothers of 4-12 year-old children (n = 756) were randomly allocated among four arms: Three different branded TVCs and a fourth, control TVC unrelated to handwashing. TVCs were embedded in blocks of unrelated commercials and shown once a week over four weeks in participants' own homes. Mobile messages: New mothers (n = 598) and mothers of 4-7 year-old children (n = 501) were enrolled in a treatment or control arm. Mothers in the treatment arm received branded mobile phone messages twice weekly for 8 weeks (new mothers) or 4 weeks (mothers of 4-7 year-olds). For TVCs, there were higher rates of handwashing with soap at key occasions in the first (RR: 1.33, p = .002) and second (RR: 1.26, p = .041) of three treatment arms, or 0.4 additional handwashes with soap on key occasions daily. In the mobile study, new mothers (adj-RR: 1.04, p = .035) and general mothers (RR: 1.07, p = .007) receiving the intervention were more likely to wash their hands with soap on key occasions than those in the control group, corresponding to 1.3 and 1.0 more occasions daily. These interventions were associated with significantly greater handwashing with soap, consistent with the hypothesis that branded mass communications can impact habitual lifestyle behaviors relevant to public health.