A systematic review of the effectiveness of antimicrobial rinse-free hand sanitizers for prevention of illness-related absenteeism in elementary school children

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID-19 pandemic.

OBJECTIVES

To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 11 new RCTs and cluster-RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID-19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID-19 pandemic. Many studies were conducted during non-epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza-like illness (ILI)/COVID-19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate-certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory-confirmed influenza/SARS-CoV-2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate-certainty evidence). Harms were rarely measured and poorly reported (very low-certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low-certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low-certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate-certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low-certainty evidence).  One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non-inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID-19 patients.  Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta-analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate-certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low-certainty evidence), and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low-certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low-certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low-certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports.

AUTHORS' CONCLUSIONS

The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory-confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs.

Co-designing the Embodiment of a Minimalist Social Robot to Encourage Hand Hygiene Practises Among Children in India

We conducted an empirical study to co-design a social robot with children to bring about long-term behavioural changes. As a case study, we focused our efforts to create a social robot to promote handwashing in community settings while adhering to minimalistic design principles. Since cultural views influence design preferences and technology acceptance, we selected forty children from different socio-economic backgrounds across India as informants for our design study. We asked the children to design paper mock-ups using pre-cut geometrical shapes to understand their mental models of such a robot. The children also shared their feedback on the eight resulting different conceptual designs of minimalistic caricatured social robots. Our findings show that children had varied expectations of the robot's emotional intelligence, interactions, and social roles even though it was being designed for a specific context of use. The children unequivocally liked and trusted anthropomorphized caricatured designs of everyday objects for the robot's morphology. Based on these findings, we present our recommendations for the physical and interaction features of a minimalist social robot assimilating the children's inputs and social robot design principles grounded in prior research. Future studies will examine the children's interactions with a built prototype.

Factors influencing sanitation and hygiene practices among students in a public university in Bangladesh

INTRODUCTION

Improved hygiene and sanitation practices in educational settings are effective for the prevention of infections, controlling the transmission of pathogens, and promoting good health. Bangladesh has made remarkable advances in improving higher education in recent decades. Over a hundred universities were established to expand higher education facilities across the country. Hundreds of thousands of graduate students spend time in university settings during their studies. However, little is known about the sanitation and hygiene practice of the university-going population. This study aims to understand and uncover which factors influence students' sanitation and hygiene behavior in university settings.

METHODS

This study was conducted in a public university named Shahjalal University of Science and Technology located in a divisional city of Bangladesh. Based on the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH), we adopted an exploratory qualitative study design. We developed semi-structured interview guides entailing sanitation and hygiene behavior, access, and practice-related questions and tested their efficacy and clarity before use. We conducted seventeen in-depth interviews (IDIs), and four focus group discussions (FGDs, [6-8 participants per FGD]) with students, and seven key informant interviews (KIIs) with university staff. Thematic analysis was used to analyze the data. Triangulation of methods and participants was performed to achieve data validity.

RESULTS

Despite having reasonable awareness and knowledge, the sanitation and hygiene practices of the students were remarkably low. A broad array of interconnected factors influenced sanitation and hygiene behavior, as well as each other. Individual factors (gender, awareness, perception, and sense of health benefits), contextual factors (lack of cleanliness and maintenance, and the supply of sanitary products), socio-behavioural factors (norms, peer influence), and factors related to university infrastructure (shortage of female toilets, lack of monitoring and supervision of cleaning activities) emerged as the underpinning factors that determined the sanitation and hygiene behavior of the university going-population.

CONCLUSION

The results of this study suggest that despite the rapid expansion of on-campus university education, hygiene practices in public universities are remarkably poor due to a variety of dynamic and interconnected factors situated in different (individual, contextual, socio-phycological) levels. Therefore, multi-level interventions including regular supply of WASH-related materials and agents, promoting low-cost WASH interventions, improving quality cleaning services, close monitoring of cleaning activities, promoting good hygiene behavior at the individual level, and introducing gender-sensitive WASH infrastructure and construction may be beneficial to advance improved sanitation and hygiene practices among university students.

Quick determination and discrimination of commercial hand sanitisers using attenuated total reflectance-Fourier transform infrared spectroscopy and chemometrics

Due to the outbreak of the COVID-19 pandemic, practicing personal hygiene such as frequent hand sanitising has become a norm. The making of effective hand sanitiser products should follow the recommended formulations, but the high demand worldwide for such affordable products could have made them a candidate for counterfeiting, thus deserving forensic determination and profiling for source determination or supply chain tracing. In this study, determination and discrimination of hand sanitisers was carried out by employing attenuated total reflectance-Fourier transform infrared (ATR-FTIR) spectroscopy combined with chemometrics. Fifty commercially available hand sanitisers were obtained from the market and analysed. ATR-FTIR profiles of each sanitiser were compared and decomposed by principal component analysis (PCA) followed by linear discriminant analysis (LDA). Physical observation enabled the discrimination of seven samples based on their respective colours, the presence of beads and their colours, and the physical forms of formulations. Subsequently, eight distinct patterns were observed through visual comparison of ATR-FTIR profiles of the remaining 43 samples. An initial unsupervised exploratory PCA model indicated the separation of two main groups with ATR-FTIR profiles similar to those of ethanol and isopropanol, respectively. The PCA score-LDA model provided good predictions, with a 100% correct classification into eight different groups. In conclusion, this study demonstrated a quick determination and discrimination of hand sanitiser samples, allowing screening for any restricted components and sample-to-sample comparison.

Could Alcohol-Based Hand Sanitizer Be an Option for Hand Hygiene for Households in Rural Bangladesh?

In low- and middle-income countries (LMICs), hand sanitizer may be a convenient alternative to soap and water to increase hand hygiene practices. We explored perceptions, acceptability, and use of hand sanitizer in rural Bangladesh. We enrolled 120 households from three rural villages. Promoters distributed free alcohol-based hand sanitizer, installed handwashing stations (bucket with tap, stand, basin, and bottle for soapy water), and conducted household visits and community meetings. During Phase 1, promoters recommended handwashing with soap or soapy water, or hand sanitizer after defecation, after cleaning a child's anus/feces, and before food preparation. In Phase 2, they recommended separate key times for hand sanitizer: before touching a child ≤ 6 months and after returning home. Three to 4 months after each intervention phase, we conducted a survey, in-depth interviews, and group discussions with child caregivers and male household members. After Phase 1, 82/89 (92%) households reported handwashing with soap after defecation versus 38 (43%) reported hand sanitizer use. Participants thought soap and water removed dirt from their hands, whereas hand sanitizer killed germs. In Phase 2, 76/87 (87%) reported using hand sanitizer after returning home and 71/87 (82%) before touching a child ≤ 6 months. Qualitative study participants reported that Phase 2-recommended times for hand sanitizer use were acceptable, but handwashing with soap was preferred over hand sanitizer when there was uncertainty over choosing between the two. Hand sanitizer use was liked by household members and has potential for use in LMICs, including during the coronavirus pandemic.

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review published in 2007, 2009, 2010, and 2011. The evidence summarised in this review does not include results from studies from the current COVID-19 pandemic.

OBJECTIVES

To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, CINAHL on 1 April 2020. We searched ClinicalTrials.gov, and the WHO ICTRP on 16 March 2020. We conducted a backwards and forwards citation analysis on the newly included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs of trials investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, and gargling) to prevent respiratory virus transmission. In previous versions of this review we also included observational studies. However, for this update, there were sufficient RCTs to address our study aims.   DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Three pairs of review authors independently extracted data using a standard template applied in previous versions of this review, but which was revised to reflect our focus on RCTs and cluster-RCTs for this update. We did not contact trialists for missing data due to the urgency in completing the review. We extracted data on adverse events (harms) associated with the interventions.

