Effect of infection control measures on the frequency of diarrheal episodes in child care: a randomized, controlled trial. Combining drinking water treatment and hand washing for diarrhoea prevention, a cluster randomised controlled trial. A cluster-randomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools. An educational intervention for altering water-sanitation behaviors to reduce childhood diarrhea in urban Bangladesh. II. A randomized trial to assess the impact of the intervention on hygienic behaviors and rates of diarrhea. Evaluation of an hygienic intervention in child day-care centers. Community-based hygiene education to reduce diarrhoeal disease in rural Zaire: impact of the intervention on diarrhoeal morbidity. Effectiveness of a training program in reducing infections in toddlers attending day care centers. Effect of handwashing on child health: a randomised controlled trial. Diarrheal illness among infants and toddlers in day care centers: effects of active surveillance and staff training without subsequent monitoring. Effect of intensive handwashing in the prevention of diarrhoeal illness among patients with AIDS: a randomized controlled study. [Hand-hygiene and sickness among small children attending day care centers. An intervention study]. Handwashing to prevent diarrhea in day-care centers. Prevention of diarrhoea and dysentery by hand washing. Occurrence of infectious symptoms in children in day care homes.
Diarrheal infections are common in children who attend child care, and preventing transmission of disease in this setting depends on actions by child care staff. We set out to discover whether transmission of gastrointestinal infections in child care could be reduced by improved infection control procedures.
                We performed a cluster randomized, controlled trial of an infection control intervention conducted in child care centers for 1 city in Australia. The intervention was training of child care staff about transmission of infection and handwashing and focused on both staff and child behavior. Implementation of the intervention was recorded by an observer. Illness was measured by parent report in telephone interviews every 2 weeks.
                There were 311 child-years of surveillance for diarrheal episodes. The rate of episodes of diarrhea was 1.9 per child-year in intervention centers and 2.7 per child-year in control centers. Multivariable analysis showed that diarrheal episodes were significantly reduced in intervention center children by 50%. However, the impact of the intervention was confined to children over 24 months of age. For those centers in which children's compliance with handwashing was high, diarrheal episodes were reduced by 66%.
                This trial supports education about infection control, for staff and children in child care, as a means of reducing transmission of diarrhea. Reduction in episodes of diarrhea in children in child care was limited to children over 24 months of age. To evaluate the effectiveness of point of use water treatment with flocculent-disinfectant on reducing diarrhoea and the additional benefit of promoting hand washing with soap.
                The study was conducted in squatter settlements of Karachi, Pakistan, where diarrhoea is a leading cause of childhood death. Interventions were randomly assigned to 47 neighbourhoods. Households in 10 neighbourhoods received diluted bleach and a water vessel; nine neighbourhoods received soap and were encouraged to wash hands; nine neighbourhoods received flocculent-disinfectant water treatment and a water vessel; 10 neighbourhoods received disinfectant-disinfectant water treatment and soap and were encouraged to wash hands; and nine neighbourhoods were followed as controls. Field workers visited households at least once a week from April to December 2003 to promote use of the interventions and to collect data on diarrhoea.
                Study participants in control neighbourhoods had diarrhoea on 5.2% of days. Compared to controls, participants living in intervention neighbourhoods had a lower prevalence of diarrhoea: 55% (95% CI 17%, 80%) lower in bleach and water vessel neighbourhoods, 51% (95% CI 12%, 76%) lower in hand washing promotion with soap neighbourhoods, 64% lower (95% CI 29%, 90%) in disinfectant-disinfectant neighbourhoods, and 55% (95% CI 18%, 80%) lower in disinfectant-disinfectant plus hand washing with soap neighbourhoods.
