The DOI matches its Crossref record; 54 of the 59 references it cites were found in a registry or an index; 4 of the 35 sources its claims cite were checked for support.
Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middle-income countries: a systematic review and meta-analysis
Open accessAbstract
Background Acute respiratory infection (ARI) is a leading cause of morbidity and mortality globally, with 83% of ARI mortality occurring in low-income and middle-income countries (LMICs) before the COVID-19 pandemic. We aimed to estimate the effect of interventions promoting handwashing with soap on ARI in LMICs. Methods In our systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, Global Health, and Global Index Medicus for studies of handwashing with soap interventions in LMICs from inception to May 25, 2021. We included randomised and non-randomised controlled studies of interventions conducted in domestic, school, or childcare settings. Interventions promoting hand hygiene methods other than handwashing with soap were excluded, as were interventions in health-care facilities or the workplace. The primary outcome was ARI morbidity arising from any pathogen for participants of any age. Secondary outcomes were lower respiratory infection, upper respiratory infection, influenza confirmed by diagnostic test, COVID-19 confirmed by diagnostic test, and all-cause mortality. We extracted relative risks (RRs), using random-effects meta-analysis to analyse study results, and metaregression to evaluate heterogeneity. We assessed risk of bias in individual studies using an adapted Newcastle-Ottawa scale, and assessed the overall body of evidence using a Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The study is registered with PROSPERO, CRD42021231414. Findings 26 studies with 161 659 participants met inclusion criteria, providing 27 comparisons (21 randomised). Interventions promoting handwashing with soap reduced any ARI compared with no handwashing intervention (RR 0·83 [95% CI 0·76–0·90], I 2 88%; 27 comparisons). Interventions also reduced lower respiratory infections (0·78 [0·64–0·94], I 2 64%; 12 comparisons) and upper respiratory infections (0·74 [0·59–0·93], I 2 91%; seven comparisons), but not test-confirmed influenza (0·94 [0·42–2·11], I 2 90%; three comparisons), test-confirmed COVID-19 (no comparisons), or all-cause mortality (prevalence ratio 0·95 [95% CI 0·71–1·27]; one comparison). For ARI, no heterogeneity covariates were significant at p<0·1 and the GRADE rating was moderate certainty evidence. Interpretation Interventions promoting handwashing with soap can reduce ARI in LMICs, and could help to prevent the large burden of respiratory disease. Funding Bill & Melinda Gates Foundation, Reckitt Global Hygiene Institute, and UK FCDO.
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TL;DR
In LMICs, interventions promoting handwashing with soap reduced any acute respiratory infection by about 17% (RR 0.83, 95% CI 0.76–0.90) in a meta-analysis of 27 comparisons. Effects were also seen for lower and upper respiratory infections, but not for test-confirmed influenza, and no COVID-19 comparisons were identified.
Key findings
- 26 studies with 161,659 participants provided 27 comparisons (21 randomised). Interventions promoting handwashing with soap reduced any ARI versus no handwashing intervention: RR 0.83 (95% CI 0.76–0.90), I² 88%; GRADE moderate certainty.
- Lower respiratory infections were reduced: RR 0.78 (95% CI 0.64–0.94), I² 64%; upper respiratory infections were reduced: RR 0.74 (95% CI 0.59–0.93), I² 91%.
- No significant effect was found for test-confirmed influenza: RR 0.94 (95% CI 0.42–2.11), I² 90%; there were no test-confirmed COVID-19 comparisons; all-cause mortality had one comparison: prevalence ratio 0.95 (95% CI 0.71–1.27).
- Sensitivity analyses: randomised studies only RR 0.84 (0.76–0.93); domestic settings only RR 0.89 (0.81–0.97); majority handwashing messages RR 0.81 (0.73–0.90); studies adjusting for clustering RR 0.89 (0.82–0.96). No metaregression covariate was significant at p<0.10.
Methods
- Systematic review and meta-analysis reported per PRISMA 2020 and registered with PROSPERO (CRD42021231414). Searched MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, Global Health, and Global Index Medicus from inception to May 25, 2021, for English or French studies in LMICs; included randomised and non-randomised controlled studies in domestic, school, or childcare settings; excluded non-soap hand hygiene and health-care or workplace interventions.