MAIN RESULTS

We included 44 new RCTs and cluster-RCTs in this update, bringing the total number of randomised trials to 67. There were no included studies conducted during the COVID-19 pandemic. Six ongoing studies were identified, of which three evaluating masks are being conducted concurrent with the COVID pandemic, and one is completed. Many studies were conducted during non-epidemic influenza periods, but several studies were conducted during the global H1N1 influenza pandemic in 2009, and others in epidemic influenza seasons up to 2016. Thus, studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Compliance with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included nine trials (of which eight were cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and seven in the community). There is low certainty evidence from nine trials (3507 participants) that wearing a mask may make little or no difference to the outcome of influenza-like illness (ILI) compared to not wearing a mask (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.82 to 1.18. There is moderate certainty evidence that wearing a mask probably makes little or no difference to the outcome of laboratory-confirmed influenza compared to not wearing a mask (RR 0.91, 95% CI 0.66 to 1.26; 6 trials; 3005 participants). Harms were rarely measured and poorly reported. Two studies during COVID-19 plan to recruit a total of 72,000 people. One evaluates medical/surgical masks (N = 6000) (published Annals of Internal Medicine, 18 Nov 2020), and one evaluates cloth masks (N = 66,000). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). There is uncertainty over the effects of N95/P2 respirators when compared with medical/surgical masks on the outcomes of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; very low-certainty evidence; 3 trials; 7779 participants) and ILI (RR 0.82, 95% CI 0.66 to 1.03; low-certainty evidence; 5 trials; 8407 participants). The evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirator compared to a medical/surgical mask probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; moderate-certainty evidence; 5 trials; 8407 participants). Restricting the pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies. One ongoing study recruiting 576 people compares N95/P2 respirators with medical surgical masks for healthcare workers during COVID-19. Hand hygiene compared to control Settings included schools, childcare centres, homes, and offices. In a comparison of hand hygiene interventions with control (no intervention), there was a 16% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.84, 95% CI 0.82 to 0.86; 7 trials; 44,129 participants; moderate-certainty evidence), suggesting a probable benefit. When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.98, 95% CI 0.85 to 1.13; 10 trials; 32,641 participants; low-certainty evidence) and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials; 8332 participants; low-certainty evidence) suggest the intervention made little or no difference. We pooled all 16 trials (61,372 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. The pooled data showed that hand hygiene may offer a benefit with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.84 to 0.95; low-certainty evidence), but with high heterogeneity. Few trials measured and reported harms. There are two ongoing studies of handwashing interventions in 395 children outside of COVID-19. We identified one RCT on quarantine/physical distancing. Company employees in Japan were asked to stay at home if household members had ILI symptoms. Overall fewer people in the intervention group contracted influenza compared with workers in the control group (2.75% versus 3.18%; hazard ratio 0.80, 95% CI 0.66 to 0.97). However, those who stayed at home with their infected family members were 2.17 times more likely to be infected. We found no RCTs on eye protection, gowns and gloves, or screening at entry ports.

AUTHORS' CONCLUSIONS

The high risk of bias in the trials, variation in outcome measurement, and relatively low compliance with the interventions during the studies hamper drawing firm conclusions and generalising the findings to the current COVID-19 pandemic. There is uncertainty about the effects of face masks. The low-moderate certainty of the evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of randomised trials did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks during seasonal influenza. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, especially in those most at risk of ARIs.

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.

A systematic review of hand-hygiene and environmental-disinfection interventions in settings with children

BACKGROUND

Helping adults and children develop better hygiene habits is an important public health focus. As infection causing bacteria can live on one's body and in the surrounding environment, more effective interventions should simultaneously encourage personal-hygiene (e.g. hand-hygiene) and environmental-disinfecting (e.g. cleaning surfaces). To inform the development of a future multi-faceted intervention to improve public health, a systematic literature review was conducted on behavior change interventions designed to increase hand-hygiene and environmental-disinfecting in settings likely to include children.

METHODS

The search was conducted over two comprehensive data-bases, Ebsco Medline and Web of Science, to locate intervention studies that aimed to increase hand-hygiene or environmental-disinfecting behavior in settings likely to include children. Located article titles and abstracts were independently assessed, and the full-texts of agreed articles were collaboratively assessed for inclusion. Of the 2893 titles assessed, 29 met the eligibility criteria. The extracted data describe the Behavior Change Techniques (version 1) that the interventions employed and the interventions' effectiveness. The techniques were then linked to their associated theoretical domains and to their capability-opportunity-motivation (i.e., COM-B model) components, as described in the Behavior Change Wheel. Due to the heterogeneity of the studies' methods and measures, a meta-analysis was not conducted.

RESULTS

A total of 29 studies met the inclusion criteria. The majority of interventions were designed to increase hand-hygiene alone (N = 27), and the remaining two interventions were designed to increase both hand-hygiene and environmental-disinfecting. The most used techniques involved shaping knowledge (N = 22) and antecedents (N = 21). Interventions that included techniques targeting four or more theoretical domains and all the capability-opportunity-motivation components were descriptively more effective.

CONCLUSIONS

In alignment with previous findings, the current review encourages future interventions to target multiple theoretical domains, across all capability-opportunity-motivation components. The discussion urges interventionists to consider the appropriateness of interventions in their development, feasibility/pilot, evaluation, and implementation stages.

REGISTRATION

Prospero ID - CRD42019133735.

Infectious illness prevention and control methods and their effectiveness in non-health workplaces: an integrated literature review

BACKGROUND

Infectious illness in the workplace places a substantial cost burden on employers due to productivity losses from employee absenteeism and presenteeism.

AIM

Given the clear impacts of infectious illness on workplaces, this review aimed to investigate the international literature on the effectiveness and cost-benefit of the strategies non-healthcare workplaces use to prevent and control infectious illnesses in these workplaces.

METHODS

MEDLINE, CINAHL Plus with Fulltext and Business Source Complete were searched concurrently using EBSCO Host 1995-2016.

FINDINGS

Infection prevention and control strategies to reduce workplace infectious illness and absenteeism evaluated in the literature include influenza vaccination programs, use of alcohol-based hand sanitiser and paid sick days. While the reported studies have various methodological flaws, there is good evidence of the effectiveness of influenza vaccination in preventing workplace infectious illness and absences and moderate evidence to support hand hygiene programs.

DISCUSSION

Some studies used more than one intervention concurrently, making it difficult to determine the relative benefit of each individual strategy. Workplace strategies to prevent and control infectious illness transmission may reduce costs and productivity losses experienced by businesses and organisations related to infectious illness absenteeism and presenteeism.

Importance of implementation level when evaluating the effect of the Hi Five Intervention on infectious illness and illness-related absenteeism

BACKGROUND

There is limited research on the importance of implementation when evaluating the effect of hand hygiene interventions in school settings in developed countries. The aim of this study was to examine the association between an implementation index and the effect of the intervention. The Hi Five Intervention was evaluated in a 3-armed cluster randomized controlled trial involving 43 randomly selected Danish schools.

METHODS

Analyses investigating the association between implementation of the Hi Five Intervention and infectious illness days, infectious illness episodes, illness-related absenteeism, and hand hygiene were carried out in a multilevel model (school, class, and child).

RESULTS

The level of implementation was associated with hand hygiene and potentially associated with number of infectious illness days and infectious illness episodes among children. This association was not found for illness-related absenteeism.

CONCLUSIONS

Classes that succeeded in achieving a high level of implementation of the Hi Five Intervention had a lower number of infectious illness days and infectious illness episodes, suggesting that the Hi Five Intervention, if implemented adequately, may be relevant as a tool to decrease infectious illness in a Danish school setting.

The effect of hand-hygiene interventions on infectious disease-associated absenteeism in elementary schools: A systematic literature review

BACKGROUND

Hand-hygiene interventions are widely used in schools but their effect on reducing absenteeism is not well known.

METHODS

The aim of our literature review was to determine whether implementation of a hand-hygiene intervention reduced infectious disease-associated absenteeism in elementary schools. The eligible studies (N = 19), published between 1996 and 2014, were summarized and the methodologic quality of each was assessed.

