Cited by 310Child Nutrition and Water AccessFood Safety and HygieneViral gastroenteritis research and epidemiology

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Effect of Intensive Handwashing Promotion on Childhood Diarrhea in High-Risk Communities in Pakistan: A Randomized Controlled Trial

Luby, Stephen P., Agboatwalla, Mubina, Painter, John, Altaf, Arshad, Billhimer, Ward L., Hoekstra, Robert M.·2004·JAMA

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Abstract

CONTEXT: Washing hands with soap prevents diarrhea, but children at the highest risk of death from diarrhea are younger than 1 year, too young to wash their own hands. Previous studies lacked sufficient power to assess the impact of household handwashing on diarrhea in infants. OBJECTIVE: To evaluate the effect of promoting household handwashing with soap among children at the highest risk of death from diarrhea. DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized controlled trial of 36 low-income neighborhoods in urban squatter settlements in Karachi, Pakistan. Field workers visited participating households at least weekly from April 15, 2002, to April 5, 2003. Eligible households located in the study area had at least 2 children younger than 15 years, at least 1 of whom was younger than 5 years. INTERVENTIONS: Weekly visits in 25 neighborhoods to promote handwashing with soap after defecation and before preparing food, eating, and feeding a child. Within intervention neighborhoods, 300 households (1523 children) received a regular supply of antibacterial soap and 300 households (1640 children) received plain soap. Eleven neighborhoods (306 households and 1528 children) comprised the control group. MAIN OUTCOME MEASURE: Incidence density of diarrhea among children, defined as the number of diarrheal episodes per 100 person-weeks of observation. RESULTS: Children younger than 15 years living in households that received handwashing promotion and plain soap had a 53% lower incidence of diarrhea (95% confidence interval [CI], -65% to -41%) compared with children living in control neighborhoods. Infants living in households that received handwashing promotion and plain soap had 39% fewer days with diarrhea (95% CI, -61% to -16%) vs infants living in control neighborhoods. Severely malnourished children (weight for age z score, <-3.0) younger than 5 years living in households that received handwashing promotion and plain soap had 42% fewer days with diarrhea (95% CI, -69% to -16%) vs severely malnourished children in the control group. Similar reductions in diarrhea were observed among children living in households receiving antibacterial soap. CONCLUSION: In a setting in which diarrhea is a leading cause of child death, improvement in handwashing in the household reduced the incidence of diarrhea among children at high risk of death from diarrhea.