- Primary outcome was any ARI morbidity; secondary outcomes were lower respiratory infection, upper respiratory infection, test-confirmed influenza, test-confirmed COVID-19, and all-cause mortality. Used random-effects meta-analysis, metaregression, adapted Newcastle-Ottawa risk-of-bias assessment, and GRADE.
- Included 26 studies, 161,659 participants, and 27 comparisons (21 randomised); 13 studies in Asia, nine in Africa, and three in Latin America; 18 interventions in domestic settings and nine in primary school or childcare settings; soap was provided in 16 interventions.
Limitations
- Paper-stated: masking participants in handwashing interventions is impossible; primary outcome symptoms were typically caregiver- or self-reported; outcome measurement staff were not masked in almost all studies, so reporting bias could overstate effects, though exposure misclassification or low compliance might offset this.
- Paper-stated: grey literature was not systematically searched; between-study heterogeneity was high and only partly explained by metaregression; non-randomised studies carry increased risk of bias; only two studies reported results by sex.
- Evident from the text: some secondary outcomes rest on very few comparisons (test-confirmed influenza n=3; all-cause mortality n=1; no COVID-19 comparisons), and the primary analysis had substantial heterogeneity (I² 88%), limiting precision and certainty for those outcomes.
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Claims the paper makes
37 Own result · 25 Not checked yet · 16 Own method · 11 Own interpretation · 2 Supported · 1 Couldn’t confirm · 1 No basis given · accuracy not yet measured
The cited sources that could be checked couldn’t confirm or dispute this claim.
In the paper
“Fourth, meta-analyses have not distinguished between lower and upper respiratory infections, as applied in global burden of disease estimation.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Could not verifycites [2] Abbafati, 2020, Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019, Lancet sourceExperimental — accuracy not yet measured
The Results (Global trends; page unavailable) report lower respiratory infections as a distinct cause of disease burden, but do not compare them with upper respiratory infections. Searches for upper respiratory infections and for the claimed meta-analytic distinction found no passage in our copy addressing whether meta-analyses distinguished the two. (LLM, conf=0.73)
plain- Asserted: passes — The authors put it forward as true.
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- Could not verify
Every source the paper cites for this claim was checked and supports it.
In the paper
“Handwashing practices at key moments are less prevalent in LMICs compared with high-income countries (HICs)”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Supportedcites [10] Wolf, 2019, Handwashing with soap after potential faecal contact: global, regional and country estimates, Int J Epidemiol source
The Results (Objective 3, Table 5; page not provided) estimate that 21.7% of potential faecal contacts were followed by handwashing with soap in low- and middle-income countries, compared with 50.6% in high-income countries. This supports the claimed comparison for handwashing after potential faecal contact. (LLM, conf=0.94)
plaincorrelational- Asserted: passes — The authors put it forward as true.
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- Supported
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For ARI, no heterogeneity covariates were significant at p<0•1”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Abstract
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In the paper
“test-confirmed COVID-19 (no comparisons)”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Abstract
plain- Asserted: passes — The authors put it forward as true.
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Interventions promoting handwashing with soap reduced any ARI compared with no handwashing intervention (RR 0•83 [95% CI 0•76-0•90], I² 88%; 27 comparisons).”
- Also stated in: § Added value of this study · plain
“In random effects meta-analysis of 27 comparisons, interventions promoting handwashing with soap reduced ARI by about 17% (relative risk 0•83 [95% CI 0•76-0•90], I 2 88%) compared with no handwashing intervention.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Abstract
plaindirect- Asserted: passes — The authors put it forward as true.