                With an intense community-based intervention and supplies provided free of cost, each of the home-based interventions significantly reduced diarrhoea. There was no benefit by combining hand washing promotion with water treatment. Intensive handwashing promotion can reduce diarrheal and respiratory disease incidence. To determine whether less intensive, more scalable interventions can improve health, we evaluated a school-based handwashing program. We randomized 87 Chinese schools to usual practices: standard intervention (handwashing program) or expanded intervention (handwashing program, soap for school sinks, and peer hygiene monitors). We compared student absence rates, adjusting for cluster design. In control schools, children experienced a median 2.0 episodes (median 2.6 days) of absence per 100 student-weeks. In standard intervention schools, there were a median 1.2 episodes (P = 0.08) and 1.9 days (P = 0.14) of absence per 100 student-weeks. Children in expanded intervention schools experienced a median 1.2 episodes (P = 0.03) and 1.2 days (P = 0.03) of absence per 100 student-weeks. Provision of a large-scale handwashing promotion program and soap was associated with significantly reduced absenteeism. Similar programs could improve the health of children worldwide. An educational intervention was designed to improve three water-sanitation behaviors empirically shown to be associated with high rates of childhood diarrhea in Dhaka, Bangladesh: lack of handwashing before preparing food, open defecation by children in the family compound, and inattention to proper disposal of garbage and feces, increasing the opportunity for young children to place waste products in their mouth. Fifty-one communities, each comprising 38 families, were randomized either to receive (n = 25) or not to receive (n = 26) the intervention. During the six months after the intervention, the rate of diarrhea (per 100 person-weeks) in children under six years of age was 4.3 in the intervention communities and 5.8 in the control communities (26% protective efficacy; p less than 0.0001). A corresponding improvement in handwashing practices before preparing food was noted, although no improvement was observed for defecation and waste disposal practices. These data suggest that educational interventions for water-sanitation practices can have an important beneficial effect upon childhood diarrhea in developing countries, particularly when the interventions are designed in a simple way to promote naturally occurring salutory behaviors that are empirically associated with lower rates of childhood diarrhea. nan Diarrhoeal disease is a leading cause of morbidity in young children in rural Zaire. Few diarrhoea prevention programmes have been implemented in Bandundu Province, where available data suggest an annual prevalence rate of 10%. The urgent need to reduce diarrhoeal morbidity in Zaire, together with the potential effectiveness and feasibility of hygiene education as a diarrhoea prevention strategy, led to the development of the present research project.
                A randomized, controlled trial of an education intervention to reduce diarrhoea through improved personal and domestic hygiene behaviours was conducted in 18 geographically separate village clusters (sites) in rural Zaire. For 12 weeks baseline information on the diarrhoeal morbidity of 2082 children aged 3-35 months was collected at weekly home visits, and structured observations of hygiene practices related to diarrhoea were made on a subset of 300 families. Intervention messages addressed disposal of animal faeces from the yard, handwashing after defecation and before meal preparation and eating, and disposal of children's faeces. Three months after the start of the intervention and exactly 1 year after the baseline studies, a second diarrhoeal morbidity study and a second observational study were conducted in order to evaluate the intervention.
                Children in intervention communities experienced an 11% reduction in the risk of reporting diarrhoea during the peak diarrhoeal season, compared to controls (P < 0.025). The largest differences were seen among children aged 24-35 months, with those from intervention communities reporting significantly fewer episodes, shorter mean durations and hence fewer days of diarrhoea. There was some evidence that greater reductions in diarrhoea occurred in sites where the quality of the intervention, a scored measure of volunteer efficacy and community participation, was highest.
