Environmental Health Webliography

Annotated bibliographies on environmental health topics

Handwashing: an annotated bibliography, January-April 2011

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This annotated bibliography has citations and abstracts to 8 peer-review handwashing studies published from January to April 2011. This bibliography will be updated on a periodic basis. Please contact WASHplus if you know of other handwashing studies to include.

1. Am J Trop Med Hyg. 2011 Apr;84(4):510-6.

Variability in hand contamination based on serial measurements: implications for assessment of hand-cleansing behavior and disease risk.

Ram PK, Jahid I, Halder AK, Nygren B, Islam MS, Granger SP, Molyneaux JW, Luby SP.

Measuring hand contamination at critical times, such as eating, can be  challenging. We examined whether hand contamination measured at random, such as on arrival (initial), predicts contamination at critical times. Mothers of young  children in Bangladesh rinsed both hands in 200 mL of ringer’s solution. We compared results of serial samples with respect to fecal coliform counts. Among 39 mothers, the geometric mean of fecal coliforms was 307 colony-forming units (cfu)/100 mL at initial collection and 3,001 cfu/100 mL during critical times (P  = 0.0006).

There was no correlation between initial and critical time fecal coliform counts (R = 0.13, P = 0.43). The mean difference between initial and critical time counts was 3.5 (standard deviation = 1.4) on the log base-10 scale. Contamination of the same subjects’ hands varied substantially within a few hours. Because hand contamination measured at random cannot reliably predict hand contamination at times of potential pathogen transmission, single random hand rinses are not valid proxy measures for handwashing behavior.

2. Lancet Infect Dis. 2011 Apr;11(4):312-21.

Hygiene: new hopes, new horizons.

Curtis V, Schmidt W, Luby S, Florez R, Touré O, Biran A. The Hygiene Centre, London School of Hygiene and Tropical Medicine, London, UK.

Although promotion of safe hygiene is the single most cost-effective means of preventing infectious disease, investment in hygiene is low both in the health and in the water and sanitation sectors. Evidence shows the benefit of improved hygiene, especially for improved handwashing and safe stool disposal. A growing understanding of what drives hygiene behaviour and creative partnerships are providing fresh approaches to change behaviour.

However, some important gaps in our knowledge exist. For example, almost no trials of the effectiveness of interventions to improve food hygiene in developing countries are available. We also need to figure out how best to make safe hygiene practices matters of daily  routine that are sustained by social norms on a mass scale. Full and active involvement of the health sector in getting safe hygiene to all homes, schools, and institutions will bring major gains to public health.

3. Trop Med Int Health. 2011 Apr;16(4):466-77.

Systematic review: handwashing behaviour in low- to middle-income countries: outcome measures and behaviour maintenance.

Vindigni SM, Riley PL, Jhung M.

Objectives – To describe global approaches to handwashing research in low- and middle-income communities, schools and health care settings using behavioural outcome measurement and temporal study design.

Methods – Peer-reviewed and grey literature was screened for handwashing studies that evaluated behaviour change. Relevant articles were assessed by their research approach, including the investigator’s selected outcome measure and time frame of various study components (e.g., formative research, intervention and evaluation).

Results –  The initial search yielded 527 relevant articles. After application of exclusion criteria, we identified 27 unique studies (30 total articles). Of the 27 articles, most were focused in the community setting. Fifteen (56%) documented observed handwashing behaviour, while 18 (67%) used proxy measures (e.g., soap presence, diarrhoea) and 14 (52%) used self-reported behaviour. Several studies used multiple outcome measures. While all studies had an evaluation of behaviour change, there was a dearth of studies that evaluated long-term maintenance of behaviour change after the intervention’s conclusion.

Conclusions – While the literature is replete with a variety of handwashing studies in community, school and health care settings, none have been able to definitively document long-term behaviour change, thereby challenging the sustainability of various interventions. Additionally, there is a need to better understand which research approach is most effective in promoting long-term behaviour compliance in global low- and middle-income settings.

4. Emerg Infec Dis Volume 17, Number 4–April 2011

Effects of Hand Hygiene Campaigns on Incidence of Laboratory-confirmed Influenza and Absenteeism in Schoolchildren, Cairo, Egypt

Link to full-text

Maha Talaat, et al

To evaluate the effectiveness of an intensive hand hygiene campaign on reducing absenteeism caused by influenza-like illness (ILI), diarrhea, conjunctivitis, and laboratory-confirmed influenza, we conducted a randomized control trial in 60 elementary schools in Cairo, Egypt. Children in the intervention schools were required to wash hands twice each day, and health messages were provided through entertainment activities. Data were collected on student absenteeism and reasons for illness. School nurses collected nasal swabs from students with ILI, which were tested by using a qualitative diagnostic test for influenza A and B.

Compared with results for the control group, in the intervention group, overall absences caused by ILI, diarrhea, conjunctivitis, and laboratory-confirmed influenza were reduced by 40%, 30%, 67%, and 50%, respectively (p<0.0001 for each illness). An intensive hand hygiene campaign was effective in reducing absenteeism caused by these illnesses.

5. J Water Health. 2011 Mar;9(1):80-93.

Knowledge, attitudes, practices and implications of safe water management and good hygiene in rural Bangladesh: assessing the impact and scope of the BRAC WASH programme.

Fisher S, Kabir B, Lahiff E, Maclachlan M. Centre for Global Health, 3-4 Foster Place, Trinity College, Dublin 2, Ireland.