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- Also stated in: § Added value of this study · plain
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In the paper
“or all-cause mortality (prevalence ratio 0•95 [95% CI 0•71-1•27]; one comparison)”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Abstract
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“Interventions also reduced lower respiratory infections (0•78 [0•64-0•94], I² 64%; 12 comparisons)”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Abstract
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“Meta-regression and sensitivity analysis show that the main finding is unaltered as a result.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Added value of this study
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In the paper
“but not test-confirmed influenza (0•94 [0•42-2•11], I² 90%; three comparisons)”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Abstract
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“For the outcome of upper respiratory infection, analysis of seven comparisons revealed an RR 0•74 (0•59-0•93, 91%), with low certainty evidence.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“When we included only studies that adjusted appropriately for clustering (21 comparisons), the pooled RR was 0•89 (0•82-0•96).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
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“Only one study provided data for both 0-5 years and 5-14 years subgroup analyses, 28 so these subgroups broadly represent different contexts and interventions.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“When restricted to children aged 5-14 years (eight comparisons), the pooled RR for any ARI was 0•76 (0•64-0•90).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“The primary analysis of 27 comparisons for any ARI provided an RR in favour of handwashing interventions of 0•83 (95% CI 0•76-0•90, I² 88%; figure 2).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“When we included only studies with quality ratings above the 25th percentile (21 comparisons), the pooled RR was 0•84 (0•76-0•93).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“We identified no intervention studies with a COVID-19 outcome, in line with a meta-analysis of public health measures and COVID-19, which identified only studies assessing associations with self-reported handwashing.55”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
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“In metaregression for any ARI there was no evidence (at p<0•10) for an association with any of the previously specified covariates (appendix p 24).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“No studies meeting the inclusion criteria reported a COVID-19 outcome, and only one reported all-cause mortality (with prevalence ratio of 0•95 [95% CI 0•71-1•27]).46”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“In a meta-analysis of only randomised studies (21 comparisons), the pooled RR for any ARI was 0•84 (0•76-0•93), which did not reveal considerable deviation from the primary analysis (RR 0•83).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“When we included only studies in domestic settings (18 comparisons), the pooled RR was 0•89 (0•81-0•97).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
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In the paper
“For the outcome of lower respiratory infections, the analysis of 12 comparisons revealed an RR of 0•78 (95% CI 0•64-0•94, I² 64%; table 2), with moderate certainty evidence.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“For the outcome of influenza infection confirmed by diagnostic test, analysis of three comparisons revealed an RR of 0•94 (0•42-2•11, 90%), with very low certainty evidence.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“When we included only studies in which handwashing was the behavioural target of the majority of messages (18 comparisons), the pooled RR was 0•81 (0•73-0•90; figure 3).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plaincorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“Second, symptoms included in our primary outcome were typically caregiver-reported or selfreported.56”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [56] Wood, 2008, Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study, BMJ source
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“When meta-analysis for the primary outcome was restricted to children aged 0-5 years (15 comparisons), the pooled RR for any ARI was 0•82 (0•75-0•90).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plaincorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“Of the seven studies that used structured observations of behaviour as opposed to self-report, 57 four saw improvements at some crucial times, but not others (appendix pp 10-12).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [57] Ram
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In the paper
“First, the evidence base is out of date.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [14] Aiello, 2008, Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis, Am J Public Health source
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“could help to prevent the large burden of respiratory disease”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Abstract
hedgedconditional- Asserted: passes — The authors put it forward as true.
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In the paper
“Second, the evidence base is misaligned with the geography of the endemic disease burden.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [12] Jefferson, 2020, Physical interventions to interrupt or reduce the spread of respiratory viruses, Cochrane Database Syst Rev
- Not checked yetcites [15] Luby, 2005, Effect of handwashing on child health: a randomised controlled trial, Lancet source
- Not checked yetcites [16] McGuinness, 2018, Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review, Trop Med Int Health source
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“Such interventions are an important means of preventing ARIs in LMICs.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Implications of all the available evidence
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“promoting handwashing with soap more broadly could reduce the large endemic burden of respiratory disease.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Implications of all the available evidence
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In the paper
“the GRADE rating was moderate certainty evidence”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Abstract
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In the paper
“the latest published meta-analysis to include any ARI as an outcome was reported in 2008 by Aiello and colleagues”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [14] Aiello, 2008, Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis, Am J Public Health source
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In the paper
“the most recent study (focused on viral illness) included only five.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [12] Jefferson, 2020, Physical interventions to interrupt or reduce the spread of respiratory viruses, Cochrane Database Syst Rev
plain- Asserted: passes — The authors put it forward as true.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Interventions promoting handwashing with soap can reduce ARI in LMICs”
- Also stated in: § Implications of all the available evidence · plain
“Interventions promoting handwashing with soap can reduce ARI.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Abstract
plaindirectn = 659- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Implications of all the available evidence · plain
In the paper
“The metaanalysis by Aiello and colleagues included only one LMIC study”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [15] Luby, 2005, Effect of handwashing on child health: a randomised controlled trial, Lancet source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
None of the sources cited for this claim have been checked yet.
