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UNC-Chapel Hill ENVR 890 - Effect of washing hands with soap on diarrhoea risk in the community

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Effect of washing hands with soap on diarrhoea risk in the community: a systematic reviewMethodsSearch strategyReview strategyMeta-analysisResultsMeta-analysisDiscussionPrincipal findingsEstimating potential reductions in mortalityStrengths and weaknesses of the reviewMeaning and implications of the studyFuture researchImplicationsAcknowledgmentsReferencesFor personal use. Only reproduce with permission from The Lancet Publishing Group.We set out to determine the impact of washing hands withsoap on the risk of diarrhoeal diseases in the communitywith a systematic review with random effects meta-analysis. Our data sources were studies linkinghandwashing with diarrhoeal diseases. Seven interventionstudies, six case-control, two cross-sectional, and twocohort studies were located from electronic databases,hand searching, and the authors’ collections. The pooledrelative risk of diarrhoeal disease associated with notwashing hands from the intervention trials was 1·88 (95%CI 1·31–2·68), implying that handwashing could reducediarrhoea risk by 47%. When all studies, when only thoseof high quality, and when only those studies specificallymentioning soap were pooled, risk reduction ranged from42–44%. The risks of severe intestinal infections and ofshigellosis were associated with reductions of 48% and59%, respectively. In the absence of adequate mortalitystudies, we extrapolate the potential number of diarrhoeadeaths that could be averted by handwashing at about amillion (1·1 million, lower estimate 0·5 million, upperestimate 1·4 million). Results may be affected by the poorquality of many of the studies and may be inflated bypublication bias. On current evidence, washing hands withsoap can reduce the risk of diarrhoeal diseases by 42–47%and interventions to promote handwashing might save amillion lives. More and better-designed trials are needed tomeasure the impact of washing hands on diarrhoea andacute respiratory infections in developing countries.Lancet Infect Dis 2003; 3: 275–81Diarrhoeal diseases are amongst the top three killers ofchildren in the world today.1At least 20 viral, bacterial, andprotozoan enteric pathogens, including Salmonella spp,Shigella spp, Vibrio cholerae, and rotavirus, multiply in thehuman gut, exit in excreta, and transit through theenvironment, causing diarrhoea in new hosts. Becausediarrhoeal diseases are of faecal origin, interventions thatprevent faecal material entering the domestic environmentof the susceptible child are likely to be of greatestsignificance for public health.2The key primary barriers tothe transmission of enteric pathogens are safe stool disposaland adequate handwashing (figure 1), especially aftercontact with faecal material during anal cleansing of adultsand children.3Hands serve as vectors, transmittingpathogens to foodstuffs and drinks and to the mouths ofsusceptible hosts. In a 1997 review Huttly quoted five studieson handwashing with a median reduction in diarrhoeaincidence of 35%.4We carried out a systematic review of the effects ofwashing hands with soap on diarrhoea risk and estimatedpotential reductions in diarrhoea mortality.MethodsSearch strategy We aimed to identify all studies published in English up to theend of 2002 relating handwashing to the risk of infectiousintestinal or diarrhoeal diseases in the community. Medline,CAB Abstracts, Embase, Web of Science, and the CochraneLibrary were systematically searched using appropriatetextwords and thesaurus terms for papers relating tohandwashing, use of soap, as well as disease terms such asdiarrhoea, typhoid, enteric, cholera, shigellosis, dysentery, andmortality. Searches were also undertaken by hand withreference lists from these papers, the authors’ own collections,and review articles. No limitations were placed on date orgeographical location. In addition, researchers attending ahygiene conference were asked if they had unpublished dataon handwashing, but no suitable data sets were identified.Review strategyStudies were retained for the meta-analysis if theyprovided point estimates and 95% CIs (or the means toTHE LANCET Infectious Diseases Vol 3 May 2003 http://infection.thelancet.com275Effect of washing hands with soap on diarrhoearisk in the community: a systematic reviewVal Curtis and Sandy CairncrossVC is Senior Lecturer in Hygiene Promotion and SC is Professor ofEnvironmental Health at the Department of Infectious and TropicalDiseases, London School of Hygiene and Tropical Medicine, London,UK.Correspondence: Dr Val Curtis, Department of Infectious andTropical Diseases, London School of Hygiene and Tropical Medicine,Keppel Street, London WC1E 7HT, UK. Tel +44 (0)20 7927 2628; fax +44 (0)20 7636 7843; email [email protected] 1. Handwashing, a barrier to transmission of enteric pathogens.For personal use. Only reproduce with permission from The Lancet Publishing Group.THE LANCET Infectious Diseases Vol 3 May 2003 http://infection.thelancet.com276ReviewHandwashing and diarrhoea riskTable 1. Characteristics and results of the 17 studies of handwashing and diarrhoea retained for the meta-analysisStudy Location, Type of study Exposure/intervention Age Methodological Outcome Relative risk Soap setting group shortcomings* (95% CI) use spe-cifiedBlack et al, US urban Intervention trial Instructions for carers to Children aged 1,5,6 Diarrhoea 1·92 (1·32–2·81) Yes19816daycare wash hands with soap 6–28 monthsbefore handling foodafter carer or child toiletKhan, Bangladesh, Intervention trial Soap and water pitchers All ages 5 Diarrhoea 1·60 (0·90–2·86) Yes19827urban provided. Handwashing Shigella 2·34 (1·26–4·33) Yeswith soap, after defecation and before eatingSircar et al, India, urban Intervention trial Soap given with advice to All ages 1,2,5,6 Diarrhoea 1·02 (0·93–1·13) Yes19878slum wash hands after defecation and before handling foodHan and Hlaing Myanmar, Intervention trial Mothers and children asked Children aged 5 Diarrhoea 1·43 (1·08–1·85) Yes19899poor urban to wash hands with soap 5–59 months Dysentery 1·08 (0·45–2·56) Yesafter defecation and before preparing main


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