                The results of this study suggest that hygiene education may be an effective approach to reduce the incidence and duration of diarrhoeal episodes in rural Zaire. Children aged 2 years appear to benefit the most. A Hawthorne effect of the education may contribute to diarrhoeal reductions. The objective of this study was to assess the effectiveness of a hygiene program in reducing the incidence of respiratory and diarrheal diseases in toddlers attending day care centers. A randomized field trial was conducted in 52 day care centers in Quebec, Canada, between September 1, 1996 and November 30, 1997. Absences for any reasons and the daily occurrence of colds and/or diarrhea in toddlers were recorded on calendars by the educators. The number of fecal coliforms on children's hands and on educators' hands was measured during three unannounced visits. Overall, 1,729 children were followed in 47 day care centers for a total of 153,643 child-days. The incidence rate of diarrhea was considerably reduced by the effect of monitoring (IRR = 0.73, 95% CI = 0.54,0.97), and the intervention reduced the incidence rate of upper respiratory tract infections (IRR = 0.80, 95% CI = 0.68,0.93). Monitoring alone also had an important effect in reducing the level of bacterial contamination on children's and educators' hands. The results indicate that both an intervention program and monitoring alone play a role in reducing infections in children attending day care centers. More than 3.5 million children aged less than 5 years die from diarrhoea and acute lower respiratory-tract infection every year. We undertook a randomised controlled trial to assess the effect of handwashing promotion with soap on the incidence of acute respiratory infection, impetigo, and diarrhoea.
                In adjoining squatter settlements in Karachi, Pakistan, we randomly assigned 25 neighbourhoods to handwashing promotion; 11 neighbourhoods (306 households) were randomised as controls. In neighbourhoods with handwashing promotion, 300 households each were assigned to antibacterial soap containing 1.2% triclocarban and to plain soap. Fieldworkers visited households weekly for 1 year to encourage handwashing by residents in soap households and to record symptoms in all households. Primary study outcomes were diarrhoea, impetigo, and acute respiratory-tract infections (ie, the number of new episodes of illness per person-weeks at risk). Pneumonia was defined according to the WHO clinical case definition. Analysis was by intention to treat.
                Children younger than 5 years in households that received plain soap and handwashing promotion had a 50% lower incidence of pneumonia than controls (95% CI (-65% to -34%). Also compared with controls, children younger than 15 years in households with plain soap had a 53% lower incidence of diarrhoea (-65% to -41%) and a 34% lower incidence of impetigo (-52% to -16%). Incidence of disease did not differ significantly between households given plain soap compared with those given antibacterial soap.
                Handwashing with soap prevents the two clinical syndromes that cause the largest number of childhood deaths globally-namely, diarrhoea and acute lower respiratory infections. Handwashing with daily bathing also prevents impetigo. From October 1981 to September 1984, the authors conducted a three-year longitudinal study of diarrhea among infants and toddlers attending day care centers in Maricopa County, Arizona. In the third year of study, they evaluated the effects on diarrhea rates of staff training without external monitoring and of active surveillance conducted throughout the study. From 21 study day care centers, they randomly selected 10 ("intervention day care centers") to receive staff training in procedures to reduce transmission of infectious diarrhea. Continuing active surveillance in the 10 intervention and 11 control day care centers found no difference between diarrhea rates in intervention day care centers in the pre- and posttraining years and no difference between diarrhea rates in the two groups of centers either before or after the training intervention. Biweekly family-based surveys during the two months after training also demonstrated no difference between infant-toddler diarrhea rates in intervention and control day care centers. These surveys found the 21 study day care centers to have significantly higher diarrhea rates than did day care homes or households not using day care, but significantly lower rates than day care centers not included in the active surveillance. Continuous surveillance without training was associated with a significant decrease in diarrheal illness during the course of longitudinal study. One-time staff training without subsequent monitoring did not result in additional decreases and did not lower day care center diarrhea rates to the levels observed in day care homes and households not using day care. Patients with AIDS frequently develop diarrhoeal illness. In this randomized, controlled study, 260 patients were screened for those who had not had diarrhoea in the preceding 3 months and who had received a stable highly active antiretroviral therapy regimen for at least 6 weeks prior to the study enrollment. A