In the paper
“Third, reviews have been restrictive in terms of included study designs.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [16] McGuinness, 2018, Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review, Trop Med Int Health source
- Not checked yetcites [17] Wolf, 2018, Impact of drinking water, sanitation and handwashing with soap on childhood diarrhoeal disease: updated meta-analysis and meta-regression, Trop Med Int Health source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“For the outcome of upper respiratory infection, analysis of seven comparisons revealed an RR 0•74 (0•59-0•93, 91%), with low certainty evidence.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Limitations of the evidence we assessed include risks of bias inherent in the original study designs.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Since our estimate for interventions in LMICs is similar in magnitude to the global estimate of Aiello and colleagues (21%) but has greater precision, 10 and is similar to a recent estimate for viral ARI globally (16%), 12 our results are also applicable to HICs.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Only one study provided data for both 0-5 years and 5-14 years subgroup analyses, 28 so these subgroups broadly represent different contexts and interventions.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
In the paper
“To our knowledge, this study is the first meta-analysis of the effect of handwashing with soap interventions on any ARI since the 2008 study by Aiello and colleagues.14”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [14] Aiello, 2008, Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis, Am J Public Health source
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“There was limited evidence of publication bias in a funnel plot (appendix p 18), with an Egger test p value of 0•40.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“For the outcome of influenza infection confirmed by diagnostic test, analysis of three comparisons revealed an RR of 0•94 (0•42-2•11, 90%), with very low certainty evidence.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Interventions promoting handwashing with soap reduced ARI morbidity by about 17% (RR 0•83 [95% CI 0•76-0•90]).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“The GRADE rating for any ARI was moderate certainty evidence (appendix p 19).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
In the paper
“the authors did not conduct a meta-analysis”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [16] McGuinness, 2018, Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review, Trop Med Int Health source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
In the paper
“The review by McGuinness and colleagues included only randomised controlled trials”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [16] McGuinness, 2018, Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review, Trop Med Int Health source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“For the outcome of lower respiratory infections, the analysis of 12 comparisons revealed an RR of 0•78 (95% CI 0•64-0•94, I² 64%; table 2), with moderate certainty evidence.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Nonetheless, risk of bias remains if outcome measurement staff were not masked to allocation, as in almost all studies (appendix pp 13-15).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
plainconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Probably not a substantial claim. 33
- It may state two separate claims as one. 20
Every source the paper cites for this claim was checked and supports it.
In the paper
“An LMIC-focused systematic review by McGuinness and colleagues with similar inclusion criteria to ours did not conduct a meta-analysis, but identified 14 randomised studies up to 2017.16”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
What the sources say
- Supportedcites [16] McGuinness, 2018, Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review, Trop Med Int Health source
The Search strategy and selection criteria section limits the review to randomised trials in LMICs and gives a search end date of 17 October 2017. The Results section reports 14 eligible studies, all cluster RCTs. The Discussion says the authors did not pool outcomes, supporting the statement that they did not conduct a meta-analysis. The comparison with the citing review’s criteria is the citing authors’ own framing. (LLM, conf=0.94)
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
- Supported
None of the sources cited for this claim have been checked yet.
In the paper
“Since our estimate for interventions in LMICs is similar in magnitude to the global estimate of Aiello and colleagues (21%) but has greater precision, 10 and is similar to a recent estimate for viral ARI globally (16%), 12 our results are also applicable to HICs.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
What the sources say
- Could not verifycites [10] Wolf, 2019, Handwashing with soap after potential faecal contact: global, regional and country estimates, Int J Epidemiol sourceExperimental — accuracy not yet measured
The Introduction and Methods address the prevalence of handwashing with soap after potential faecal contact, not the effect of interventions on viral acute respiratory infections. Although the References list an Aiello meta-analysis, searches for the 16% viral-ARI estimate, the 21% estimate, and the claimed precision comparison found no passage reporting them. The cited paper therefore does not verify the claim attributed to it. (LLM, conf=0.78)
- Not checked yetcites [12] Jefferson, 2020, Physical interventions to interrupt or reduce the spread of respiratory viruses, Cochrane Database Syst Rev
plain- Asserted: passes — The authors put it forward as true.
