The Need of Handwashing - Literature review Example

The global burden of infectious disease has been haunting the health conditions of the society. For the longest time, proper hygiene has been regarded as the most effective way to reduce the transmission of diseases (Gould 2010, p.50). While there are several ways to maintain hygiene, the unelaborated practice of hand washing alone has been considered as a single effective measure for disease prevention. For this reason, several researches have been conducted to explore the importance of hand washing and its impacts on health. The literatures covered in this paper are all peer-reviewed and published journal gathered from online journal databases like Pubmed, Proquest and ScienceDirect. Only those studies conducted among subjects in United Kingdom in the last five years were selected. Several aspects of hand washing including health implications, promotion programs, practices and beliefs are discussed by each the researches. Introduction It is of utmost importance to establish first the need of hand washing. Basically it serves the purpose of preventing the transmission of infectious diseases. While there are several infectious diseases that cannot be prevented by mere hand washing, the simpler ones are actually of more significance because of its prevalence in the society. As such, focus has been given to diarrhea, being one of the leading causes of child death (Boschi-Pinto 2008) and viral respiratory infections. Moreover, bacteria causing these diseases are usually transferred between surfaces (Curtis et al. 2011, p.312), through hand contamination, for example. The researches conducted, are therefore rooted on the premise that since hand washing can prevent the transfer of disease-causing bacteria between surfaces, the different aspects of this practice should be explored in depth. The Practice of Hand Washing The study of Curtis et al. (2011, p.312) emphasized that through the practice of proper hygiene, reducing the global burden of infectious disease need not to be costly. But despite this, it is quite unfortunate, that the importance of this practice has been overlooked in the area of public health. Yet through the information obtained by the authors, they were able to find hope that the present situation in terms of hygiene would gradually improve. In the beginning of the paper, Curtis et al. (2011, p. 312) established the evidence that there is indeed a risk that has to be controlled by identifying the means by which public health practitioners estimate the threats. These are the same steps being followed by the World Health Organization. The first step is evaluating the possibility that a particular practice to increase the likelihood of infection (Curtis et al. 2001, p. 312). The second step is risk mapping which was carried out by explaining that bacteria can be transferred between surfaces (Curtis et al. 2011, p.312) as mentioned early on. As such, a practice that would prevent this transfer – say, hand hygiene at the very least – would be effective in disease control. The third source is establishing a relationship between a practice and the incidence of disease (Curtis et al. 2011, p.312). Lastly, Curtis et al. (2011, p.312) cited randomized controlled trials as valuable means of establishing facts. The authors found that from several hygienic practices, hand washing is indeed the most studied. To narrow than the impacts of hand washing, they focused on diarrhea, which was said to be one of the leading infectious diseases in the world. According to the study, hand washing with soap can prevent diarrhea to as much as 43-47% (Curtis et al. 2001). Since the importance of hand washing has already been proven, several programs to promote this practice have been formulated. In England, for example, norm-based messages were used in motorway service stations to encourage the practice of hand washing. In addition, several policies have been implemented by the health sector to further promote hand washing practices. As what would be discussed later on, the importance of hand washing has become a global concern even in health care facilities which are supposed to provide disease protection for patients. Indeed the study of Curtis et al. (2011) serves a rich source of information on the different aspects of hand washing. However, a downside of this kind of study is that it is too broad that it covered several countries, both developed and developing, which may not be comparable. Moreover, since it is merely a compendium of various sources, it is difficult to make a conclusion by looking at the data alone. Nevertheless, it is able to formulate suggestions in the direction of research towards hand washing and other related public health practices. Methods of Hand Washing Meanwhile, Burton et al. (2011) put importance on the improvement of hand washing and as such they have been specific on the use of soap and water as most effective compared to other means. In their study, twenty subjects were instructed to purposely put their hands in contact with different surfaces (Burton et al. 2011). They were asked to do this self-contamination twenty-four times such that after each session, they would have to perform one of the following methods: washing with water only, washing with soap and water and not washing at all. In