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      The Effect of Handwashing at Recommended Times with Water Alone and With Soap on Child Diarrhea in Rural Bangladesh: An Observational Study

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          Abstract

          By observing handwashing behavior in 347 households from 50 villages across rural Bangladesh in 2007, Stephen Luby and colleagues found that hand washing with soap or hand rinsing without soap before food preparation can both reduce the burden of childhood diarrhea.

          Abstract

          Background

          Standard public health interventions to improve hand hygiene in communities with high levels of child mortality encourage community residents to wash their hands with soap at five separate key times, a recommendation that would require mothers living in impoverished households to typically wash hands with soap more than ten times per day. We analyzed data from households that received no intervention in a large prospective project evaluation to assess the relationship between observed handwashing behavior and subsequent diarrhea.

          Methods and Findings

          Fieldworkers conducted a 5-hour structured observation and a cross-sectional survey in 347 households from 50 villages across rural Bangladesh in 2007. For the subsequent 2 years, a trained community resident visited each of the enrolled households every month and collected information on the occurrence of diarrhea in the preceding 48 hours among household residents under the age of 5 years. Compared with children living in households where persons prepared food without washing their hands, children living in households where the food preparer washed at least one hand with water only (odds ratio [OR] = 0.78; 95% confidence interval [CI] = 0.57–1.05), washed both hands with water only (OR = 0.67; 95% CI = 0.51–0.89), or washed at least one hand with soap (OR = 0.30; 95% CI = 0.19–0.47) had less diarrhea. In households where residents washed at least one hand with soap after defecation, children had less diarrhea (OR = 0.45; 95% CI = 0.26–0.77). There was no significant association between handwashing with or without soap before feeding a child, before eating, or after cleaning a child's anus who defecated and subsequent child diarrhea.

          Conclusions

          These observations suggest that handwashing before preparing food is a particularly important opportunity to prevent childhood diarrhea, and that handwashing with water alone can significantly reduce childhood diarrhea.

          Please see later in the article for the Editors' Summary

          Editors' Summary

          Background

          The resurgence of donor interest in regarding water and sanitation as fundamental public health issues has been a welcome step forward and will do much to improve the health of the 1.1 billion people world-wide without access to clean water and the 2.4 billion without access to improved sanitation. However, improving hygiene practices is also very important—studies have consistently shown that handwashing with soap reduces childhood diarrheal disease—but in reality is particularly difficult to do as this activity involves complex behavioral changes. Therefore although public health programs in communities with high child mortality commonly promote handwashing with soap, this practice is still uncommon and washing hands with water only is still common practice—partly because of the high cost of soap relative to income, the risk that conveniently placed soap would be stolen or wasted, and the inconvenience of fetching soap.

          Handwashing promotion programs often focus on five “key times” for handwashing with soap—after defecation, after handling child feces or cleaning a child's anus, before preparing food, before feeding a child, and before eating—which would require requesting busy impoverished mothers to wash their hands with soap more than ten times a day.

          Why Was This Study Done?

          In addition to encouraging handwashing only at the most critical times, clarifying whether handwashing with water alone, a behavior that is seemingly much easier for people to practice, but for which there is little evidence, may be a way forward. In order to guide more focused and evidence-based recommendations, the researchers evaluated the control group of a large handwashing, hygiene/sanitation, and water quality improvement program—Sanitation, Hygiene Education and Water supply-Bangladesh (SHEWA-B), organized and supported by the Bangladesh Government, UNICEF, and the UK's Department for International Development. The researchers analyzed the relationship between handwashing behavior as observed at baseline and the subsequent experience of child diarrhea in participating households to identify which specific handwashing behaviors were associated with less diarrhea in young children.

          What Did the Researchers Do and Find?

          The SHEWA-B intervention targeted 19.6 million people in rural Bangladesh in 68 subdistricts. In this study and with community and household consent, the researchers organized trained field workers, using a pretested instrument, to note handwashing behavior at key times and recorded handwashing behavior of all observed household at baseline in 50 randomly selected villages that served as nonintervention control households to compare with outcomes to communities receiving the SHEWA-B program. The fieldworkers recruited community monitors, female village residents who completed 3 days training on how to administer the monthly diarrhea survey, to record the frequency of diarrhea in children aged less than 3 years in control households for the subsequent two years. The researchers used statistical models to evaluate the association between the exposure variables (household characteristics and observed handwashing) and diarrhea.

          Using these methods, the researchers found that compared to no handwashing at all before food preparation, children living in households where the food preparer washed at least one hand with water only, washed both hands with water only, or washed at least one hand with soap, had less diarrhea with odds ratios (ORs) of 0.78, 0.67, and 0.19, respectively. In households where residents washed at least one hand with soap after defecation, children had less diarrhea (OR = 0.45), but there was no significant association between handwashing with or without soap before feeding a child, before eating, or after cleaning a child's anus, and subsequent child diarrhea.