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- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
- Could not verify
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“26 studies with 161 659 participants met inclusion criteria, providing 27 comparisons (21 randomised).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Abstract
plainn = 161,659- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The remaining nine interventions included multiple broader messages (eg, related to drinking water treatment or mask-wearing; table 1).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“No studies meeting the inclusion criteria reported a COVID-19 outcome, and only one reported all-cause mortality (with prevalence ratio of 0•95 [95% CI 0•71-1•27]).46”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Only two studies reported results by sex.31,32”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Of the 27 interventions included in this review, 18 were conducted in domestic settings, and the remaining nine in primary school or childcare settings.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“In our review, we identified 20 randomised studies and six non-randomised studies.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For 18 interventions, handwashing with soap was the behavioural target in the majority of intervention messages, of which 14 had it as the exclusive focus.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The 26 studies included 161 659 participants, with 13 studies in Asia, nine in Africa, and three in Latin America (table 1).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plainn = 161,659- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“We reviewed full texts of 45 studies, of which 26 met our inclusion criteria.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The 95% CIs for test-confirmed influenza overlaps 1, but our estimate was based on only three comparisons.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Soap was provided in 16 interventions.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Between-study heterogeneity was relatively high by the standards of clinical interventions, and we were able to explain it only partly via metaregression.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The RR 95% CIs for lower and upper respiratory infections overlap substantially, and are similar to that for any ARI (table 2).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For the primary outcome (any ARI), we included 27 comparisons from 26 studies-this included 21 comparisons from randomised studies and six from non-randomised studies.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Galiani et al (2015); 33 domestic and school
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“In our lower respiratory infection analysis, however, five of 12 comparisons were for more objective outcomes (watch-timed rapid respiratory rate), with a similar pooled RR to the primary outcome.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“who estimated that hand hygiene improvements reduced ARIs by 21% (95% CI 5-34)”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [14] Aiello, 2008, Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis, Am J Public Health source
hedgeddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
None of the sources cited for this claim have been checked yet.
In the paper
“Two of these studies 47,48 assessed interventions delivered to household members of a confirmed influenza case, and were probably delivered too late to prevent domestic transmission.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [47] Ram, 2015, Impact of intensive handwashing promotion on secondary household influenza-like illness in rural Bangladesh: findings from a randomized controlled trial, PLoS One source
- Not checked yetcites [48] Simmerman, 2011, Findings from a household randomized controlled trial of hand washing and face masks to reduce influenza transmission in Bangkok, Thailand, Influenza Other Respir Viruses source
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Observed heterogeneity might be partly due to the variety in promotional approaches, follow-up periods, and case definitions.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“ARI-causing pathogens can be transmitted via airborne, surface, or person-to-person contact routes.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [7] Fitzner, 2018, Revision of clinical case definitions: influenza-like illness and severe acute respiratory infection, Bull World Health Organ source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Two reviewers (IR and SB) independently screened titles, abstracts, and full texts of studies identified during searches.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Implications of all the available evidence
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Non-randomised intervention studies with appropriate controls bring an increased risk of bias, but provide a broader view of community-based public health interventions which are challenging to evaluate.52”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [52] Rychetnik, 2002, Criteria for evaluating evidence on public health interventions, J Epidemiol Community Health source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Therefore, we did not attempt to correct standard errors of incorrectly analysed studies (22% of comparisons, n=6), instead accounting for this issue in sensitivity analysis and risk of bias scoring.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > When studies reported multiple ARI symptoms and
plainn = 6- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“another systematic review conducted in 2017 by McGuinness and colleagues did focus on ARI in LMICs and included 14 studies”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [16] McGuinness, 2018, Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review, Trop Med Int Health source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“A further strength is in distinguishing between lower and upper respiratory infections, which previous handwashing meta-analyses have not done.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Data extraction and risk of bias assessment were performed independently by two reviewers (IR and SB) using a structured Excel spreadsheet.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Data analysis