RESULTS

Our review indicated evidence is available to show hand-hygiene interventions had an effect on reducing acute gastrointestinal illness-associated absenteeism but inadequate evidence is available to show an effect on respiratory illness-associated absenteeism.

CONCLUSIONS

The methodologic quality assessment of eligible studies revealed common design flaws, such as lack of randomization, blinding, and attrition, which must be addressed in future studies to strengthen the evidence base on the effect of hand-hygiene interventions on school absenteeism.

Effectiveness of hand hygiene interventions in reducing illness absence among children in educational settings: a systematic review and meta-analysis

OBJECTIVE

To undertake a systematic review and meta-analysis to establish the effectiveness of handwashing in reducing absence and/or the spread of respiratory tract (RT) and/or gastrointestinal (GI) infection among school-aged children and/or staff in educational settings.

DESIGN

Randomised-controlled trials (RCTs).

SETTING

Schools and other settings with a formal educational component in any country.

PATIENTS

Children aged 3-11 years, and/or staff working with them.

INTERVENTION

Interventions with a hand hygiene component.

MAIN OUTCOME MEASURES

Incidence of RT or GI infections or symptoms related to such infections; absenteeism; laboratory results of RT and/or GI infections.

RESULTS

Eighteen cluster RCTs were identified; 13 school-based, 5 in child day care facilities or preschools. Studies were heterogeneous and had significant quality issues including small numbers of clusters and participants and inadequate randomisation. Individual study results suggest interventions may reduce children's absence, RT infection incidence and symptoms, and laboratory confirmed influenza-like illness. Evidence of impact on GI infection or symptoms was equivocal.

CONCLUSIONS

Studies are generally not well executed or reported. Despite updating existing systematic reviews and identifying new studies, evidence of the effect of hand hygiene interventions on infection incidence in educational settings is mostly equivocal but they may decrease RT infection among children. These results update and add to knowledge about this crucial public health issue in key settings with a vulnerable population. More robust, well reported cluster RCTs which learn from existing studies, are required.

How prepared are Nigerian schools for ebola virus disease prevention and control?

BACKGROUND

Nigeria was one of the West African countries gripped by the fear of the spread of the Ebola virus disease (EVD), leading to a long period of delay in resumption of primary and secondary schools for academic activities in September 2014. The aim of this study was to assess the preparedness of schools in the north central region of Nigeria toward EVD prevention and control within 1 month of resumption of schools.

METHODS

This was a descriptive cross-sectional study among 76 schools selected using a multistage sampling method. Research instruments were self-administered, semi-structured questionnaires. Data was analyzed using the SPSS software version 17.0.

FINDINGS

Half (38) of the schools reported that some of the children could have traveled to EVD-infected areas during the holiday period; 77.6% (59) had their teachers formally trained on EVD prevention and control before resumption; 50% (38) set up a committee on EVD prevention; and 62.9% (63) carried out awareness-raising activities on school assembly ground. Based on some preventive measures criteria, 55.2% (42) were categorized ready, whereas 44.7% (34) were not ready for EVD prevention and control within 1 month of resumption of students back to school. About 76.3% (58) said they would like to sustain these EVD prevention efforts; 14.5% (11) would like to sustain such efforts at least until the end of the present term. Determinants of readiness for EVD prevention and control include being a private school, being an urban school, belief that children could have traveled to an EVD-infected area, and school having standard operating procedure or policy guidelines on EVD prevention and control.

CONCLUSION

The persistent call for postponement of school resumption might have been due to the unpreparedness of many of schools to meet EVD prevention and control guidelines. Schools need to take more proactive and sustainable measures toward effective control of the ongoing epidemic and prevention of future occurrences.

The Hi Five study: design of a school-based randomized trial to reduce infections and improve hygiene and well-being among 6-15 year olds in Denmark

BACKGROUND

Infectious illnesses such as influenza and diarrhea are leading causes of absenteeism among Danish school children. Interventions in school settings addressing hand hygiene have shown to reduce the number of infectious illnesses. However, most of these studies include small populations and almost none of them are conducted as randomized controlled trials. The overall aim of the Hi Five study was to develop, implement and evaluate a multi-component school-based intervention to improve hand hygiene and well-being and to reduce the prevalence of infections among school children in intervention schools by 20% compared to control schools. This paper describes the development and the evaluation design of Hi Five.

METHODS/DESIGN

The Hi Five study was designed as a tree-armed cluster-randomized controlled trial. A national random sample of schools (n = 44) was randomized to one of two intervention groups (n = 29) or to a control group with no intervention (n = 15). A total of 8,438 six to fifteen-year-old school children were enrolled in the study. The Hi Five intervention consisted of three components: 1) a curriculum component 2) mandatory daily hand washing before lunch 3) extra cleaning of school toilets during the school day. Baseline data was collected from December 2011 to April 2012. The intervention period was August 2012 to June 2013. The follow-up data was collected from December 2012 to April 2013.

DISCUSSION

The Hi Five study fills a gap in international research. This large randomized multi-component school-based hand hygiene intervention is the first to include education on healthy and appropriate toilet behavior as part of the curriculum. No previous studies have involved supplementary cleaning at the school toilets as an intervention component. The study will have the added value of providing new knowledge about usability of short message service (SMS, text message) for collecting data on infectious illness and absenteeism in large study populations.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN19287682 , 21 December 2012.

Hand sanitiser provision for reducing illness absences in primary school children: a cluster randomised trial

BACKGROUND

The potential for transmission of infectious diseases offered by the school environment are likely to be an important contributor to the rates of infectious disease experienced by children. This study aimed to test whether the addition of hand sanitiser in primary school classrooms compared with usual hand hygiene would reduce illness absences in primary school children in New Zealand.

METHODS AND FINDINGS

This parallel-group cluster randomised trial took place in 68 primary schools, where schools were allocated using restricted randomisation (1:1 ratio) to the intervention or control group. All children (aged 5 to 11 y) in attendance at participating schools received an in-class hand hygiene education session. Schools in the intervention group were provided with alcohol-based hand sanitiser dispensers in classrooms for the winter school terms (27 April to 25 September 2009). Control schools received only the hand hygiene education session. The primary outcome was the number of absence episodes due to any illness among 2,443 follow-up children whose caregivers were telephoned after each absence from school. Secondary outcomes measured among follow-up children were the number of absence episodes due to specific illness (respiratory or gastrointestinal), length of illness and illness absence episodes, and number of episodes where at least one other member of the household became ill subsequently (child or adult). We also examined whether provision of sanitiser was associated with experience of a skin reaction. The number of absences for any reason and the length of the absence episode were measured in all primary school children enrolled at the schools. Children, school administrative staff, and the school liaison research assistants were not blind to group allocation. Outcome assessors of follow-up children were blind to group allocation. Of the 1,301 and 1,142 follow-up children in the hand sanitiser and control groups, respectively, the rate of absence episodes due to illness per 100 child-days was similar (1.21 and 1.16, respectively, incidence rate ratio 1.06, 95% CI 0.94 to 1.18). The provision of an alcohol-based hand sanitiser dispenser in classrooms was not effective in reducing rates of absence episodes due to respiratory or gastrointestinal illness, the length of illness or illness absence episodes, or the rate of subsequent infection for other members of the household in these children. The percentage of children experiencing a skin reaction was similar (10.4% hand sanitiser versus 10.3% control, risk ratio 1.01, 95% CI 0.78 to 1.30). The rate or length of absence episodes for any reason measured for all children also did not differ between groups. Limitations of the study include that the study was conducted during an influenza pandemic, with associated public health messaging about hand hygiene, which may have increased hand hygiene among all children and thereby reduced any additional effectiveness of sanitiser provision. We did not quite achieve the planned sample size of 1,350 follow-up children per group, although we still obtained precise estimates of the intervention effects. Also, it is possible that follow-up children were healthier than non-participating eligible children, with therefore less to gain from improved hand hygiene. However, lack of effectiveness of hand sanitiser provision on the rate of absences among all children suggests that this may not be the explanation.

