Elsevier

The Lancet

Volume 366, Issue 9481, 16–22 July 2005, Pages 225-233
The Lancet

Articles
Effect of handwashing on child health: a randomised controlled trial

https://doi.org/10.1016/S0140-6736(05)66912-7Get rights and content

Summary

Background

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.

Methods

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.

Findings

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.

Interpretation

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.

Introduction

Every year, more than 3·5 million children aged less than 5 years die from diarrhoea and acute lower respiratory-tract infection.1 These deaths are concentrated in low-income communities in developing countries.2, 3, 4 Several studies have shown that regular handwashing with soap reduces the incidence of diarrhoea in children younger than 5 years in communities with a high incidence of diarrhoea,5, 6, 7 although we are unaware of any reports of the effect of handwashing on acute respiratory-tract infections in settings where pneumonia is a leading cause of death.

In developed countries, the promotion of handwashing has reduced respiratory-tract infections in several settings. Controlled trials of handwashing promotion in child-care centres have reported a 14% reduction in upper respiratory-tract infection in Canada;8 a 12% reduction in upper respiratory-tract infection in children aged 24 months or less in Australia;9 and a 32% reduction in colds in one US child-care centre in the USA.10 In a school of children aged 5 to 12 years in the USA, a handwashing promotion programme in selected classrooms was associated with a 21% fall in absences from respiratory illness.11 Another programme at a US Navy training centre that included directives to wash hands five times per day resulted in a 45% reduction in total outpatient visits for respiratory illness.12

Impetigo is another condition that is common in low-income countries with high humidity, which affects mothers of young children. A previous study13 in Karachi, Pakistan, investigated the effect of antibacterial soap on impetigo. Incidence of impetigo in children living in households receiving antibacterial soap (1·10 episodes per 100 person-weeks) was 23% lower than that in households receiving plain soap (p=0·28) and was 43% lower than the standard habit and practice controls (p=0·02).

In Karachi, more than 4 million low-income residents live in squatter settlements where they do not legally own the land, and municipal infrastructure is restricted.14 A study undertaken in these communities concluded that 41% of deaths of children aged less than 5 years were due to diarrhoea and 15% due to acute respiratory-tract infections.15

We undertook the Karachi Soap Health Study as a randomised controlled trial to measure the broad health benefits brought about by improvement of handwashing and bathing with soap in settings where communicable diseases are leading causes of childhood morbidity and mortality.

Section snippets

Patients

The study site and intervention for the Karachi Soap Health Study has been described previously.16 Briefly, the study was undertaken in adjoining multi-ethnic squatter settlements in central Karachi in collaboration with Health Oriented Preventive Education (HOPE), a non-governmental organisation that supports community-based health and development initiatives. Although handwashing, typically with water only, is part of ritual preparation for prayer in these societies, thorough washing of hands

Results

The 36 neighbourhoods in the study had a median of 26 participating households per neighbourhood (IQR 21–30). In the 25 neighbourhoods randomly assigned to handwashing promotion, antibacterial soap was randomly allocated to 300 households and plain soap to 300 households. 11 neighbourhoods (306 households) were randomly assigned to undertake standard habits and practices (control). During 51 weeks of follow-up, information was obtained on 210 133 person-weeks, representing 89% of the study

Discussion

In squatter settlements of Karachi, where diarrhoea and acute respiratory infections are leading causes of death, washing hands with soap reduced both syndromes by half. Incidence of impetigo also fell by almost a third in households encouraged to regularly wash hands and bathe daily. Handwashing was effective in reducing disease incidence in malnourished children, although the reductions in the youngest children were not significant. However, we did not detect any difference in disease

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