Hand Washing May Reduce Episodes of Diarrhea by 30%CME

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.

Release Date: January 24, 2008;Reviewed and Renewed:February 19, 2009;Valid for credit through February 19, 2010

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The content of this CME activity, "Hand Washing May Reduce Episodes of Diarrhea by 30%," was developed by the faculty.
To participate in this activity: 1) review the target audience, learning objectives and author disclosures, 2) study the education content 3) answer the posttest and evaluation 4) view/print certificate View details

Learning Objectives

Upon completion of this activity, participants will be able to:

  1. Describe the impact of interventions to promote hand washing on diarrheal episodes.
  2. Compare the impact of interventions to promote hand washing on institutions, communities, and rates of diarrhea in at-risk populations.
Authors and Disclosures

Laurie Barclay, MD
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Désirée Lie, MD, MSEd
Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.

Brande Nicole Martin
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

January 24, 2008 — Hand washing reduced episodes of diarrhea by 30%, according to a Cochrane review in the January 23 issue of the Cochrane Database Systematic Review.

"Diarrhoea is a common cause of morbidity and a leading cause of death among children aged less than five years, particularly in low- and middle-income countries," write Dr. Regina Ejemot, from the University of Calabar, Calabar, Nigeria, and colleagues. "It is transmitted by ingesting contaminated food or drink, by direct person-to-person contact, or from contaminated hands. Hand washing is one of a range of hygiene promotion interventions that can interrupt the transmission of diarrhoea-causing pathogens."

The objective of this review was to evaluate the efficacy of interventions to promote hand washing on reducing episodes of diarrhea in children and adults. The reviewers searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE, EMBASE, LILACS, PsycINFO, Science Citation Index and Social Science Citation Index, ERIC (1966 - May 2007), SPECTR, Bibliomap, RoRe, and The Grey Literature, through May 2007. They also searched reference lists of articles and contacted investigators and organizations in the field.

To be included in the review, studies had to be randomized controlled trials (RCTs), where the unit of randomization was an institution such as a daycare center, a household, or a community. In addition, these trials had to compare interventions to promote hand washing (using educational programs, leaflets, and discussions) with a hygiene promotion that included hand washing but no specific intervention to promote hand washing.

Two authors independently determined whether specific trials met inclusion criteria and evaluated the methodologic quality of the included studies. Whenever it was feasible, the generic inverse variance method and random-effects model with 95% confidence intervals (CI) were used to pool incidence rate ratios (IRR).

Of 14 trials meeting selection criteria, 8 were institution based, 5 were community based, and 1 was in a high-risk group of patients with AIDS. Interventions promoting hand washing were associated with a decrease in diarrheal episodes of 29% in institutions in high-income countries (IRR, 0.71; 95% CI, 0.60 - 0.84; 7 trials) and 31% in communities in low- or middle-income countries (IRR, 0.69; 95% CI, 0.55 - 0.87; 5 trials).

"Hand washing can reduce diarrhoea episodes by about 30%," the review authors conclude. "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."

The methodologic quality of the included trials was limited, in part because of inadequate blinding, possible bias introduced by intensive monitoring of diarrheal episodes, and study dropout. Only 6 of the 14 included trials reported using an adequate method to generate the allocation sequence. The benefits of hand-washing promotion on reducing the incidence of diarrhea varied widely among trials.

"Hand washing interventions are efficacious in reducing diarrhoeal episodes by about 30% and should be promoted," the review authors conclude. "The challenge is to find effective ways of getting people to wash their hands appropriately."

The University of Calabar and Institute of Tropical Diseases Research and Prevention in Nigeria, the University of Alabama at Birmingham, and the International Health Group, Liverpool School of Tropical Medicine, United Kingdom, supported this review. The review authors have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online January 23, 2008.

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:

  1. Describe the impact of interventions to promote hand washing on diarrheal episodes.
  2. Compare the impact of interventions to promote hand washing on institutions, communities, and rates of diarrhea in at-risk populations.

Clinical Context

The World Health Organization reports more than 3 million episodes of diarrhea annually and estimates that more than 2.2 million diarrheal deaths occur mainly in children, especially in low- and middle-income countries. Through incapacitation and premature death, the estimated disability-adjusted life-years for diarrheal disease are 99.2 million. Hand washing is an intervention that has been shown to reduce transmission of diarrhea-causing organisms, but the habit requires cultural, social, educational, and behavioral changes, among them being provision of clean water. Studies suggest a reduction of up to 47% in communities with soap-and-water hand washing.