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Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N., Perencevich, E. N., Polgreen, P. M., Schweizer, M. L., Trexler, P. A., et al. (2014) · Infection Control and Hospital Epidemiology · doi:10.1086/651677 · Cited by 81
Can a handwashing intervention make a difference? Results from a randomized controlled trial in Jerusalem preschools
Rosen, L., Manor, O., Engelhard, D., Brody, D. L., Rosen, B., Peleg, H., Meir, M., & Zucker, D. M. (2005) · Preventive Medicine · doi:10.1016/j.ypmed.2005.09.012 · Cited by 80
Health shocks and their long-lasting impact on health behaviors: Evidence from the 2009 H1N1 pandemic in Mexico
Agüero, J. M., & Beleche, T. (2017) · Journal of Health Economics · doi:10.1016/j.jhealeco.2017.03.008 · Cited by 80
“Moreover, intensive small-scale interventions show significant reductions in diarrhea (e.g., Ejemot-Nwadiaro et al., 2008; Luby et al., 2004; Luby et al., 2005),3 but scaling up similar inter- 2 For example, Koplik (1902) summarizes the research of the previous decade and recommends the…”
Are hygiene and public health interventions likely to improve outcomes for Australian Aboriginal children living in remote communities? A systematic review of the literature
McDonald, E., Bailie, R. S., Brewster, D., & Morris, P. S. (2008) · BMC Public Health · doi:10.1186/1471-2458-8-153 · Cited by 79
“Eleven studies were considered not eligible for inclusion and the reasons for this include: three were cross sectional studies [56-58]; one an ethnographic study [ 59 ]; two studies did not include the use of a control group [60,61]; two papers were reviews [62,63]; one paper only provided information on study design…”
Result
Impact of Water, Sanitation and Hygiene Interventions on Growth, Non-diarrheal Morbidity and Mortality in Children Residing in Low- and Middle-income Countries: A Systematic Review
Gera, T., Shah, D., & Sachdev, H. S. (2018) · Indian Pediatrics · doi:10.1007/s13312-018-1279-3 · Cited by 77
“Of these 107 references were excluded and 62 publications (41 studies) were included in the final analyses [10-71].”
Background
The World Health Organization ‘5 Moments of Hand Hygiene’
Chou, D. T. S., Achan, P., & Ramachandran, M. (2012) · Journal of Bone and Joint Surgery - British Volume · doi:10.1302/0301-620x.94b4.27772 · Cited by 76
Hard to handle: understanding mothers' handwashing behaviour in Ghana
Scott, B. E., Lawson, D. W., & Curtis, V. (2007) · Health Policy and Planning · doi:10.1093/heapol/czm014 · Cited by 71
“can reduce rates of diarrhoea among the under fives by 42–47% (Curtis and Cairncross 2003; Luby et al. 2004) and rates of respiratory infections by 16% (Rabie and Curtis 2006).”
BackgroundInfluential
Associação entre condições socioeconômicas, sanitárias e de atenção básica e a morbidade hospitalar por doenças de veiculação hídrica no Brasil
Paiva, R. F. D. P. D. S., & de Souza, M. F. D. P. (2018) · Cadernos de Saúde Pública · doi:10.1590/0102-311x00017316 · Cited by 71
A Nationwide Survey on the Hand Washing Behavior and Awareness
Jeong, J. S., Choi, J. K., Jeong, I. S., Paek, K. R., In, H.-K., & Park, K. D. (2007) · Journal of Preventive Medicine and Public Health · doi:10.3961/jpmph.2007.40.3.197 · Cited by 69
“Ë ¥& Ì@jkÍÎj°±` SARS, +Ï ÐÑp, P4, ÒÓÔ, C, ÁiK ÕD Ö8H×;?IDØo¢1⁄44g> ÙS'eÚÛ¢Æ [5], &Ì;^_ Ã< ;Ü1⁄44ÝÞfg¥ßà <áÞ, CÂ 40-50% >ÂP âhã£°a°Ê£ [6-9].”
Ethics in Public Health Research
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Herd Protection from Drinking Water, Sanitation, and Hygiene Interventions
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Rough Guide to Impact Evaluation of Environmental and Development ProgramsPreprint
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Microbiological Evaluation of the Efficacy of Soapy Water to Clean Hands: A Randomized, Non-Inferiority Field Trial
Amin, N., Pickering, A. J., Ram, P. K., UNICOMB, L. E., Najnin, N., Homaira, N., Ashraf, S., Abedin, J., Islam, M. S., & Luby, S. P. (2014) · American Journal of Tropical Medicine and Hygiene · doi:10.4269/ajtmh.13-0475 · Cited by 66
“5) 9 (2) Both hands 121 (94) 114 (89) 65 (97) 300 (71) Handwashing agent used within the last 1 hour (multiple responses allowed) After defecation Any soap and water (soap, soapy water, or detergent) 27 (96) 19 (83) 13 (100) 59 (92) Water only 1 (4) 3 (13) 0 4 (6) Other 0 1 (4) 0 1 (2) After toileting Any soap and wat…”
Preventing dengue through mobile phones: Evidence from a field experiment in Peru
Dammert, A. C., Galdo, J. C., & Galdo, V. (2014) · Journal of Health Economics · doi:10.1016/j.jhealeco.2014.02.002 · Cited by 64
Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene
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Handwashing among schoolchildren in an ethnically diverse population in northern rural Vietnam
Xuan, L. T. T., & Hoat, L. N. (2013) · Global Health Action · doi:10.3402/gha.v6i0.18869 · Cited by 62
Impact on childhood mortality of interventions to improve drinking water, sanitation, and hygiene (WASH) to households: Systematic review and meta-analysis
Waddington, H. S., Masset, E., Bick, S., & Cairncross, S. (2023) · PLoS Medicine · doi:10.1371/journal.pmed.1004215 · Cited by 78
New treatments compared to established treatments in randomized trials
Djulbegović, B., Kumar, A., Glasziou, P., Perera, R., Reljic, T., Stanton, L., Raftery, J. P., Johansen, M., Tanna, G. L. D., Miladinović, B., et al. (2012) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.mr000024.pub3 · Cited by 60
Communicating risk and promoting disease mitigation measures in epidemics and emerging disease settings
Schiavo, R., Leung, M. M., & Brown, M. (2014) · Pathogens and Global Health · doi:10.1179/2047773214y.0000000127 · Cited by 59
Cryptosporidium spp., Giardia duodenalis, Enterocytozoon bieneusi and Other Intestinal Parasites in Young Children in Lobata Province, Democratic Republic of São Tomé and Principe
Lobo, M., Augusto, J. B., Antunes, F., Ceita, J., Xiao, L., Codices, V., & Matos, O. (2014) · PLoS ONE · doi:10.1371/journal.pone.0097708 · Cited by 58
Evidence-Based Global Health
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A glossary of culture in epidemiology
Hruschka, D. J., & Hadley, C. (2008) · Journal of Epidemiology & Community Health · doi:10.1136/jech.2008.076729 · Cited by 56
Examining the relationship between socio-economic status, WASH practices and wasting