CONCLUSIONS

The provision of hand sanitiser in addition to usual hand hygiene in primary schools in New Zealand did not prevent disease of severity sufficient to cause school absence.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12609000478213. Please see later in the article for the Editors' Summary.

The impact of common infections on school absenteeism during an academic year

BACKGROUND

School absenteeism because of infections is one of the most important problems facing both public and private primary schools. The aim of the study was to assess the impact of infections on school absenteeism and their reduction with a handwashing program using hand sanitizer.

METHODS

The study was an 8-month-long, randomized, controlled open study (N = 1,609 children, aged 4-12 years old) at 5 state schools in Almeria (Spain). The experimental group (EG) washed their hands with soap and water, complemented with the use of hand sanitizer, and the control group (CG) followed the usual handwashing procedure. The total number of episodes and days missed as well as those because of upper respiratory infections and gastrointestinal infections were compared in both groups with a Z-test.

RESULTS

The students were absent 12,386 days in 7,945 episodes. The incidence of total absent episodes and percent of missed days, including those because of upper respiratory infections and gastrointestinal infections, were significantly lower in the EG than the CG (P < .001), and this was maintained through the flu pandemic period.

CONCLUSION

School absenteeism because of infections in schools is reduced when a hand hygiene program utilizing sanitizing gels is properly carried out, especially during the flu season.

Impact of health campaign on hand hygiene with alcohol-based hand rubs in a non-clinical setting

BACKGROUND

Hand hygiene has been acknowledged as the single most important measure to prevent nosocomial infections. Likewise, for non-clinical settings, hand hygiene is recognized as a key element to prevent the spread of infectious diseases, nevertheless poor compliance has been documented. The feasibility of hand hygiene interventions in open-community settings with adults is mostly unclear.

AIM

To investigate the acceptability and feasibility of a health campaign to promote hand hygiene with alcohol-based hand disinfectants at workplaces in a non-clinical setting.

METHODS

The surveys were conducted as part of a prospective, controlled intervention study with volunteers from the administration of the Ernst-Moritz-Arndt-University Greifswald, the municipality of Greifswald and the state of Mecklenburg-West Pomerania. Participants in the intervention group were provided with alcohol-based hand disinfection; the control group was unchanged. Eleven volunteers filled out an initial survey at the beginning of the intervention regarding demographic and health-related questions as well as questions about the type of work, and a survey after completion of the intervention to evaluate the study's impact on the participants' attitudes toward hand hygiene. Participants in the experimental group filled out a monthly questionnaire regarding their compliance with hand hygiene measures, feasibility of hand disinfection and possible side-effects.

FINDINGS

From 850 employees asked to participate, 134 were included in the study, and surveys from 129 participants (intervention: 64 vs control: 65) were accepted for analysis. Overall, datasets of 1230 person-months (79.46% of total possible follow-up surveys) were collected. Return rate and compliance remained high during the study period. Hand disinfection did not lead to skin problems in the majority of person-months. After the intervention, a majority of participants would favour a further use of hand disinfectants.

CONCLUSION

Campaigns that enforce the use of alcohol-based hand disinfectants can have a sustainable effect on the compliance with hand hygiene measures in non-clinical settings. Campaigns have been shown to be feasible and effective in the prevention of transmissible diseases, therefore employers should consider whether hand hygiene campaigns to introduce waterless hand rubs could be included in companies' health programmes.

Access to waterless hand sanitizer improves student hand hygiene behavior in primary schools in Nairobi, Kenya

Handwashing is difficult in settings with limited resources and water access. In primary schools within urban Kibera, Kenya, we investigated the impact of providing waterless hand sanitizer on student hand hygiene behavior. Two schools received a waterless hand sanitizer intervention, two schools received a handwashing with soap intervention, and two schools received no intervention. Hand cleaning behavior after toilet use was monitored for 2 months using structured observation. Hand cleaning after toileting was 82% at sanitizer schools (N = 2,507 toileting events), 38% at soap schools (N = 3,429), and 37% at control schools (N = 2,797). Students at sanitizer schools were 23% less likely to have observed rhinorrhea than control students (P = 0.02); reductions in student-reported gastrointestinal and respiratory illness symptoms were not statistically significant. Providing waterless hand sanitizer markedly increased student hand cleaning after toilet use, whereas the soap intervention did not. Waterless hand sanitizer may be a promising option to improve student hand cleansing behavior, particularly in schools with limited water access.

Implementation of non-pharmaceutical interventions by New York City public schools to prevent 2009 influenza A

Introduction

Children are important transmitters of influenza in the community and a number of non-pharmaceutical interventions (NPIs), including hand washing and use of hand sanitizer, have been recommended to mitigate the transmission of influenza, but limited information is available regarding schools' ability to implement these NPIs during an influenza outbreak. We evaluated implementation of NPIs during fall 2009 in response to H1N1 pandemic influenza (pH1N1) by New York City (NYC) public schools.

Methods

From January 25 through February 9, 2010, an online survey was sent to all the 1,632 NYC public schools and principals were asked to participate in the survey or to designate a school nurse or other school official with knowledge of school policies and characteristics to do so.

Results

Of 1,633 schools, 376(23%) accessed and completed the survey. Nearly all respondents (99%) implemented at least two NPIs. Schools that had a Flu Response Team (FRT) as a part of school emergency preparedness plan were more likely to implement the NPI guidelines recommended by NYC public health officials than schools that did not have a FRT. Designation of a room for isolating ill students, for example, was more common in schools with a FRT (72%) than those without (53%) (p<0.001).

Conclusions

Implementing an NPI program in a large school system to mitigate the effects of an influenza outbreak is feasible, but there is potential need for additional resources in some schools to increase capacity and adherence to all recommendations. Public health influenza-preparedness plans should include school preparedness planning and FRTs.

Can a school-based hand hygiene program reduce asthma exacerbations among elementary school children?

BACKGROUND

Viral upper respiratory tract infections have been implicated as a major cause of asthma exacerbations among school-aged children. Regular hand washing is the most effective method to prevent the spread of viral respiratory tract infections, but effective hand-washing practices are difficult to establish in schools.

OBJECTIVES

This randomized controlled trial evaluated whether a standardized regimen of hand washing plus alcohol-based hand sanitizer could reduce asthma exacerbations more than schools' usual hand hygiene practices.

METHODS

This was a 2-year, community-based, randomized controlled crossover trial. Schools were randomized to usual care and then intervention (sequence 1) or intervention and then usual care (sequence 2). Intervention schools were provided with alcohol-based hand sanitizer, hand soap, and hand hygiene education. The primary outcome was the proportion of students experiencing an asthma exacerbation each month. Generalized estimating equations were used to model the difference in the marginal rate of exacerbations between sequences while controlling for individual demographic factors and the correlation within each student and between students within each school.

RESULTS

Five hundred twenty-seven students with asthma were enrolled among 31 schools. The hand hygiene intervention did not reduce the number of asthma exacerbations compared with the schools' usual hand hygiene practices (P = .132). There was a strong temporal trend because both sequences experienced fewer exacerbations during year 2 compared with year 1 (P < .001).

CONCLUSIONS

Although the intervention was not found to be effective, the results were confounded by the H1N1 influenza pandemic that resulted in substantially increased hand hygiene behaviors and resources in usual-care schools. Therefore these results should be viewed cautiously.

Hand hygiene to reduce community transmission of influenza and acute respiratory tract infection: a systematic review

Hand hygiene may be associated with modest protection against some acute respiratory tract infections, but its specific role in influenza transmission in different settings is unclear. We aimed to review evidence that improving hand hygiene reduces primary and secondary transmission of (i) influenza and (ii) acute respiratory tract infections in community settings. We searched Medline, Embase, Global Health and Cochrane databases up to 13 February 2012 for reports in any language of original research investigating the effect of hand hygiene on influenza or acute respiratory tract infection where aetiology was unspecified in community settings including institutions such as schools, and domestic residences. Data were presented and quality rated across outcomes according to the Grading of Recommendations Assessment, Development and Evaluation system. Sixteen articles met inclusion criteria. There was moderate to low-quality evidence of a reduction in both influenza and respiratory tract infection with hand hygiene interventions in schools, greatest in a lower-middle-income setting. There was high-quality evidence of a small reduction in respiratory infection in childcare settings. There was high-quality evidence for a large reduction in respiratory infection with a hand hygiene intervention in squatter settlements in a low-income setting. There was moderate- to high-quality evidence of no effect on secondary transmission of influenza in households that had already experienced an index case. While hand hygiene interventions have potential to reduce transmission of influenza and acute respiratory tract infections, their effectiveness varies depending on setting, context and compliance.