This is a systematic review of studies addressing interventions to promote hand washing to estimate an effect size (IRR) for its impact on diarrheal episodes.

Study Highlights

  • Studies had to be RCTs such as cluster randomized trials, where the unit was an institution (eg, daycare center), household, or community, and a control group was included.
  • Excluded were observational, case-control, and controlled before-and-after studies.
  • Participants were adults and children in institutional settings, communities, or households.
  • Activities that promoted hand washing included small group discussions, meetings, posters, radio and television shows, and use of badges or T-shirts and games.
  • Primary outcomes were acute primary diarrhea defined as 3 or more loose or watery stools in a 24-hour period, persistent diarrhea lasting 14 or more days, and dysentery defined as bloody diarrhea.
  • Secondary outcomes were diarrhea-related death, behavioral changes, and changes in knowledge and attitudes toward hand washing.
  • A comprehensive literature search was conducted on multiple databases; researchers, organizations, and the Grey Literature were consulted.
  • 2 independent reviewers assessed trial eligibility and quality, and IRRs were pooled, where appropriate, with the random-effects model.
  • 3 categories of studies were identified and IRRs for diarrhea outcomes calculated.
  • Of 37 potentially eligible trials, 14 met inclusion criteria, of which 8 were institution-based RCTs (by clusters with use of classrooms or daycare centers), 5 were community-based trials, and 1 examined an at-risk population with AIDS.
  • Of the 14 trials, only 6 reported using an adequate method to generate the allocation sequence.
  • There was wide variation in the benefits of hand-washing promotion on the incidence of diarrhea.
  • All studies were conducted in adults, in children younger than 15 years, and mostly in those younger than 7 years.
  • For the 8 institution-based trials, 7711 participants were included (daycare providers, educators, and young children) with primary outcomes examined across 161 daycare centers and 87 schools.
  • Most studies involved high-income countries: Australia, Europe, and North America with 1 study from China.
  • Follow-up ranged from 4 to 12 months, and none reported deaths.
  • There was a 29% reduction in the incidence of diarrhea in the intervention group (IRR, 0.71), and all except 1 trial showed a benefit.
  • 2 trials reported positive behavioral change in infection control in daycare centers, with an IRR of 0.34.
  • For the 5 community-based trials, 8055 participants included mothers, caregivers, and children with clusters from 18 to 1923 provided with hygiene training or educational materials.
  • The studies included entire communities (villages or neighborhoods) and were conducted in low- and middle-income countries in Africa and Asia.
  • Length of follow-up was 4 to 12 months.
  • Risk reduction for diarrhea was 31%, with an IRR of 0.69 in low- or middle-income countries.
  • 3 trials provided soap and water, with a greater IRR of 0.57.
  • 1 trial from the United States examined hand washing with 148 patients with AIDS as participants and used hygiene education and hand-washing demonstrations with weekly telephone calls.
  • Episodes of diarrhea for 1 year were reduced from 2.92 to 1.24, a reduction of 1.68 episodes with the intervention group reporting hand washing 7 vs 4 times a day.

Pearls for Practice

  • Use of interventions to promote hand washing is associated with a 30% reduction in the rate of diarrhea.
  • Risk reduction in diarrhea is greater in community-based interventions involving soap and water, and positive behavioral change can be seen in daycare centers and in patients with AIDS.

Principio del formulario


According to this review by Ejemot and colleagues, the IRR of diarrhea associated with interventions to promote hand washing at institutions and in communities is best described by which of the following?
/ 1.0
/ 0.7
/ 0.5
/ 0.3

According to this review by Ejemot and colleagues, positive behavioral change in hand washing was most likely to be demonstrated in which of the following settings?
/ Outpatient clinics
/ High schools
/ Patients with AIDS
/ Villages

Final del formulario

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Target Audience

This article is intended for primary care clinicians, public health clinicians, infectious disease specialists, and other specialists who care for patients at risk for infectious diarrhea.

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The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

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News Author

Laurie Barclay, MD
is a freelance reviewer and writer for Medscape.

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

CME Author

Désirée Lie, MD, MSEd
Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California

Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.

Brande Nicole Martin
is the News CME editor for Medscape Medical News.

Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

Medscape Medical News2008. ©2008Medscape

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