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“We assessed the body of evidence as a whole for each outcome using a modified GRADE approach.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > When studies reported multiple ARI symptoms and
What the sources say
- Not checked yetcites [34] Schünemann
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“First, masking of participants in handwashing interventions is impossible.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
In the paper
“Our systematic review and meta-analysis is reported according to PRISMA 2020 guidelines.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Study design
What the sources say
- Not checked yetcites [18] Page, 2021, The PRISMA 2020 statement: an updated guideline for reporting systematic reviews, BMJ source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Alternatively, high heterogeneity might also reflect missing influential covariates in multiple studies or measurement error, factors which would also affect the magnitude of effect estimates.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“The funders had no role in study design, collection and interpretation of data, writing the report, or in the decision to submit for publication.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Role of the funding source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Differences between reviewers over title and abstract screening, full text review, and reasons for exclusion were reconciled with a third reviewer (OC).”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Implications of all the available evidence
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“This study is registered with PROSPERO, CRD42021231414.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Table 1: Included studies
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“This high heterogeneity might be expected for interventions reliant on uptake and adherence to behaviours, and for studies employing various strategies with different durations and intensities.53”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [53] Turner, 2012, Predicting the extent of heterogeneity in meta-analysis, using empirical data from the Cochrane Database of Systematic Reviews, Int J Epidemiol source
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“a recent systematic review of the effect of handwashing on diarrhoeal disease included ten non-randomised studies”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [17] Wolf, 2018, Impact of drinking water, sanitation and handwashing with soap on childhood diarrhoeal disease: updated meta-analysis and meta-regression, Trop Med Int Health source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“A strength of our study is in using transparent aggregation of different symptoms and case definitions to construct broader outcomes for meta-analysis.27”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [27] Borenstein, 2009
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
In the paper
“including reduced access to water supply on premises or to handwashing facilities with soap and water.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Introduction
What the sources say
- Not checked yetcites [11]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
None of the sources cited for this claim have been checked yet.
In the paper
“We assessed risk of bias in individual studies using an adapted Newcastle-Ottawa scale applied in previous systematic reviews of the effect of handwashing with soap on diarrhoea.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > When studies reported multiple ARI symptoms and
What the sources say
- Not checked yetcites [17] Wolf, 2018, Impact of drinking water, sanitation and handwashing with soap on childhood diarrhoeal disease: updated meta-analysis and meta-regression, Trop Med Int Health source
- Not checked yetcites [19] Wolf, 2022, Effectiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in low-income and middle-income settings: a systematic review and meta-analysis, Lancet source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
None of the sources cited for this claim have been checked yet.
In the paper
“For example, I² statistics were higher than 60% for many meta-analyses within recent Cochrane reviews of interventions such as medical masks to prevent viral illness 12 and indoor residual spraying for malaria.54”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
What the sources say
- Not checked yetcites [12] Jefferson, 2020, Physical interventions to interrupt or reduce the spread of respiratory viruses, Cochrane Database Syst Rev
- Not checked yetcites [54] Pryce, 2022, Indoor residual spraying for preventing malaria in communities using insecticide-treated nets, Cochrane Database Syst Rev
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Our review suggests that the scarcity of such campaigns might be a missed opportunity, and promoting handwashing with soap more broadly could reduce the large endemic burden of respiratory disease.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. It may state two separate claims as one.
- Rests on an assumption: Handwashing campaigns in normal times are rare.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Limitations of our review processes include that we did not systematically search grey literature, so studies not published in indexed journals might have been omitted.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Reporting bias could therefore lead to effects being overstated, but any overestimate might be offset by factors such as less-than-full participation in interventions by the target population (ie, exposure misclassification) or low compliance.”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Discussion
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
The paper relies on this without support.
Handwashing with soap can prevent many ARIs by mechanically removing pathogens from hands, and by rupturing many bacteria and viruses.
“Handwashing with soap can prevent many ARIs by mechanically removing pathogens from hands, and by rupturing many bacteria and viruses.”
The paper relies on this without support.
There is no biological reason to assume handwashing with soap interrupts transmission of upper and lower respiratory infections differently.