Impact of a hygiene curriculum and the installation of simple handwashing and drinking water stations in rural Kenyan primary schools on student health and hygiene practices

School-based hygiene and water treatment programs increase student knowledge, improve hygiene, and decrease absenteeism, however health impact studies of these programs are lacking. We collected baseline information from students in 42 schools in Kenya. We then instituted a curriculum on safe water and hand hygiene and installed water stations in half ("intervention schools"). One year later, we implemented the intervention in remaining schools. Through biweekly student household visits and two annual surveys, we compared the effect of the intervention on hygiene practices and reported student illness. We saw improvement in proper handwashing techniques after the school program was introduced. We observed a decrease in the median percentage of students with acute respiratory illness among those exposed to the program; no decrease in acute diarrhea was seen. Students in this school program exhibited sustained improvement in hygiene knowledge and a decreased risk of respiratory infections after the intervention.

Appropriate time-interval application of alcohol hand gel on reducing influenza-like illness among preschool children: a randomized, controlled trial

BACKGROUND

We studied the efficacy of different time-interval applications of alcohol hand gel as a strategy for the prevention of influenza-like illness (ILI) in preschool-age children.

METHODS

We performed a classroom-based cluster randomization at a kindergarten school in Bangkok, Thailand. A total of 1437 children were placed into 3 test groups, based on the frequency of alcohol hand gel use for hand hygiene: only before lunch (q lunch), every 120 minutes (q 120), and every 60 minutes (q 60). The primary outcome was a change in the school absenteeism rate caused by ILI.

RESULTS

The rates of absenteeism from confirmed ILI (sick days/present days) were 0.026 in the q lunch group, 0.025 in the q 120 group, and 0.017 in the q 60 group. Significant reductions in absenteeism rates were seen when comparing the q 60 group with the q 120 group (rate difference, 0.009; 95% confidence interval [CI], -0.002 to 0.015; P = .008) and comparing the q 60 group with the q lunch group (rate difference, 0.0096; 95% CI, 0.004-0.016; P = .002). No such differences were detected between the q 120 and q lunch groups (rate difference, 0.001; 95% CI, 0.005-0.007; P = .743).

CONCLUSIONS

The compulsory hourly use of alcohol gel as classroom hand disinfection could significantly reduce the rate of absenteeism from ILI in preschool-age children.

Assessing the impact of a school-based water treatment, hygiene and sanitation programme on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial

OBJECTIVES

There has been increased attention to access to water, sanitation and hygiene (WASH) at schools in developing countries, but a dearth of empirical studies on the impact. We conducted a cluster-randomized trial of school-based WASH on pupil absence in Nyanza Province, Kenya, from 2007 to 2008.

METHODS

Public primary schools nested in three geographical strata were randomly assigned and allocated to one of three study arms [water treatment and hygiene promotion (WT & HP), additional sanitation improvement, or control] to assess the effects on pupil absence at 2-year follow-up.

RESULTS

We found no overall effect of the intervention on absence. However, among schools in two of the geographical areas not affected by post-election violence, those that received WT and HP showed a 58% reduction in the odds of absence for girls (OR 0.42, CI 0.21-0.85). In the same strata, sanitation improvement in combination with WT and HP resulted in a comparable drop in absence, although results were marginally significant (OR 0.47, 0.21-1.05). Boys were not impacted by the intervention.

CONCLUSION

School WASH improvements can improve school attendance for girls, and mechanisms for gendered impacts should be explored. Incomplete intervention compliance highlights the challenges of achieving consistent results across all settings.

Back to the future: rising to the Semmelweis challenge in hand hygiene

Hand hygiene is the single most important intervention for reducing healthcare associated infections and preventing the spread of antimicrobial resistance. This sentence begins most publications regarding hand hygiene in the medical literature. But why - as we mark 150 years since the publication of Ignaz Semmelweis' landmark monograph on the subject - do we continue to repeat it? One might be tempted to regard it as a truism. However, while tremendous progress has certainly been made in this field, a significant amount of work is yet to be done in both strengthening the evidence regarding the impact of hand hygiene and maximizing its implementation. Hand hygiene cannot yet be taken for granted. This article summarizes historical perspectives, dynamics of microbial colonization and efficacy of hand cleansing methods and agents, elements and impacts of successful hand hygiene promotion, as well as scale-up and sustainability. We also explore hand hygiene myths and current challenges such as monitoring, behavior change, patient participation and research priorities.

Redesigning a large school-based clinical trial in response to changes in community practice

Background Asthma exacerbations are seasonal with the greatest risk in elementary-age students occurring shortly after returning to school following summer break. Recent research suggests that this seasonality in children is primarily related to viral respiratory tract infections. Regular hand washing is the most effective method to prevent the spread of viral respiratory infections; unfortunately, achieving hand washing recommendations in schools is difficult. Therefore, we designed a study to evaluate the effect of hand sanitizer use in elementary schools on exacerbations among children with asthma.

Purpose To describe the process of redesigning the trial in response to changes in the safety profile of the hand sanitizer as well as changes in hand hygiene practice in the schools.

Methods The original trial was a randomized, longitudinal, subject-blinded, placebo-controlled, community-based crossover trial. The primary aim was to evaluate the incremental effectiveness of hand sanitizer use in addition to usual hand hygiene practices to decrease asthma exacerbations in elementary-age children. Three events occurred that required major modifications to the original study protocol: (1) safety concerns arose regarding the hand sanitizer’s active ingredient; (2) no substitute placebo hand sanitizer was available; and (3) community preferences changed regarding hand hygiene practices in the schools.

Results The revised protocol is a randomized, longitudinal, community-based crossover trial. The primary aim is to evaluate the incremental effectiveness of a two-step hand hygiene process (hand hygiene education plus institutionally provided alcohol-based hand sanitizer) versus usual care to decrease asthma exacerbations. Enrollment was completed in May 2009 with 527 students from 30 schools. The intervention began in August 2009 and will continue through May 2011. Study results should be available at the end of 2011.

Limitations The changed design does not allow us to directly measure the effectiveness of hand sanitizer use as a supplement to traditional hand washing practices.

Conclusions The need to balance a rigorous study design with one that is acceptable to the community requires investigators to be actively involved with community collaborators and able to adapt study protocols to fit changing community practices.

Reduction in the incidence of influenza A but not influenza B associated with use of hand sanitizer and cough hygiene in schools: a randomized controlled trial

BACKGROUND

Laboratory-based evidence is lacking regarding the efficacy of nonpharmaceutical interventions (NPIs) such as alcohol-based hand sanitizer and respiratory hygiene to reduce the spread of influenza.

METHODS

The Pittsburgh Influenza Prevention Project was a cluster-randomized trial conducted in 10 elementary schools in Pittsburgh, PA, during the 2007 to 2008 influenza season. Children in 5 intervention schools received training in hand and respiratory hygiene, and were provided and encouraged to use hand sanitizer regularly. Children in 5 schools acted as controls. Children with influenza-like illness were tested for influenza A and B by reverse-transcriptase polymerase chain reaction.

RESULTS

A total of 3360 children participated in this study. Using reverse-transcriptase polymerase chain reaction, 54 cases of influenza A and 50 cases of influenza B were detected. We found no significant effect of the intervention on the primary study outcome of all laboratory-confirmed influenza cases (incidence rate ratio [IRR]: 0.81; 95% confidence interval [CI]: 0.54, 1.23). However, we did find statistically significant differences in protocol-specified ancillary outcomes. Children in intervention schools had significantly fewer laboratory-confirmed influenza A infections than children in control schools, with an adjusted IRR of 0.48 (95% CI: 0.26, 0.87). Total absent episodes were also significantly lower among the intervention group than among the control group; adjusted IRR 0.74 (95% CI: 0.56, 0.97).