this case, eight sequences of self-contamination were done for each method mentioned. After performing each task, swabs were obtained from their fingers and cultured in the laboratory. It was found that while washing with water substantially reduced the amount of fecal bacteria, using soap is even more effective in eradicating bacteria (Burton et al. 2011). What is more remarkable about this study is the fact that the soap used in the experiment is non-bacterial. Therefore, with the advent of bacterial soaps in the market, hand washing as means to control diseases becomes more promising. Policy Implementation Meanwhile, it has been mentioned in the study of Curtis et al. (2011) that several policies have been implemented regarding the issue of hand washing. In response to a stronger need of ensuring proper hand washing practices in the control of diseases, the World Health Organization launched the program, “Save Lives: Clean Your Hands” in 2009 in the aim to increase public awareness on the importance of infection control and to promote compliance (WHO 2011). The impact of this program in several European countries was highlighted in the study of Magiorakos et al. (2010). Norm-based messages used in motorway service stations in England to promote hand washing (Curtis et al. 2001) is just part of the larger campaign of United Kingdom called, My Five Moments for Hand Hygiene. This campaign has been specifically developed for hospitals (Magiorakos et al. 2010) perhaps because of the prevalence of nosocomial infections which is defined as those not present before hospitalization and was therefore, acquired in the hospital or shortly after discharge (Alora 1983, p.31). Unfortunately, most of these infections are spread through direct contact of the hands of healthcare practitioners (Boyce & Pittet 2002). In England, this campaign is implemented by the use of educational tools and materials in a series of one-day workshops (Magiorakos et al. 2010). One of the highlights of this workshop is a film depicting a patient’s experiences from the time he was loaded in the ambulance to the time he was hospitalized and back home after discharge. Throughout the course, several opportunities where hand washing has to be practiced were shown (Magiorakos et al. 2010). In such case, the trainees are educated on how proper hand washing can be applied to different health care settings. Meanwhile, Scotland has another way of promoting the WHO initiative in addition to merely educating health workers. The Local Health Board Coordinators of Scotland is in charge of auditing hand hygiene practices and compliance in various hospitals (Magiorakos et al. 2010). It is assumed that by doing so, Scotland would be able to reach its target of increasing compliance among the staff in healthcare facilities. Hand Washing in Healthcare Settings While there are policies to promote hand washing especially in healthcare settings, it is not guaranteed that staff and even the patients comply with it. There are several factors that play a role in whether or not concerned individuals adhere to the policies. All these were explored in the study of Randle, Arthur & Vaughan (2010). The study was carried out by observing the staff, patients and visitors twenty-four hours in a large teaching hospital where access to hand hygiene facilities are readily available. In order to measure compliance, an observational tool which has already been validated previously was employed. Based on preliminary observations, it was found that there are five main opportunities in which hand hygiene must be practiced beforehand: patient contact, body fluid exposure, aseptic procedures, after contact and after exposure to the patients’ surroundings (Randle et al. 2010). A code was assigned in each of these opportunities and participants were scored based on these codes. Surprisingly, it was found that among the participants, doctors exhibited the highest level of non-compliance (Randle et al. 2010). This was explained by the fact that, in accordance with other related studies, doctors possess a sense of power and autonomy such that they do not want to be imposed upon with standardized rules; hence, they are often resistant to change. On the other hand, nurses showed the highest degree of compliance with hand washing practices in the hospital (Randle et al. 2010). The researchers referred to explanations provided by other studies – that is, altruism is highly associated with the profession of nurses. However, it should be noted that the compliance level of nurses and other staff is not far from that of patients and visitors. There are no existing data regarding compliance of patients in hand washing; therefore, conclusion cannot be made on whether there has been an improvement or not. Nevertheless, it was noted that the reason behind non-compliance among patients is the fact that they feel that they should be the ones being cared for (Randle et al. 2010). In such case, they do not need to perform these practices because of the belief that their welfare should be the responsibility of the healthcare workers. The study of Randle et al. (2010) provided an insight on the factors behind compliance and therefore may serve as a basis for further improvement of policies. Furthermore, Randle et al. (2010) was able to impart that while strict