Raihan, M. J., Farzana, F. D., Sultana, S., Haque, M. A., Rahman, A. S., Waid, J. L., McCormick, B., Choudhury, N., & Ahmed, T. (2017) · PLoS ONE · doi:10.1371/journal.pone.0172134 · Cited by 55
Urban infrastructure in Latin America and the Caribbean: public policy priorities
Jaitman, L. (2015) · Latin American Economic Review · doi:10.1007/s40503-015-0027-5 · Cited by 58
Effect of hygiene promotion on the risk of reinfection rate of intestinal parasites in children in rural Uzbekistan
Gungoren, B., Latipov, R., Régallet, G., & Musabaev, E. I. (2007) · Transactions of the Royal Society of Tropical Medicine and Hygiene · doi:10.1016/j.trstmh.2007.02.011 · Cited by 51
“There is a lack of evidence showing how improved hygiene can help to reverse such grim figures and contribute to the well-being of children because it is more difficult to measure the effectiveness of hygiene promotion programs than water and sanitation interventions (Almedom et al., 1997; Carneiro et al., 2002; Curti…”
Background
Benefits trickling away: the health impact of extending access to piped water and sanitation in urban Yemen
Klasen, S., Lechtenfeld, T., Meier, K., & Rieckmann, J. (2012) · Journal of Development Effectiveness · doi:10.1080/19439342.2012.720995 · Cited by 51
“More explicitly, in a randomised control trial from urban Pakistan Luby et al. (2004) find that hand washing substantially reduces diarrhoea among children.”
Background
Effect of intensive handwashing in the prevention of diarrhoeal illness among patients with AIDS: a randomized controlled study
Huang, D. B., & Zhou, J. (2007) · Journal of Medical Microbiology · doi:10.1099/jmm.0.46867-0 · Cited by 51
“Many intensive handwashing promotion studies have been conducted among children, persons in the developing world and health care workers (Haggerty et al., 1994; Luby et al., 2004; Shahid et al., 1996).”
Background
COVID-19: Critical discussion on the applications and implications of chemicals in sanitizers and disinfectants.
Atolanı, O., Baker, M. T., Adeyemı, O. S., Ismaeel, R. O., Hamid, A. A., Ameen, M., Oguntoye, S. O., & USMAN, L. A. (2020) · EXCLI journal · doi:10.17179/excli2020-1386 · Cited by 50
“…alcohols such as either ethanol, isopropyl alcohol, propan-1-ol or propan-2-ol; and additives such as colorants, stabilizers, fragrance and sometimes preservatives which may include formaldehyde, parabens among other chemicals (Luby et al., 2004, 2005; Kramer et al., 2007; Napolitani et al., 2020).”
Clean hands reduce the burden of disease
Pittet, D. (2005) · The Lancet · doi:10.1016/s0140-6736(05)66886-9 · Cited by 51
Impact of intensive handwashing promotion on secondary household influenza-like illness in rural Bangladesh: findings from a randomized controlled trial
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“In a year-long trial of handwashing promotion in Karachi, Pakistan, diarrhea rates were 50% lower in the intervention group over the course of a year of surveillance but did not differ at all during the first two months following the introduction of the intervention, suggesting that the behavior had not changed early…”
BackgroundSelf-citation
Bacterial and fungal isolation from face masks under the COVID-19 pandemic
Park, A.-M., Khadka, S., Sato, F., Omura, S., Fujita, M., Hashiwaki, K., & Tsunoda, I. (2022) · Scientific Reports · doi:10.1038/s41598-022-15409-x · Cited by 49
Recommendations for hand hygiene in community settings: a scoping review of current international guidelines
MacLeod, C., Braun, L., Caruso, B. A., Chase, C., Chidziwisano, K., Chipungu, J., Dreibelbis, R., Ejemot-Nwadiaro, R. I., Gordon, B. A., Mills, J. E., et al. (2023) · BMJ Open · doi:10.1136/bmjopen-2022-068887 · Cited by 57
Hygiene Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Skin and Soft Tissue Infections: A Cluster-Randomized Controlled Trial Among High-Risk Military Trainees
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Acute Gastroenteritis in Children
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Water and hygiene interventions to reduce diarrhoea in rural Afghanistan: a randomized controlled study
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“…shown to be effective in reducing diarrhoea in studies elsewhere (Esrey et al. 1991; Mintz et al. 1995; Quick et al. 1999; 2006; Curtis & Cairncross 2003; Luby et al. 2004; Fewtrell et al. 2005; Clasen et al. 2006), but there is little evidence regarding their level of effectiveness in Afghanistan.”
Background
Narrative Review of Primary Preventive Interventions against Water-Borne Diseases: Scientific Evidence of Health-EDRM in Contexts with Inadequate Safe Drinking Water
Chan, E. Y. Y., Tong, K. H. Y., Dubois, C., Mcdonnell, K., Kim, J. H., Hung, K. K. C., & Kwok, K. O. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph182312268 · Cited by 58
“The use of the more economical regular soap is now favored in most handwashing campaigns as similar reduction in diarrheal incidence has been observed with the use of regular soap and antibacterial soap [68,72].”
BackgroundResult
Current knowledge, attitude and behaviour of hand and food hygiene in a developed residential community of Singapore: a cross-sectional survey
Pang, J., Chua, J., & Hsu, L. Y. (2015) · BMC Public Health · doi:10.1186/s12889-015-1910-3 · Cited by 43
“In addition, an annual hand and food hygiene campaign, which had been shown to be effective in reducing diarrhoea disease even in mostly rural areas [13, 14, 42].”
Background
Integrating human rights approaches into public health practices and policies to address health needs amongst Rohingya refugees in Bangladesh: a systematic review and meta-ethnographic analysis
Wali, N., Chen, W. L., Rawal, L. B., Amanullah, A. S. M., & Renzaho, A. M. N. (2018) · Archives of Public Health · doi:10.1186/s13690-018-0305-1 · Cited by 43
Effect of Infections and Environmental Factors on Growth and Nutritional Status in Developing Countries
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Field trial of a low cost method to evaluate hand cleanliness
Luby, S. P., Agboatwalla, M., Billhimer, W. L., & Hoekstra, R. M. (2007) · Tropical Medicine & International Health · doi:10.1111/j.1365-3156.2007.01847.x · Cited by 41
“…trial households randomized to soap and handwashing promotion received three times as much soap as control households reported purchasing (Luby et al. 2004), yet we measured no difference in the proportion of mothers’ hands that were contaminated in households that received soap compared…”
BackgroundResultInfluential