CONCLUSIONS

NPIs (respiratory hygiene education and the regular use of hand sanitizer) did not reduce total laboratory-confirmed influenza. However, the interventions did reduce school total absence episodes by 26% and laboratory-confirmed influenza A infections by 52%. Our results suggest that NPIs can be an important adjunct to influenza vaccination programs to reduce the number of influenza A infections among children.

Comparative studies of hand disinfection and handwashing procedures as tested by pupils in intervention programs

BACKGROUND

The objective of this study was to determine the effect of mandatory, scheduled hand disinfection (HD) on actual absenteeism because of infectious illness in elementary school pupils in Denmark.

METHODS

A 3-month intervention study between 2 schools was performed on 656 pupils ages 5 to 15 years. The pupils at the intervention school (IS; n = 318) were required to disinfect their hands 3 times during school hours. Those at the control school (CS; n = 338) continued their usual handwashing (HW) practices, but they had been IS regarding mandatory HW the previous year. All absences because of illness were recorded, and data were analyzed statistically.

RESULTS

Comparison between the IS and itself (CS in 2007) demonstrated a significant difference (P = .018) in reducing absenteeism because of infectious illness, both for girls (P = .011) and boys (P = .029). The CS (IS in 2007) did not show any difference between 2007 and 2008 (P = .86).

CONCLUSION

Intervention with mandatory HW may have a lasting pedagogical effect in reducing absenteeism because of infectious illness when exposed to role models. HD could be effective in reducing absenteeism because of infectious illness and a well-placed supplement to HW.

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a global threat. Antiviral drugs and vaccinations may be insufficient to prevent their spread.

OBJECTIVES

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

SEARCH STRATEGY

We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2010, Issue 3), which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to October 2010), OLDMEDLINE (1950 to 1965), EMBASE (1990 to October 2010), CINAHL (1982 to October 2010), LILACS (2008 to October 2010), Indian MEDLARS (2008 to October 2010) and IMSEAR (2008 to October 2010).

SELECTION CRITERIA

In this update, two review authors independently applied the inclusion criteria to all identified and retrieved articles and extracted data. We scanned 3775 titles, excluded 3560 and retrieved full papers of 215 studies, to include 66 papers of 67 studies. We included physical interventions (screening at entry ports, isolation, quarantine, social distancing, barriers, personal protection, hand hygiene) to prevent respiratory virus transmission. We included randomised controlled trials (RCTs), cohorts, case-controls, before-after and time series studies.

DATA COLLECTION AND ANALYSIS

We used a standardised form to assess trial eligibility. We assessed RCTs by randomisation method, allocation generation, concealment, blinding and follow up. We assessed non-RCTs for potential confounders and classified them as low, medium and high risk of bias.

MAIN RESULTS

We included 67 studies including randomised controlled trials and observational studies with a mixed risk of bias. A total number of participants is not included as the total would be made up of a heterogenous set of observations (participant people, observations on participants and countries (object of some studies)). The risk of bias for five RCTs and most cluster-RCTs was high. 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. Benefit from reduced transmission from children to household members is broadly supported also in other study designs where the potential for confounding is greater. Nine case-control studies suggested implementing transmission barriers, isolation and hygienic measures are effective at containing respiratory virus epidemics. Surgical masks or N95 respirators were the most consistent and comprehensive supportive measures. N95 respirators were non-inferior to simple surgical masks but more expensive, uncomfortable and irritating to skin. Adding virucidals or antiseptics to normal handwashing to decrease respiratory disease transmission remains uncertain. Global measures, such as screening at entry ports, led to a non-significant marginal delay in spread. There was limited evidence that social distancing was effective, especially if related to the risk of exposure.

AUTHORS' CONCLUSIONS

Simple and low-cost interventions would be useful for reducing transmission of epidemic respiratory viruses. Routine long-term implementation of some measures assessed might be difficult without the threat of an epidemic.

Feasibility of elementary school children's use of hand gel and facemasks during influenza season

Please cite this paper as: Allison et al. (2010) Feasibility of elementary school children’s use of hand gel and facemasks during influenza season. Influenza and Other Respiratory Viruses 4(4), 223–229.

Background  The feasibility of non‐pharmacologic interventions to prevent influenza’s spread in schools is not well known.

Objectives  To determine the acceptability of, adherence with, and barriers to the use of hand gel and facemasks in elementary schools.

Patients and Methods Intervention: We provided hand gel and facemasks to 20 teachers and their students over 4 weeks. Gel use was promoted for the first 2 weeks; mask use was promoted for the second 2 weeks. Outcomes: Acceptability, adherence, and barriers were measured by teachers’ responses on weekly surveys. Mask use was also measured by observation.

Results  The weekly survey response rate ranged from 70% to 100%. Averaged over 2 weeks, 89% of teachers thought gel use was not disruptive (week 1 – 17/20, week 2 – 16/17), 95% would use gel next winter (week 1 – 19/20, week 2 – 16/17), and 97% would use gel in a pandemic (week 1 – 20/20, week 2 – 16/17). Averaged over 2 weeks, 39% thought mask use was not disruptive (week 1 – 6/17, week 2 – 6/14), 35% would use masks next winter (week 1 – 5/17, week 2 – 6/14), and 97% would use masks in a pandemic (week 1 – 16/17, week 2 – 14/14). About 70% estimated that their students used hand gel ≥4×/day for both weeks (week 1 – 14/20, week 2 – 13/17). Students’ mask use declined over time with 59% of teachers (10/17) estimating regular mask use during week 1 and 29% (4/14) during week 2. By observation, 30% of students wore masks in week 1, while 15% wore masks in week 2. Few barriers to gel use were identified; barriers to mask use were difficulty reading facial expressions and physical discomfort.

Conclusions  Hand gel use is a feasible strategy in elementary schools. Acceptability and adherence with facemasks was low, but some students and teachers did use facemasks for 2 weeks, and most teachers would use masks in their classroom in a pandemic.

A review of gastrointestinal outbreaks in schools: effective infection control interventions

BACKGROUND

The purpose of this study was to review documented outbreaks of gastrointestinal illness in schools, published in the last 10 years, to identify etiology, mode of transmission, the number of children affected, morbidity and mortality patterns, and interventions for control and prevention.

METHODS

Searches of electronic databases, public health publications, and federal, state, and provincial public health Web sites were completed.

RESULTS

Of the 121 outbreaks that met the inclusion criteria, 51% were bacterial, 40% viral, 7% were from Cryptosporidium, and 2% from multiple organisms. Transmission routes recorded in 101 reports included foodborne (45%), person-to-person (16%), waterborne (12%), and animal contact (11%). Actions to control outbreaks included alerting medical and public health authorities or the community to the outbreak (13%), treating cases (12%), enhancing hand washing (11%), and increased vigilance during food preparation (8%). Recommendations to prevent future outbreaks were compared with previously published studies that demonstrated effectiveness.