adherence to the policies should be practiced especially in the healthcare settings, complete compliance is difficult to achieve as it was deemed to be impractical given the work demands of healthcare staff. Alternatives to Hand Washing The study of Tanner (2011) identified the means by which compliance can be encouraged among patients by focusing on their preferences in the products used for hand washing. The study was aimed towards determining how satisfied the patients with the popular hand hygiene products available in the hospital (Tanner 2011). The subjects were asked to evaluate five popular products used for hand hygiene: alcohol foams, alcohol wipes, cloths impregnated with antiseptic solution, soapy water and portable sinks (Tanner 2011). Based on the results, it was found that alcohol foam was the most preferred hand hygiene product of patients. While it has been found by the study of Burton et al. (2010), as discussed previously, that washing with soap is the most effective way to decontaminate hands from bacteria, this information remains to be helpful. The patients are already aware of the purpose of hand washing but this awareness is not the sole factor for compliance. Even if a particular method is effective, it would remain useless if patients will not practice it. Besides, alcohol foams prove to be effective in killing microbes – not to mention that it is also cost-effective (Tanner 2011). Conclusion The abovementioned literatures have explored several aspects of hand washing. Studies conducted have proven that this practice can significantly reduce the spread of diseases. Therefore, efforts should be made in ensuring compliance through policies and education programs not only to ordinary individuals but to healthcare workers as well. Yet despite the amount of researches on this matter, this subject still calls for further studies. References Burton, M et al. 2011, ‘The effect of handwashing with water or soap on bacterial contamination of hands’, International Journal of Environmental Research on Public Health, vol. 8, no.1, pp. 97-104. Curtis, V et al. 2011, ‘Hygiene: new hopes, new horizons’, The Lancet Infectious Diseases, vol. 11, no.4, pp. 312-321. Magiorakos, AP et al. 2010, ‘Pathways to clean hands: Highlights of successful hand hygiene implementation strategies in Europe’, Eurosurveillance, vol. 16, no. 18. Randle, J, Arthur, A & Vaughan, N 2010, ‘Twenty-four-hour observational study of hospital hand hygiene compliance’, Journal of Hospital Infection, vol. 76, no. 3, pp. 252-255. Tanner, J 2011, ‘Hand hygiene: Product preference and compliance’, Nursing Times, vol. 107, no. 6. Alora, B & Manaloto, C 1983, ‘Nosocomial infection: Clinical features of two hundred forty-three cases in the Santo Tomas University Hospital’, Phil Journal of Infectious Diseases, vol. 12, no. 1, pp.31-39. Boschi-Pinto C, Velebit L & Shibuya K 2008, ‘Estimating child mortality due to diarrhoea in developing countries’, WHO Bulletin, vol. 86. Boyce JM & Pittet D. 2002, ‘Guideline for hand hygiene in health-care settings. MMWR Recommendation Report, vol. 51, no. 1, p. e45. Gould, D 2010, ‘Auditing hand hygiene practice’, Nursing Standard, vol. 25, no. 2, pp. 50-56. WHO, Save lives: clean hands (2011), World Health Organization, viewed 04 April, 2011, . The Effect of Handwashing with Water or Soap on Bacterial Contamination of Hands Maxine Burton, Emma Cobb, Peter Donachie, Gaby Judah, Val Curtis, and Wolf-Peter Schmidt* Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK; E-Mails: m_burton5@hotmail.com (M.B.); Email: Emma.Cobb@lshtm.ac.uk (E.C.); Email: Peter.Donachie@lshtm.ac.uk (P.D.); Email: Gaby.Judah@lshtm.ac.uk (G.J.); Email: Val.Curtis@lshtm.ac.uk (V.C.) *Author to whom correspondence should be addressed; E-Mail: Wolf-Peter.Schmidt@lshtm.ac.uk; Tel.: +44-20-7927-2461; Fax: +44-20-7636-7843. Received November 24, 2010; Revised December 30, 2010; Accepted December 31, 2010. This article is an open-access article distributed under the terms and conditions of the Creative Commons Attribution license (http://creativecommons.org/licenses/by/3.0/). * Other Sections▼ o Abstract o 1. Introduction o 2. Experimental Section o 3. Results and Discussion o 4. Conclusions o References Abstract Handwashing is thought to be effective for the prevention of transmission of diarrhoea pathogens. However it is not conclusive that handwashing with soap is more effective at reducing contamination with bacteria associated with diarrhoea than using water only. In this study 20 volunteers contaminated their hands deliberately by touching door handles and railings in public spaces. They were then allocated at random to (1) handwashing with water, (2) handwashing with non-antibacterial soap and (3) no handwashing. Each volunteer underwent this procedure 24 times, yielding 480 samples overall. Bacteria of potential faecal origin (mostly Enterococcus and Enterobacter spp.) were found after no handwashing in 44% of samples. Handwashing with water alone reduced the presence of bacteria to 23% (p < 0.001). Handwashing with plain soap and water reduced the presence of bacteria to 8% (comparison of both handwashing arms: p < 0.001). The effect did not appear to depend on the bacteria species. Handwashing with non-antibacterial soap and water is more effective for the removal of bacteria of