A substantial component of BRAC’s WASH programme involves educating rural Bangladeshis about safe water management, good hygiene and the causes of diarrhoea. By conducting questionnaires and focus group discussions in two BRAC WASH villages and one control village, this investigation sought to assess the impact of BRAC’s programme on knowledge, practices and diarrhoeal burden, to explore the extent to which knowledge determines practices, and to evaluate which factors were most predictive of diarrhoeal incidence. It was found that the programme had a beneficial effect on the subjects’ knowledge and practices, and on the diarrhoeal incidence among their children. Furthermore, except for where personal financial expenditure was required, practices tended to follow on from knowledge. However, BRAC’s intervention affected neither the frequency of soap use in handwashing by the mother, nor the child’s consumption of unclean water outside of the home. These factors, along with the child’s consumption of unclean water inside the home, were shown to be those most predictive of diarrhoeal incidence among the under-fives. It is recommended that BRAC continues to emphasize the importance of these points, while also potentially promoting the use of less costly alternatives to soap and cheaper point-of-use treatment materials, to induce positive behaviour change.

6. Am J Trop Med Hyg. 2011 Feb;84(2):184-91.

The effects of informational interventions on household water management, hygiene behaviors, stored drinking water quality, and hand contamination in peri-urban Tanzania.

Davis J, Pickering AJ, Rogers K, Mamuya S, Boehm AB. Department of Civil and Environmental Engineering, Stanford University, Stanford, CA 94305, USA.


Safe water storage and hand hygiene have been shown to reduce fecal contamination and improve health in experimental settings; however, triggering and sustaining such behaviors is challenging. This study investigates the extent to which personalized information about Escherichia coli contamination of stored water and hands influenced knowledge, reported behaviors, and subsequent contamination levels among 334 households with less than 5-year-old children in peri-urban Dar es Salaam, Tanzania. One-quarter of the study participants received information about strategies to reduce risk of water- and sanitation-related illness.Respondents in another three study cohorts received this same information, along with their household’s water and/or hand-rinse test results. Findings from this study suggest that additional work is needed to elucidate the conditions under which such testing represents a cost-effective strategy to motivate improved household water management and hand hygiene.

7. Trop Med Int Health. 2011 Feb;16(2):233-9.

Bacterial hand contamination among Tanzanian mothers varies temporally and following household activities.

Pickering AJ, Julian TR, Mamuya S, Boehm AB, Davis J. Emmett Interdisciplinary Program in Environment and Resources, Stanford, CA, USA

Objective –  To characterize mechanisms of hand contamination with faecal indicator bacteria and to assess the presence of selected pathogens on mothers’ hands in Tanzania.

Methods –  A household observational study combined with repeated microbiological hand rinse sampling was conducted among 119 mothers in Dar es Salaam, Tanzania. All hand rinse samples were analysed for enterococci and Escherichia coli, and selected samples were analysed for genetic markers of Bacteroidales, enterovirus and pathogenic E. coli.

Results –  Using the toilet, cleaning up a child’s faeces, sweeping, cleaning dishes, preparing food and bathing were all found to increase faecal indicator bacterial levels on hands. Geometric mean increases in colony forming units per two hands ranged from 50 (cleaning dishes) to 6310 (food preparation). Multivariate modelling of hand faecal indicator bacteria as a function of activities recently performed shows that food handling, exiting the household premises and longer time since last handwashing with soap are positively associated with bacterial levels on hands, while bathing is negatively associated.  Genetic markers of Bacteroidales, enterovirus and pathogenic E. coli were each detected on a subset of mothers’ hands.

Conclusions – Escherichia coli and enterococci on hands can be significantly increased by various household activities, including those involving the use of soap and water. Thus, faecal indicator bacteria should be considered highly variable when used as indicators of handwashing behaviour. This work corroborates hands as important vectors of disease among Tanzanian mothers and highlights the difficulty of good personal hygiene in an environment characterized by the lack of networked sanitation and water supply services.

8. Int J Environ Res Public Health. 2011 Jan;8(1):97-104.

The effect of handwashing with water or soap on bacterial contamination of hands.

Burton M, Cobb E, Donachie P, Judah G, Curtis V, Schmidt WP. Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.


Handwashing is thought to be effective for the prevention of transmission of diarrhoea pathogens. However it is not conclusive that handwashing with soap is more effective at reducing contamination with bacteria associated with diarrhoea than using water only. In this study 20 volunteers contaminated their hands deliberately by touching door handles and railings in public spaces. They were then allocated at random to (1) handwashing with water, (2) handwashing with non-antibacterial soap and (3) no handwashing. Each volunteer underwent this procedure 24 times, yielding 480 samples overall. Bacteria of potential faecal origin (mostly Enterococcus and Enterobacter spp.) were found after no handwashing in 44% of samples.

Handwashing with water alone reduced the presence of bacteria to 23% (p < 0.001). Handwashing with plain soap and water reduced the presence of bacteria to 8% (comparison of both handwashing arms: p < 0.001). The effect did not appear to depend on the bacteria species. Handwashing with non-antibacterial soap and water is more effective for the removal of bacteria of potential faecal origin from hands than handwashing with water alone and should therefore be more useful for the prevention of transmission of diarrhoeal diseases.


Written by WASHplus

April 7, 2011 at 5:38 pm

Posted in Handwashing

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