COCHRANE COLUMNTaryn YoungThe aim of the Column is to highlight CochraneReviews of relevance to public health, and tostimulate debate on relevance, feasibility and accept-ability. This month we feature the review by Ejemotet al. on hand washing for prevention of diarrhoea.The Cochrane Collaboration (http://www.cochrane.org) is an international, non-profit organization thatprepares and disseminates up-to-date systematicreviews on the effects of healthcare interventions inorder to help people make well-informed decisions.Systematic reviews aim to answer focused healthcarequestions by systematically identifying and evaluatingall relevant research studies and synthesizing theirresults.If you are interested in contributing to the CochraneColumn or The Cochrane Collaboration, contact me atthe South African Cochrane Centre.Hand washing for preventing DiarrhoeaRI Ejemot,* JE Ehiri, MM Meremikwu and JA CritchleyBackgroundDiarrhoea causes over 2.2 million deaths every year,mostly among children under 5 years of age1,2in lowand middle income countries. When prolonged, itcontributes to reduced resistance to infections,impaired growth and development.3Most, diarrhoea disease pathogens are transmittedthrough the faeco-oral route,4and over 70% of alldiarrhoea cases can be attributed to contaminatedfood or water.4–6Any behaviour that increases humancontact with faecal matter, such as omitting handwashing after defecation, after handling children’sfaeces, and before handling foodcan all contribute totransmission.7–10In particular, hand contact withready-to-eat food (food consumed without furtherwashing, cooking or processing/preparation by theconsumer) represents a important mechanism bywhich diarrhoea-causing pathogens contaminate foodand water.11A number of strategies for control of diarrhoea havebeen identified by the WHO.12These include improve-ment of water supply for households and commu-nities13as well as hygiene promotion interventions.14The latter constitutes a range of activities aimed atencouraging individuals and communities to adoptsafer practices within, in order to prevent hygiene-related diseases that lead to diarrhea;15hand washingis one such intervention.Hand washing may require infrastructural, culturaland behavioural change, which take time to develop,as well as substantial resources such as soap andwater.16–18Given the many possible ways to reducediarrhoeal disease, it is important to assess theeffectiveness of hand washing interventions.MethodsSearch strategyWe searched the Cochrane Infectious Diseases GroupSpecialized Register, CENTRAL (The Cochrane Library2007, Issue 2), MEDLINE, EMBASE, LILACS,PsycINFO, Science Citation Index and Social ScienceCitation Index, ERIC (1966 to May 2007), SPECTR,Bibliomap, RoRe, The Grey Literature and referencelists of articles. We also contacted researchers andorganizations in the field. Our search was notrestricted by publication status or language.Selection criteriaRandomized controlled trials, where the unit of ran-domization was an institution (e.g. day-care centre,household or community), or individuals, comparinginterventions specifically to promote hand washing orgeneral hygiene promotion including hand washingwith controls.Data analysisWe identified three categories of studies—institution-based interventions (day-care centres or primaryThese summaries have been derived from Cochrane reviews publishedin The Cochrane Database of Systematic Reviews in The Cochrane Library.Their content has, as far as possible, been checked with the authorsof the original reviews, but the summaries should not be regarded asan official product of The Cochrane Collaboration (www.cochrane.org).South African Cochrane Centre, Medical Research Council,PO Box 19070, Tygerberg 7505, South Africa.E-mail: [email protected]* Corresponding author. Department of Public Health, Collegeof Medical Sciences, University of Calabar, PMB 1115,Calabar, Nigeria.E-mail: [email protected] or [email protected] by Oxford University Press on behalf of the International Epidemiological Associationß The Author 2008; all rights reserved.International Journal of Epidemiology 2008;37:470–473doi:10.1093/ije/dyn069470schools), mainly conducted in industrialized coun-tries, community-based interventions conducted inlow- and middle- income countries, and interventionsin people at high risk of diarrhoea. Given thedifferences between interventions in these settings,we analysed and presented the results separately.Most trials reported either the incidence rate ratioand 95% CI (confidence interval), or the number ofepisodes of diarrhoea and the person-time at risk, butfew reported the proportion of the population experi-encing at least one attack of diarrhoea. The trial amongAIDS patients reported information only on the meannumber of diarrhea episodes and standard deviation.ResultsFourteen randomized controlled trials met the inclu-sion criteria. Eight trials were institution-based inhigh-income countries, five were community-based inlow or middle-income countries, and one was in ahigh-risk group (AIDS patients). Considering onlytrial results which adjusted for cluster randomization,interventions promoting hand washing resulted in a39% reduction in diarrhoea episodes in children ininstitutions in high-income countries (IRR 0.61, 95%CI 0.40 to 0.92; 2 trials) and a 32% reduction in suchepisodes in children living in communities in low ormiddle-income countries (IRR 0.68, 95% CI 0.52 to0.90; 4 trials). The trial in148 adult AIDS patientsalso showed a significant reduction in episodes ofdiarrhoea (Weighted mean difference 1.68, 95% CI1.93 to 1.43).ConclusionsHand washing can reduce diarrhoea episodes byabout 30%. This significant reduction is comparableto the effect of providing clean water in low-incomeareas. The challenge is to find ways of encouragingpeople to wash their hands properly. Trials withlonger follow up and that test different methods ofpromoting hand washing are needed.The full text of the Cochrane Review is available inThe Cochrane Library: Ejemot RI, Ehiri JE, MeremikwuMM, Critchley JA. Hand washing for preventingdiarrhoea. Cochrane Database of Systematic Reviews2008, Issue 1. Art. No.: CD004265. DOI: 10.1002/14651858.CD004265.pub2.References1Bern C, Martines J, de Zoysa I, Glass RI. The magnitudeof the global problem of diarrhoeal diseases: a ten-yearupdate. Bull World Health Organ 1992;70:705–14.2World Health Organization. The World
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