potential faecal origin from hands than handwashing with water alone and should therefore be more useful for the prevention of transmission of diarrhoeal diseases. Keywords: hygiene, trial, infection * Other Sections▼ o Abstract o 1. Introduction o 2. Experimental Section o 3. Results and Discussion o 4. Conclusions o References 1. Introduction Diarrhoeal diseases are one of the leading causes of child death around the world [1]. The World Health Organisation (WHO) recognises the spread of diarrhoeal diseases as a serious global problem [2] and estimates that each year, there are more than 2.2 million lives lost due to these infections, more than from malaria, HIV/AIDS and measles combined [1]. The majority of these deaths are in children under 5 years of age [3]. It has been suggested that handwashing may substantially reduce the risk of diarrhoeal diseases [4]. Promotion of improved hand hygiene has been recognised as an important public health measure but it is unclear how much hand hygiene is required to interrupt transmission of diarrhoea pathogens. In particular it has not been conclusively shown whether use of soap is essential to remove pathogens from hands. Recent hygiene promotion campaigns especially in low income settings have not been unanimous in recommending soap use [4]. A number of studies have compared different hand hygiene methods in hospital settings [5]. In contrast, few studies have been published on the effect of hand hygiene on bacterial contamination of hands in the community. Hoque and colleagues found that a wide variety of hand cleansing means in poor settings (soap, ash, mud) are effective in reducing the contamination with coliform bacteria on hands [6,7]. In a small randomised trial the same author reported that soap may be more effective than water in reducing the presence of coliform bacteria on hands [6]. Luby and colleagues found that a simple microbiological method with three fingers directly imprinting a MacConkey agar for thermotolerant coliforms was unable to distinguish between households who were given soap during a large randomized handwashing trial and control households [8]. They concluded that the method was unsuitable for the evaluation of handwashing practices. However, the lack of difference in bacterial contamination may have been due to lack of compliance with the intervention. We thought that a proof-of-principle trial was needed where participants would be given specific tasks to contaminate their hands in a naturalistic setting and where handwashing was done under supervision. We conducted a randomised controlled trial to determine whether non-antibacterial soap is better at reducing bacteria of potential faecal origin than water only. A further goal was to clarify whether a simple microbiological test that can be applied to large groups in a relatively short time [9,10] would be able to distinguish people who practice handwashing from those who don’t. * Other Sections▼ o Abstract o 1. Introduction o 2. Experimental Section o 3. Results and Discussion o 4. Conclusions o References 2. Experimental Section This study was carried out between July and August 2009. Overall, 20 volunteers were taken to a large, frequently visited British museum, or asked to travel on a bus or the underground. They were asked to deliberately wipe their hands over hand contact surfaces such as handrails, door handles and seats with the aim of contaminating their hands with whatever bacteria were present. Using a pre-determined random sequence, not known to the participants during self-contamination, participants were then asked to wash their hands with soap, to use water only or not to wash at all. Each volunteer underwent this sequence 24 times, 8 times for each of the three hand hygiene approaches (soap, water, no handwash). Participants assigned to handwashing were asked to wash their hands as they would normally do, without instructions on length of time or thoroughness. The volunteers allocated to handwashing were then provided with a paper towel to dry their hands. A wet NaCl-soaked charcoal swab was then wiped across the fingers of the dominant hand of the participant. The participants were finally given an alcohol gel to clean their hands (78% total alcohol content, Ethanol 71% / Propanol 29%, Softalind Viscorub, Braun-Melsungen). The swabs were returned to the laboratory within 5 hours of being taken. In total, 480 samples were collected; 160 after handwashing with plain soap, 160 after handwashing with water alone and 160 with no handwashing. During the experimental phase we measured the amount of time taken to conduct handwashing with and without soap, once for each volunteer. Upon arrival at the laboratory the swabs were immediately cut into a universal tube containing 10 mL of Purple MacConkey broth using aseptic techniques. The swabs were incubated at 35 °C for 48 hours. All samples were then streaked onto the MacConkey agar No.3 and Bile Aesculin agar. MacConkey agar No. 3 is a selective media which can differentiate between coliforms and non-lactose fermenters, whilst inhibiting gram-positive cocci. These plates were incubated for 18–24 hours at 35 °C. For all other colonies produced on MacConkey agar No. 3 and those which were spot indole negative, a gram stain, catalase and oxidase test was carried out followed by an API 20E