Authors: Luby, S. P., Agboatwalla, M., Painter, J., Altaf, A., Billhimer, W. L., & Hoekstra, R. M.
Affiliations: Centers for Disease Control and Prevention (US)
ORCID: Luby, Stephen P.
Altaf, Arshad
Hoekstra, Robert M.
Venue: JAMA
Publisher: American Medical Association (AMA)
Published: 2004-06-02
Volume: 291
Issue: 21
Pages: 2547
ISSN: 0002-9955 (ISSN-L)
0098-7484
DOI: 10.1001/jama.291.21.2547
OpenAlex: W2165965969
Cited by: 309
References: 23
Citations by year: 2026: 5 · 2025: 8 · 2024: 13 · 2023: 10 · 2022: 13 · 2021: 16 · 2020: 6 · 2019: 12 · 2018: 9 · 2017: 13 · 2016: 16 · 2015: 21 · 2014: 28 · 2013: 11 · 2012: 17
FWCI: 13.77
Type: journal article
Language: en
Open access: closed
Locations: JAMA (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
Life Sciences › Agricultural and Biological Sciences › Food Science › Food Safety and Hygiene
Health Sciences › Medicine › Infectious Diseases › Viral gastroenteritis research and epidemiology
Keywords: handwashing with soap, childhood diarrhea, infants, severe malnutrition, antibacterial soap, urban slums, low-income communities, diarrhea prevention, child mortality
MeSH terms: Adolescent, Adult, Child, Child, Preschool, Diarrhea, Infantile, Family, Female, Hand Disinfection, Humans, Hygiene, Infant, Male, Pakistan, Poverty, Risk Factors, Soaps

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Effect of Intensive Handwashing Promotion on Childhood Diarrhea in High-Risk Communities in Pakistan: A Randomized Controlled Trial

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