Abstract
.We assessed the impact of handwashing promotion on reported respiratory illness as a secondary outcome from among > 60,000 low-income households enrolled in a cluster-randomized trial conducted in Bangladesh. Ninety geographic clusters were randomly allocated into three groups: cholera-vaccine-only; vaccine-plus-behavior-change (handwashing promotion and drinking water chlorination); and control. Data on respiratory illness (fever plus either cough or nasal congestion or breathing difficulty within previous 2 days) and intervention uptake (presence of soap and water at handwashing station) were collected through monthly surveys conducted among a different subset of randomly selected households during the intervention period. We determined respiratory illness prevalence across groups and used log-binomial regression to examine the association between respiratory illness and presence of soap and water in the handwashing station. Results were adjusted for age, gender, wealth, and cluster-randomized design. The vaccine-plus-behavior-change group had more handwashing stations with soap and water present than controls (45% versus 25%; P < 0.001). Reported respiratory illness prevalence was similar across groups (vaccine-plus-behavior-change versus control: 2.8% versus 2.9%; 95% confidence interval [CI]: −0.008, 0.006; P = 0.6; cholera-vaccine-only versus control: 3.0% versus 2.9%; 95% CI: −0.006, 0.009; P = 0.4). Irrespective of intervention assignment, respiratory illness was lower among people who had soap and water present in the handwashing station than among those who did not (risk ratioadjusted: 0.82; 95% CI: 0.69–0.98). With modest uptake of the handwashing intervention, we found no impact of this large-scale intervention on respiratory illness. However, those who actually had a handwashing station with soap and water had less illness. This suggests improving the effectiveness of handwashing promotion in achieving sustained behavior change could result in health benefits.
Highlights
The focus of many hand hygiene interventions has been to reduce diarrhea, but data from a systematic review and a meta-analysis show that hygiene behavior change, including handwashing with soap has been effective in reducing respiratory illness.[5,6]
We examined whether the presence of soap and water at primary handwashing stations was associated with a reduction in respiratory illness, irrespective of intervention assignment of participants
The overall prevalence of respiratory illness across the follow-up period was calculated for each group, and we used binomial regression with a logarithmic link to calculate risk ratios (RR) directly and confidence intervals (CI) comparing groups, with robust standard errors to account for clustering.[29]
Summary
Acute respiratory infections continue to be a major cause of mortality in low-income countries.[1,2] Many respiratory infections are transmitted via infected droplets, but some viruses including the respiratory syncytial virus infecting the respiratory tract can be spread from one person to another by hand contact.[3,4] The focus of many hand hygiene interventions has been to reduce diarrhea, but data from a systematic review and a meta-analysis show that hygiene behavior change, including handwashing with soap has been effective in reducing respiratory illness.[5,6] The commonly used indicator to assess health impact of handwashing interventions in most of these studies is self-reported or caregiver-reported respiratory illness and, study findings may be subjected to reporting bias. Few studies have objectively measured the impact of handwashing on respiratory illness.[7,8] For example, Cowling et al objectively measured transmission of respiratory infection by using reverse-transcription polymerase chain reaction of nasal and throat swabs and reported that hand hygiene interventions prevented household transmission of influenza virus.[8] Despite benefits for both diarrhea and respiratory infection prevention, hand hygiene practices (washing hands with soap) are suboptimal. A systematic review of 42 studies estimated that 19% of the world population washes hands with
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