biochemical test to determine the identity of the bacteria. Bile Aesculin agar is a differential medium for the isolation of Enterococcus spp. and group D Streptococcus and inhibition of other gram positive bacteria. These plates were incubated at 37 °C for 18–24 hours. Enterococcus and Group D Streptococcus spp. are able to hydrolyse the aesculin to form aesculetin, producing a brown/black complex. Any white colonies on Bile Aesculin agar were presumed to be Staphylococcus spp. and any black colonies were tested with Lancefield group D antisera. Agglutination indicated a positive result for Enterococcus spp. The prevalence of bacterial contamination in the three study arms (soap, water, no handwash) was compared using logistic regression. Since the same volunteers repeatedly underwent testing, within-subject correlation was accounted for by the use of generalised estimating equations (GEE) with robust standard errors. If the cell numbers were too low for conducting regression analysis, Fishers exact test was used instead, ignoring clustering (the design effect was found to be low, see results). * Other Sections▼ o Abstract o 1. Introduction o 2. Experimental Section o 3. Results and Discussion o 4. Conclusions o References 3. Results and Discussion Table 1 shows the different organisms isolated in the three study arms. Enterococcus spp. were the most common bacteria found, followed by Enterobacter spp. Figure 1 shows the effect of handwashing with soap or water only on contamination, compared to no handwashing. Overall, handwashing with water alone reduced the prevalence of bacteria substantially. Handwashing with soap was more effective in reducing the prevalence of contamination and specifically of Enterococcus spp. There was a trend that handwashing with soap was also more effective in reducing the prevalence of other species and of multiple isolates, but the statistical support was low (Figure 1). Table 1 Table 1 Organisms found after self-contamination of hands, and handwashing with either soap, water only, or no handwashing. Figure 1 Figure 1 Effect of handwashing with water alone or soap and water compared to no handwashing. P-values derived from logistic regression adjusted for within-person correlation, except * where p-value was derived from Fishers exact test ignoring within-person correlation. (more ...) The effect of repeated measurements in the same individual was low: the design effect (the factor by which a sample size needs to be increased to achieve the same statistical power as an unclustered study) ranged from 1.2 to 1.3 (depending on the comparison group). Participants were asked to wash their hands as long and as thorough as they would normally do. The length of time required to carry out handwashing was measured once for each method in all volunteers. Participants took on average 12 seconds (standard deviation 2.8) to wash their hands with water alone, and 14 seconds (standard deviation 2.3) to wash their hands with water and soap (p = 0.02). Thus, handwashing with soap took them only slightly longer than handwashing with water alone. It seems unlikely that this small difference can explain the large difference in the removal of bacteria. Soap on its own appears to have an effect on the removal of bacteria of potential faecal origin, independent of the possibility that soap use may cause people to wash their hands longer. Unlike the study by Hoque and colleagues our trial was conducted in an experimental (albeit naturalistic) setting, where volunteers deliberately contaminated their hands. Additional testing showed that this approach increased the prevalence of contamination from around 10% to over 40% of individuals. It also improved control over the conduct of the experiment, but may affect generalisability, as the study primarily aimed at providing a proof of principle. However, we believe that the superior effect of soap on the removal of bacteria compared to water alone as the principal finding of our study is unlikely to depend on the setting. Not all of the bacteria isolated in our study are known to cause disease in humans. Surprisingly, we found few E. coli on hands which may be due to their short survival time in the environment. Overall, the effect of soap appeared to be independent of the type of bacteria (Figure 1), a view which is supported by the study by Hoque and colleagues who found a similar effect of hand hygiene on unspecified faecal coliform bacteria [6]. However, the power of our study to detect differences between species was low. We used plain non-antibacterial soap for the experiment. Future studies could address whether antibacterial soap is more effective in removing pathogens from hands. However, Luby and colleagues conducted a large double-blind randomised trial in Pakistan and found antibacterial soap no more effective in reducing diarrhoea than normal soap [11]. It is still not clear whether or in what circumstances anti-bacterial soaps offer a health advantage [12]. The bacteriological methods used in this study provide no quantification of bacterial load, unlike a study by Hoque and colleagues [7]. Quantifying the effect of different hand washing procedures on bacterial load may be particularly helpful for studies in poor settings with poor sanitation facilities, where the environmental contamination with