“There is no biological reason to assume handwashing with soap interrupts transmission of upper and lower respiratory infections differently.”
The paper relies on this without support.
Handwashing campaigns in normal times are rare.
“However, in comparison with the attention given to handwashing during these epidemics of respiratory disease, handwashing campaigns in normal times are rare.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
The source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“The exposure–response relationships (figure 1, appendix 1 p 6) linking the different WASH exposure levels (Figure 2, Figure 3, Figure 4) and diarrhoea or acute respiratory infections have been estimated in two meta-analyses.4, 7”
From Burden of disease attributable to unsafe drinking water, sanitation, and hygiene in domestic settings: a global analysis for selected adverse health outcomes (2023) · cites this paper as [7]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“and is combined with matching exposure–response relationships available through the up-to-date meta-analyses.4, 7”
From Burden of disease attributable to unsafe drinking water, sanitation, and hygiene in domestic settings: a global analysis for selected adverse health outcomes (2023) · cites this paper as [7]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“Respiratory pathogens are transmitted through the air, person-to-person contact, or via surfaces, and handwashing with soap can remove or destroy pathogens on hands, thereby reducing transmission.7”
The check wasn’t confident either way, so it gives no verdict — never disputed.
In the citing paper
“In addition, nationally representative exposure data on safely managed services is available for an increasing number of countries aggregated and published by the JMP”
From Burden of disease attributable to unsafe drinking water, sanitation, and hygiene in domestic settings: a global analysis for selected adverse health outcomes (2023) · cites this paper as [7]
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Results
“The search of five electronic databases yielded 8392 records”
§ Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middleincome countries: a systematic review and meta-analysis > Search strategy and selection criteria
“We searched MEDLINE, Embase, Web of Science, SCOPUS, the Cochrane Library, Global Health, and Global Index Medicus”
Citations
Cites
The PRISMA 2020 statement: An updated guideline for reporting systematic reviews
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., et al. (2021) · BMJ · doi:10.1136/bmj.n71 · Cited by 108,283
Rayyan-a web and mobile app for systematic reviews.
Ouzzani, M., Hammady, H., Fedorowicz, Z., & Elmagarmid, A. (2016) · Systematic Reviews · doi:10.1186/s13643-016-0384-4 · Cited by 26,092
Vos, T., Lim, S. S., Abbafati, C., Abbas, K. M., Abbasi, M., Abbasifard, M., Abbasi-Kangevari, M., Abbastabar, H., Abd-Allah, F., Abdelalim, A., et al. (2020) · The Lancet · doi:10.1016/s0140-6736(20)30925-9 · Cited by 19,358
Self-citationBorenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2009) · doi:10.1002/9780470743386 · Cited by 14,225
Murray, C. J. L., Aravkin, A. Y., Zheng, P., Abbafati, C., Abbas, K. M., Abbasi-Kangevari, M., Abd-Allah, F., Abdelalim, A., Abdollahi, M., Abdollahpour, I., et al. (2020) · The Lancet · doi:10.1016/s0140-6736(20)30752-2 · Cited by 9,854
Wood, L., Egger, M., Gluud, L. L., Schulz, K. F., Jüni, P., Altman, D. G., Gluud, C., Martin, R. M., Wood, A. J. G., & Sterne, J. A. C. (2008) · BMJ · doi:10.1136/bmj.39465.451748.ad · Cited by 2,538
Wang, H., Paulson, K. R., Pease, S. A., Watson, S., Comfort, H., Zheng, P., Aravkin, A. Y., Bisignano, C., Barber, R. M., Alam, T., et al. (2022) · The Lancet · doi:10.1016/s0140-6736(21)02796-3 · Cited by 2,069
Troeger, C., Blacker, B. F., Khalil, I. A., Rao, P. C., Cao, J., Zimsen, S. R. M., Albertson, S. B., Deshpande, A., Farag, T. H., Zegeye, A., et al. (2018) · The Lancet Infectious Diseases · doi:10.1016/s1473-3099(18)30310-4 · Cited by 2,054
Self-citationPerin, J., Mulick, A., Yeung, D., Villavicencio, F., Lopez, G., Strong, K. L., Prieto-Merino, D., Cousens, S., Black, R. E., & Liu, L. (2022) · The Lancet Child & Adolescent Health · doi:10.1016/s2352-4642(21)00311-4 · Cited by 1,667
Prüss-Ustün, A., Wolf, J., Bartram, J., Clasen, T., Cumming, O., Freeman, M. C., Gordon, B., Hunter, P. R., Medlicott, K., & Johnston, R. (2019) · International Journal of Hygiene and Environmental Health · doi:10.1016/j.ijheh.2019.05.004 · Cited by 1,308
Self-citation
Cited by
Sorted by citations
Wolf, J., Johnston, R. B., Ambelu, A., Arnold, B. F., Bain, R., Brauer, M., Brown, J., Caruso, B. A., Clasen, T., Colford, J. M., et al. (2023) · The Lancet · doi:10.1016/s0140-6736(23)00458-0 · Cited by 343
Self-citationChen, C., You, Y., Du, Y., Zhou, W., Jiang, D., Cao, K., Yang, M., Wu, X., Chen, M., Qi, J., et al. (2024) · Heliyon · doi:10.1016/j.heliyon.2024.e35841 · Cited by 40
“These infections remain a public health priority because of their potential to cause substantial death and morbidity worldwide [1,2].”