CONCLUSIONS

The risk of foodborne illness was reduced when food handlers practiced effective hand washing technique and received food safety training and certification. Student training programs on hand hygiene, enhanced cleaning and disinfection of the school, and hepatitis A vaccination were found effective. Children should be supervised on farm visits, hand washing strictly enforced, and food eaten in an area separated from the animals. Staff and students should have a positive, continuous communication with public health authorities including educational sessions and immediate reporting of possible outbreaks.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 11. Use of antiseptics and sanitizers in community settings and issues of hand hygiene compliance in health care and food industries

Hand washing with soap is a practice that has long been recognized as a major barrier to the spread of disease in food production, preparation, and service and in health care settings, including hospitals, child care centers, and elder care facilities. Many of these settings present multiple opportunities for spread of pathogens within at-risk populations, and extra vigilance must be applied. Unfortunately, hand hygiene is not always carried out effectively, and both enteric and respiratory diseases are easily spread in these environments. Where water is limited or frequent hand hygiene is required on a daily basis, such as for many patients in hospitals and astronauts in space travel, instant sanitizers or sanitary wipes are thought to be an effective way of preventing contamination and spread of organisms among coworkers and others. Most concerns regarding compliance are associated with the health care field, but the food industry also must be considered. Specific reasons for not washing hands at appropriate times are laziness, time pressure, inadequate facilities and supplies, lack of accountability, and lack of involvement by companies, managers, and workers in supporting proper hand washing. To facilitate improvements in hand hygiene, measurement of compliant and noncompliant actions is necessary before implementing any procedural changes. Training alone is not sufficient for long-lasting improvement. Multiactivity strategies also must include modification of the organization culture to encourage safe hygienic practices, motivation of employees willing to use peer pressure on noncompliant coworkers, a reward and/or penalty system, and an operational design that facilitates regular hand hygiene.

Prevention and control of health care-associated infections through improved hand hygiene

Determined actions are required to address the burden due to health care-associated infections worldwide and improve patient safety. Improving hand hygiene among health care workers is an essential intervention to achieve these goals. The World Health Organization (WHO) First Global Patient Safety Challenge, Clean Care is Safer Care, pledged to tackle the problem of health care-associated infection at its launch in 2005 and has elaborated a comprehensive set of guidelines for use in both developed and developing countries worldwide. The final version of the WHO Guidelines on Hand Hygiene in Health Care was issued in March 2009 and includes recommendations on indications, techniques, and products for hand hygiene. In this review, we discuss the role of hands in the transmission of health care-associated infection, the benefits of improved compliance with hand hygiene, and the recommendations, implementation strategies and tools recommended by WHO. We also stress the need for action to increase the pace with which these recommendations are implemented in facilities across India.

Physical interventions to interrupt or reduce the spread of respiratory viruses

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.

Mandatory handwashing in elementary schools reduces absenteeism due to infectious illness among pupils: a pilot intervention study

BACKGROUND

The objective of this study was to determine the effect of mandatory, scheduled handwashing on actual absenteeism due to infectious illness in elementary school pupils in Denmark.

METHODS

A 3-month pilot intervention study, randomized between 2 schools, was performed on 652 pupils age 5 to 15 years. The pupils at the intervention school (IS; n=290) were required to wash their hands before the first lesson, before lunch, and before going home. Those at the control school (CS; n=362) continued their usual handwashing practices. All absences due to illness were recorded, and data were analyzed statistically.

RESULTS

Multivariate analysis demonstrated a significantly reduced rate of absenteeism for the IS compared with the CS (P=.002). For girls, the rate was 1.05 periods (95% confidence interval [CI]=0.90 to 1.22) for the IS versus 1.35 (95% CI=1.26 to 1.44) for the CS. For boys, these rates were 0.87 (95% CI=0.72 to 1.05) and 1.12 (95% CI=0.92 to 1.36). An alternative approach demonstrated that the odds ratio for absence was 0.69 (95% CI=0.52 to 0.92) for the IS compared with the CS.

CONCLUSION

This study suggests that handwashing could be an effective tool to reduce absences due to infectious illness in elementary school pupils. A school policy regarding hand hygiene and teaching of hand hygiene is warranted.

Formative research on the feasibility of hygiene interventions for influenza control in UK primary schools

Background

Interventions to increase hand washing in schools have been advocated as a means to reduce the transmission of pandemic influenza and other infections. However, the feasibility and acceptability of effective school-based hygiene interventions is not clear.

Methods

A pilot study in four primary schools in East London was conducted to establish the current need for enhanced hand hygiene interventions, identify barriers to their implementation and to test their acceptability and feasibility. The pilot study included key informant interviews with teachers and school nurses, interviews, group discussions and essay questions with the children, and testing of organised classroom hand hygiene activities.

Results

In all schools, basic issues of personal hygiene were taught especially in the younger age groups. However, we identified many barriers to implementing intensive hygiene interventions, in particular time constraints and competing health issues. Teachers' motivation to teach hygiene and enforce hygienic behaviour was primarily educational rather than immediate infection control. Children of all age groups had good knowledge of hygiene practices and germ transmission.

Conclusion

The pilot study showed that intensive hand hygiene interventions are feasible and acceptable but only temporarily during a period of a particular health threat such as an influenza pandemic, and only if rinse-free hand sanitisers are used. However, in many settings there may be logistical issues in providing all schools with an adequate supply. In the absence of evidence on effectiveness, the scope for enhanced hygiene interventions in schools in high income countries aiming at infection control appears to be limited in the absence of a severe public health threat.

Religion and culture: potential undercurrents influencing hand hygiene promotion in health care

Background

Health care–associated infections affect hundreds of millions of patients worldwide each year. The World Health Organization's (WHO) First Global Patient Safety Challenge, “Clean Care is Safer Care,” is tackling this major patient safety problem, with the promotion of hand hygiene in health care as the project's cornerstone. WHO Guidelines on Hand Hygiene in Healthcare have been prepared by a large group of international experts and are currently in a pilot-test phase to assess feasibility and acceptability in different health care settings worldwide.

Methods

An extensive literature search was conducted and experts and religious authorities were consulted to investigate religiocultural factors that may potentially influence hand hygiene promotion, offer possible solutions, and suggest areas for future research.

Results

Religious faith and culture can strongly influence hand hygiene behavior in health care workers and potentially affect compliance with best practices. Interesting data were retrieved on specific indications for hand cleansing according to the 7 main religions worldwide, interpretation of hand gestures, the concept of “visibly dirty” hands, and the use of alcohol-based hand rubs and prohibition of alcohol use by some religions.

Conclusions

The impact of religious faith and cultural specificities must be taken into consideration when implementing a multimodal strategy to promote hand hygiene on a global scale.

Cochrane Review: Interventions for the interruption or reduction of the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics such as of influenza or severe acute respiratory syndrome (SARS) pose a significant threat. Antiviral drugs and vaccination may not be adequate to prevent catastrophe in such an event.

OBJECTIVES

To systematically review the evidence of effectiveness of interventions to interrupt or reduce the spread of respiratory viruses (excluding vaccines and antiviral drugs, which have been previously reviewed).

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, issue 4); MEDLINE (1966 to November 2006); OLDMEDLINE (1950 to 1965); EMBASE (1990 to November 2006); and CINAHL (1982 to November 2006).

SELECTION CRITERIA

We scanned 2300 titles, excluded 2162 and retrieved the full papers of 138 trials, including 49 papers of 51 studies. The quality of three randomised controlled trials (RCTs) was poor; as were most cluster RCTs. The observational studies were of mixed quality. We were only able to meta-analyse case-control data. We searched for any interventions to prevent viral transmission of respiratory viruses (isolation, quarantine, social distancing, barriers, personal protection and hygiene). Study design included RCTs, cohort studies, case-control studies, cross-over studies, before-after, and time series studies.

DATA COLLECTION AND ANALYSIS

We scanned the titles, abstracts and full text articles using a standardised form to assess eligibility. RCTs were assessed according to randomisation method, allocation generation, concealment, blinding, and follow up. Non-RCTs were assessed for the presence of potential confounders and classified as low, medium, and high risk of bias.

MAIN RESULTS

The highest quality cluster RCTs suggest respiratory virus spread can be prevented by hygienic measures 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. The 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 the more uncomfortable and expensive N95 masks were superior to simple surgical masks. The incremental effect of adding virucidals or antiseptics to normal handwashing to decrease respiratory disease remains uncertain. The lack of proper evaluation of global measures such as screening at entry ports and social distancing prevent firm conclusions about these measures.

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.