          What Do These Findings Mean?

          These findings from 50 villages across rural Bangladesh where fecal environmental contamination, undernutrition, and diarrhea are common, suggest that handwashing before preparing food is a particularly important opportunity to prevent childhood diarrhea, and also that handwashing with water alone can significantly reduce childhood diarrhea. In contrast to current standard recommendations, these results suggest that promoting handwashing exclusively with soap may be unwarranted. Handwashing with water alone might be seen as a step on the handwashing ladder: handwashing with water is good; handwashing with soap is better. Therefore, handwashing promotion programs in rural Bangladesh should not attempt to modify handwashing behavior at all five key times, but rather, should focus primarily on handwashing after defecation and before food preparation. Furthermore, research to develop and evaluate handwashing messages that account for the limited time and soap supplies available for low-income families, and are focused on those behaviors where there is the strongest evidence for a health benefit could help identify more effective strategies.

          Additional Information

          Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001052.

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          Most cited references52

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          Hand hygiene among physicians: performance, beliefs, and perceptions.

          Physician adherence to hand hygiene remains low in most hospitals. To identify risk factors for nonadherence and assess beliefs and perceptions associated with hand hygiene among physicians. Cross-sectional survey of physician practices, beliefs, and attitudes toward hand hygiene. Large university hospital. 163 physicians. Individual observation of physician hand hygiene practices during routine patient care with documentation of relevant risk factors; self-report questionnaire to measure beliefs and perceptions. Logistic regression identified variables independently associated with adherence. Adherence averaged 57% and varied markedly across medical specialties. In multivariate analysis, adherence was associated with the awareness of being observed, the belief of being a role model for other colleagues, a positive attitude toward hand hygiene after patient contact, and easy access to hand-rub solution. Conversely, high workload, activities associated with a high risk for cross-transmission, and certain technical medical specialties (surgery, anesthesiology, emergency medicine, and intensive care medicine) were risk factors for nonadherence. Direct observation of physicians may have influenced both adherence to hand hygiene and responses to the self-report questionnaire. Generalizability of study results requires additional testing in other health care settings and physician populations. Physician adherence to hand hygiene is associated with work and system constraints, as well as knowledge and cognitive factors. At the individual level, strengthening a positive attitude toward hand hygiene and reinforcing the conviction that each individual can influence the group behavior may improve adherence among physicians. Physicians who work in technical specialties should also be targeted for improvement.
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            Fresh Produce: A Growing Cause of Outbreaks of Foodborne Illness in the United States, 1973 through 1997

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              A study of cross-contamination of food-borne pathogens in the domestic kitchen in the Republic of Ireland.

              To date, there have been no published information and empirical data available on the role played by the food preparer in the domestic kitchen in the Republic of Ireland. In this study, we have looked at the incidence of potential food pathogens and their cross-infection in the domestic kitchen during the preparation of a Sunday roast chicken lunch. Key contact sites in the domestic kitchen were sampled, including the chicken carcass before and after the preparation of a roast chicken meal. Twelve contact sites in twenty-five domestic kitchens were analysed and tested for aerobic plate count, Salmonella, Campylobacter, Escherichia coli and Staphylococcus aureus. Our findings identified the ability of food-borne disease microorganisms to become disseminated from infected foods, such as fresh chickens, to hand and food contact surfaces in the domestic kitchen, reiterating the need for consumer awareness and knowledge of effective hygiene procedures in the domestic kitchen.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, USA )
                1549-1277
                1549-1676
                June 2011
                June 2011
                28 June 2011
                : 8
                : 6
                : e1001052
                Affiliations
                [1 ]International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
                [2 ]Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
                [3 ]Water and Environmental Sanitation Section, UNICEF Bangladesh, Dhaka, Bangladesh
                Aga Khan University, Pakistan
                Author notes

                Conceived and designed the experiments: SPL RBJ. Performed the experiments: AKH TH. Analyzed the data: SPL AKH. Wrote the paper: SPL AKH TH LU RBJ. ICMJE criteria for authorship read and met: SPL AKH TH LU RBJ. Agree with the manuscript's results and conclusions: SPL AKH TH LU RBJ. Wrote the first draft of the paper: SPL.

                Article
                PMEDICINE-D-10-00125
                10.1371/journal.pmed.1001052
                3125291
                21738452
                ad8869ce-e535-4848-b33d-5458e6b1e999
                This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
                History
                : 1 October 2010
                : 18 May 2011
                Page count
                Pages: 12
                Categories
                Research Article
                Medicine
                Epidemiology
                Infectious Disease Epidemiology
                Global Health
                Infectious Diseases
                Gastrointestinal Infections
                Infectious Disease Control
                Public Health
                Child Health
                Environmental Health

                Medicine
                Medicine

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