InfluentialCaruso, B. A., Ballard, A. M., Sobolik, J. S., Patrick, M., Dsouza, J., Sinharoy, S. S., Cumming, O., Wolf, J., & Ray, I. (2024) · Nature Water · doi:10.1038/s44221-024-00299-2 · Cited by 28
Self-citationZeng, H., Gan, H., Liu, Y., & Sun, B. (2024) · Journal of Global Health · doi:10.7189/jogh.14.04162 · Cited by 22
“Unsafe WaSH conditions have been well-documented to be associated with premature death and various diseases, including an increased risk of diarrhoea [5], lower respiratory infections [6], malaria [7], and soil-transmitted helminthiases [8].”
BackgroundBick, S., Ezezew, A., Opondo, C., Leurent, B., Argaw, W., Hunter, E. C., Cumming, O., Allen, E., & Dreibelbis, R. (2024) · BMC Medicine · doi:10.1186/s12916-024-03558-x · Cited by 19
“…results point to the potential success of Project WISE at interrupting the transmission of respiratory pathogens by increasing handwashing with soap, as hand hygiene interventions have been associated with reductions in risk of acute respiratory illness of 24% for school-aged children in LMICs [2].”
BackgroundSelf-citation
Metadata
- Authors
- Ross, I., Bick, S., Ayieko, P., Dreibelbis, R., Wolf, J., Freeman, M. C., Allen, E., Brauer, M., & Cumming, O.
- Affiliations
- London School of Hygiene & Tropical Medicine (GB)
- World Health Organization (CH)
- Emory University (US)
- University of British Columbia (CA)
- Corresponding author
- Ross, Ian
- ORCID
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2023-05
- Volume
- 401
- Issue
- 10389
- Pages
- 1681-1690
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- OpenAlex
- W4367172984
- Semantic Scholar
- 6cf273f3317f32616220f73c4c933e4049f72bd4
- Cited by
- 118
- References
- 59
- Citations by year
- 2026: 42 · 2025: 48 · 2024: 23 · 2023: 5
- FWCI
- 7.55
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- The Lancet (publishedVersion, cc-by)
- PubMed (publishedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (submittedVersion)
- Funders
- Bill and Melinda Gates Foundation
- World Health Organization
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Pediatric health and respiratory diseases
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Health Sciences › Medicine › Epidemiology › Pneumonia and Respiratory Infections
- Keywords
- handwashing with soap, hand hygiene, acute respiratory infections, lower respiratory tract infection, upper respiratory tract infection, influenza, COVID-19 pandemic, all-cause mortality, school-based intervention, childcare settings, low- and middle-income countries, infection control, hygiene promotion, children and adolescents, healthcare workers, healthcare facilities, community settings, health care financing
- MeSH terms
- COVID-19, Developing Countries, Humans, Influenza, Human, Respiratory Tract Infections, Soaps, Pandemics
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
A language model drew the claims from the paper on 2026-10-08, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-10-08 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Cited sources are checked with a language model’s help (gpt-6-sol).
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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