ArticlesEffect of handwashing on child health: a randomised controlled trial
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
References (42)
- et al.
Where and why are 10 million children dying every year?
Lancet
(2003) - et al.
Prevention of diarrhoea and dysentery by hand washing
Trans R Soc Trop Med Hyg
(1989) Proper handwashing promotes wellness in child care
J Pediatr Health Care
(1997)- et al.
Handwashing and respiratory illness among young adults in military training
Am J Prev Med
(2001) - et al.
Inter-observer variation in the assessment of clinical signs in sick Tanzanian children
Trans R Soc Trop Med Hyg
(2002) - et al.
Hygiene, skin infections and types of water supply in Venda, South Africa
Trans R Soc Trop Med Hyg
(1991) - et al.
Risk factors for deaths due to respiratory infections among Brazilian infants
Int J Epidemiol
(1989) - et al.
Determinants of child mortality in south-west Uganda
J Biosoc Sci
(1992) - et al.
An educational intervention for altering water-sanitation behaviors to reduce childhood diarrhea in urban Bangladesh
Am J Epidemiol
(1987)