total of 148 patients met the inclusion criteria and were enrolled: 75 patients were randomly assigned to an intensive handwashing intervention (i.e. handwashing after defecation, after cleaning infants who had defecated, before preparing food, before eating, and before and after sex) and 73 patients were randomly assigned to the control group. Patients in both groups were called weekly by telephone to determine compliance with handwashing and to determine the number of diarrhoeal episodes for the preceding week. Patients were observed for 1 year. Patients assigned to the intensive handwashing intervention group washed their hands more frequently compared with the control group (seven vs four times a day, respectively; P <0.05) and developed fewer episodes of diarrhoeal illness (1.24+/-0.9 vs 2.92+/-0.6 new episodes of diarrhoea, respectively; P <0.001) during the 1 year observation. The most common pathogens identified in both groups in patients who developed diarrhoeal illness were Giardia lamblia, Cryptosporidium, Entamoeba histolytica and Shigella flexneri. These data suggest that intensive handwashing reduces diarrhoeal illness in patients with AIDS. The purpose of the study was to evaluate the effect of intensified hygiene with frequent handwashing and several educational procedures in day-care centres. The study was conducted as a controlled trial, with an intervention group and an observation group. There was a 34% reduction in expected sickness in children in the intervention group. In the categories diarrhoea and eye-infection there was a significant drop in sickness. We conclude that broad intervention concerning hand-hygiene has a positive effect on sickness in children attending day-care centres. Diarrhea has been recognized as a frequent health problem among children enrolled in day-care centers. Thus, we evaluated the effect of a handwashing program in two day-care centers (HWC) on the incidence of diarrhea among children when compared to children in two control centers (CC). After the program was begun, the incidence of diarrhea at the HWC began to fall and after the second month of the study was consistently lower than that at the CC. The incidence of diarrhea in the HWC was approximately half that of the CC for the entire 35-week study period. Adenoviruses, rotavirus, Giardia lamblia, and enteropathogenic Escherichia coli were found in the stools of a small number of ill children, but not pathogen was identified in the stools of most children with diarrhea. These results suggest that a handwashing program will probably prevent at least some of the diarrhea in day-care centers. A 'non-blind' randomized hand washing intervention study was conducted in a low socioeconomic community in Rangoon to determine if hand washing by 494 children under 5 years old and their mothers could reduce the incidence of diarrhoea and dysentery in these children. Children and mothers in the intervention group were asked to wash their hands after defaecation and before preparing or eating their 3 main meals; 2 bars of plain soap were provided. The control group was left to follow customary practice. Diarrhoea and dysentery incidences in the 2 groups were monitored during 4 months by comparing the incidence density ratios (IDR). The diarrhoeal incidence among the children in the hand washing households was significantly lower than that among those in the control households (IDR = 0.70, 95% confidence interval (CI) = 0.54-0.92). For dysentery incidence, although there was a 40% reduction (IDR = 0.58, 95% CI = 0.22-1.55) in the children under 2 years, there seemed to be no impact in older children (IDR = 1.2, 95% CI = 0.52-2.80). The study indicates that hand washing is effective in reducing the morbidity from diarrhoea and dysentery. Transmission of enteric pathogens is facilitated in child day care centers, including family day care homes, by frequent and intimate exposure among susceptible hosts, with diaper changing as the highest-risk procedure for such transmission. The objective of this study was to evaluate the effectiveness of an intervention program in decreasing the incidence of infectious disease symptoms in children attending family day care homes during a 12-month period. Each of 24 family day care homes was randomly assigned to an intervention or control group. The intervention included four components: (1) a handwashing educational program and (2) use of vinyl gloves, (3) use of disposable diaper changing pads, and (4) use of an alcohol-based hand rinse by the day care provider. Symptoms of enteric disease (diarrhea and vomiting) were significantly reduced in intervention family day care homes (p less than or equal to 0.05), whereas respiratory symptoms were not significantly different between intervention and control family day care homes (p = 0.35). Diarrhea was reported in 1 of every 100 child care days, representing one diarrhea episode per month in a typical family day care home.
Interventions that promote hand washing can reduce diarrhoea episodes by about one-third. This significant reduction is comparable to the effect of providing clean water in low-income areas. However, trials with longer follow up and that test different methods of promoting hand washing are needed.