PLAIN LANGUAGE SUMMARY

Interventions to interrupt or reduce the spread of respiratory viruses Although respiratory viruses usually only cause minor disease, they can cause epidemics. Approximately 10% to 15% of people worldwide contract influenza annually, with attack rates as high as 50% during major epidemics. Global pandemic viral infections have been devastating because of their wide spread. In 2003 the severe acute respiratory syndrome (SARS) epidemic affected ˜8,000 people, killed 780, and caused an enormous social and economic crisis. A new avian influenza pandemic caused by the H5N1 strain might be more catastrophic. Single measures (particularly the use of vaccines or antiviral drugs) may be insufficient to interrupt the spread.We found 51 studies including randomised controlled trials (RCTs) and observational studies with a mixed risk of bias.Respiratory virus spread might be prevented by hygienic measures around younger children. These might also reduce transmission from children to other household members. Implementing barriers to transmission, isolation, and hygienic measures may be effective at containing respiratory virus epidemics. There was limited evidence that (more uncomfortable and expensive) N95 masks were superior to simple ones. Adding virucidals or antiseptics to normal handwashing is of uncertain benefit. There is insufficient evaluation of global measures such as screening at entry ports and social distancing.

Hand washing among school children in Bogotá, Colombia

OBJECTIVES

We assessed hand-washing behaviors and intentions among school children in Bogotá, Colombia, to help identify and overcome barriers to proper hygiene practices.

METHODS

Data on hand-washing behavior and intentions and individual and contextual factors were collected from 2042 sixth- through eighth-grade students in 25 schools in Bogotá via anonymous questionnaires. A member of the school administration or teaching staff completed a questionnaire about the school environment. Site inspections of bathroom facilities were conducted.

RESULTS

Only 33.6% of the sample reported always or very often washing hands with soap and clean water before eating and after using the toilet. About 7% of students reported regular access to soap and clean water at school. A high level of perceived control was the strongest predictor of positive hand-washing intentions (adjusted odds ratio [AOR]=6.0; 95% confidence interval [CI]=4.8, 7.5). Students with proper hand-washing behavior were less likely to report previous-month gastrointestinal symptoms (OR=0.8; 95% CI=0.6, 0.9) or previous-year school absenteeism (OR=0.7; 95% CI=0.6, 0.9).

CONCLUSIONS

Scarcity of adequate facilities in most schools in Bogotá prevents children from adopting proper hygienic behavior and thwarts health promotion efforts. The current renovation program of public schools in Bogotá provides a unique opportunity to meet the challenges of providing a supportive environment for adoption of healthy behaviors.

Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis

To quantify the effect of hand-hygiene interventions on rates of gastrointestinal and respiratory illnesses and to identify interventions that provide the greatest efficacy, we searched 4 electronic databases for hand-hygiene trials published from January 1960 through May 2007 and conducted meta-analyses to generate pooled rate ratios across interventions (N=30 studies). Improvements in hand hygiene resulted in reductions in gastrointestinal illness of 31% (95% confidence intervals [CI]=19%, 42%) and reductions in respiratory illness of 21% (95% CI=5%, 34%). The most beneficial intervention was hand-hygiene education with use of nonantibacterial soap. Use of antibacterial soap showed little added benefit compared with use of nonantibacterial soap. Hand hygiene is clearly effective against gastrointestinal and, to a lesser extent, respiratory infections. Studies examining hygiene practices during respiratory illness and interventions targeting aerosol transmission are needed.

How effective is good domestic kitchen hygiene at reducing diarrhoeal disease in developed countries? A systematic review and reanalysis of the UK IID study

Background

To assess whether domestic kitchen hygiene is an important contributor to the development of diarrhoea in the developed world.

Methods

Electronic searches were carried out in October 2006 in EMBASE, MEDLINE, Web of Knowledge, Cochrane central register of clinical trials and CINAHL. All publications, irrespective of study design, assessing food hygiene practices with an outcome measure of diarrhoea were included in the review. All included studies underwent data extraction and the data was subsequently analysed. The analysis was conducted by qualitative synthesis of the results. Given the substantial heterogeneity in study design and outcome measures meta-analysis was not done. In addition the existing dataset of the UK IID study was reanalysed to investigate possible associations between self-reported diarrhoea and variables indicative of poor domestic kitchen hygiene

Results

Some 14 studies were finally included in subsequent analyses. Of the 14 studies included in this systematic review, 11 were case-control studies, 2 cross-sectional surveys, and 1 RCT. Very few studies identified any significant association with good environmental kitchen hygiene. Although some of the variables in the reanalysis of the UK IID study were statistically significant no obvious trend was seen.

Conclusion

The balance of the available evidence does not support the hypothesis that poor domestic kitchen hygiene practices are important risk factors for diarrhoeal disease in developed countries.

Interventions for the interruption or reduction of the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics such as of influenza or severe acute respiratory syndrome (SARS) pose a significant threat. Antiviral drugs and vaccination may not be adequate to prevent catastrophe in such an event.

OBJECTIVES

To systematically review the evidence of effectiveness of interventions to interrupt or reduce the spread of respiratory viruses (excluding vaccines and antiviral drugs, which have been previously reviewed).

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4); MEDLINE (1966 to November 2006); OLDMEDLINE (1950 to 1965); EMBASE (1990 to November 2006); and CINAHL (1982 to November 2006).

SELECTION CRITERIA

We scanned 2300 titles, excluded 2162 and retrieved the full papers of 138 trials, including 49 papers of 51 studies. The quality of three randomised controlled trials (RCTs) was poor; as were most cluster RCTs. The observational studies were of mixed quality. We were only able to meta-analyse case-control data. We searched for any interventions to prevent viral transmission of respiratory viruses (isolation, quarantine, social distancing, barriers, personal protection and hygiene). Study design included RCTs, cohort studies, case-control studies, cross-over studies, before-after, and time series studies.

DATA COLLECTION AND ANALYSIS

We scanned the titles, abstracts and full text articles using a standardised form to assess eligibility. RCTs were assessed according to randomisation method, allocation generation, concealment, blinding, and follow up. Non-RCTs were assessed for the presence of potential confounders and classified as low, medium, and high risk of bias.

MAIN RESULTS

The highest quality cluster RCTs suggest respiratory virus spread can be prevented by hygienic measures 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. The 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 the more uncomfortable and expensive N95 masks were superior to simple surgical masks. The incremental effect of adding virucidals or antiseptics to normal handwashing to decrease respiratory disease remains uncertain. The lack of proper evaluation of global measures such as screening at entry ports and social distancing prevent firm conclusions about these measures.

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.

Febrile respiratory illness in the intensive care unit setting: an infection control perspective

PURPOSE OF REVIEW

We have examined studies published since the severe acute respiratory syndrome outbreak that elucidate the mode of transmission of respiratory pathogens and the optimal means of interrupting their transmission, focusing on transmission in the intensive care unit.

RECENT FINDINGS

The severe acute respiratory syndrome may be transmitted by the droplet, contact and occasionally the airborne route. Transmission occurred most frequently when healthcare workers failed to use standard precautions such as hand washing or personal protective equipment designed to limit droplet and contact transmission. Aerosol-generating procedures increased transmission, but incomplete use of personal protective equipment during procedures was common. Recent publications have stressed the benefits of appropriate staffing levels, the use of single occupancy rooms, the immunization of healthcare workers against influenza, and the importance of healthcare workers remaining home when ill in reducing the morbidity and mortality of respiratory infection within the intensive care unit.

SUMMARY

Most respiratory pathogens can be transmitted by more than one route. Despite this, healthcare worker awareness of clinical syndromes associated with respiratory pathogens that require airborne precautions, combined with the use of standard precautions for all patients, and contact/droplet precautions for patients with undifferentiated febrile respiratory illness should be effective in interrupting the transmission of respiratory pathogens within the intensive care unit.

School absenteeism and school refusal behavior: a review and suggestions for school-based health professionals

School absenteeism and school refusal behavior are particularly difficult problems that school health professionals often face. Unfortunately, few recommendations are available to such professionals about how to address this population. In this article, we (1) outline the major characteristics of school absenteeism and school refusal behavior, (2) review school-based health programs that have been designed in part to reduce absenteeism, and (3) provide suggestions for school health professionals regarding individual youths with school refusal behavior.