faecal organisms is much higher [13–15]. We also tested a semi-quantitative finger-print method used previously in Thailand [15] not unsimilar to the method used by Luby and colleagues [8] but found that contamination levels were too low to provide consistent results. Therefore we decided to use a qualitative method. It seems reasonable to assume that handwashing with soap is also more effective in reducing bacterial load compared to water alone. Future studies could address the effect of different hand hygiene procedures on removing gastro-intestinal or respiratory viruses such as influenza A. Hands have been implicated especially in the spread of Norovirus [16]. Viral studies are more difficult to conduct as viruses may not be as present in the environment as often as are bacteria of faecal origin, but they may be possible for example if patients with laboratory confirmed infection are recruited as volunteers. Alternatively, healthy volunteers may experimentally contaminate their hands with cultured viruses before undergoing different hand hygiene regimes, as was done in a recent study on influenza A H1N1 [17]. This study found that handwashing with soap was better at removing influenza A H1N1 than several hand sanitizers. Handwashing with water alone was not tested. * Other Sections▼ o Abstract o 1. Introduction o 2. Experimental Section o 3. Results and Discussion o 4. Conclusions o References 4. Conclusions The results demonstrate that handwashing with non-antibacterial soap is much more effective in removing bacteria from hands than handwashing with water only. Although handwashing with water alone reduced the presence of bacteria on hands substantially, the study supports the policy of many current hand hygiene campaigns promoting the use of soap [18,19]. The strong association between hand hygiene method and bacterial contamination of hands found in our study suggests that the prevalence of faecal indicator bacteria may also be used to monitor changes in hygiene behaviour in the general population, for example following hygiene promotion campaigns. Hygiene behaviour is difficult to measure because people tend to change their behaviour under observation or over-report desired practices [15,20]. We have previously shown that our test kit can be used to study associations between hygiene relevant behaviours and hand contamination [9]. We found that test results positive for bacteria of potential faecal origin were more common in people frequently shaking hands, reporting soil contact or those scoring low on a hygiene score based on self-report [9]. The microbiological method used in this and our earlier studies [9,10] is relatively simple and of low cost (around $3.80). Its suitability for large scale use in the evaluation of handwashing campaigns in low income settings where handwashing should be most beneficial remains to be investigated. A sophisticated laboratory infrastructure may not be required to conduct testing. However, modifying the method to allow semi-quantitative or quantitative analysis may be necessary if contamination rates are high [15]. * Other Sections▼ o Abstract o 1. Introduction o 2. Experimental Section o 3. Results and Discussion o 4. Conclusions o References References 1. Boschi-Pinto C, Velebit L, Shibuya K. Estimating child mortality due to diarrhoea in developing countries. Bull. WHO. 2008;86:710–707. [PMC free article] [PubMed] 2. WHO Health Statistics 2008, Mortality and Burden of Disease. WHO; Geneva, Switzerland: 2008. [(accessed on 16 November 2010).]. Available online: http://www.who.int/whosis/whostat/EN_WHS08_Table1_Mort.pdf. 3. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet. 2003;361:2226–2234. [PubMed] 4. Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. Cochrane Database Syst. Rev. 2008;1 doi: 10.1002/14651858.CD004265.pub2. Art. No. CD004265. 5. WHO Guidelines on Hand Hygiene in Health Care. WHO; Geneva, Switzerland: 2009. [(accessed on 16 November 2010).]. Available online: http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. 6. Hoque BA, Briend A. A comparison of local handwashing agents in Bangladesh. J. Trop. Med. Hyg. 1991;94:61–64. [PubMed] 7. Hoque BA, Mahalanabis D, Alam MJ, Islam MS. Post-defecation handwashing in Bangladesh: practice and efficiency perspectives. Public Health. 1995;109:15–24. [PubMed] 8. Luby SP, Agboatwalla M, Billhimer W, Hoekstra RM. Field trial of a low cost method to evaluate hand cleanliness. Trop. Med. Int. Health. 2007;12:765–771. [PubMed] 9. Dodrill L, Schmidt WP, Cobb E, Donachie P, Curtis V, de Barra M. Male commuters in North and South England: Risk factors for the presence of faecal bacteria on hands. BMC Public Health. 2010 (in press) 10. Judah G, Donachie P, Cobb E, Schmidt W, Holland M, Curtis V. Dirty hands: bacteria of faecal origin on commuters’ hands. Epidemiol. Infect. 2010;138:409–414. [PubMed] 11. Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, Altaf A, Hoekstra RM. Effect of handwashing on child health: A randomised controlled trial. Lancet. 2005;366:225–233. [PubMed] 12. Aiello AE, Larson EL, Levy SB. Consumer antibacterial soaps: Effective or just risky? Clin. Infect. Dis. 2007;45(Suppl 2):S137–S147. [PubMed] 13. Hoque BA, Mahalanabis D, Pelto B, Alam MJ. Research methodology for developing efficient handwashing options: An example from Bangladesh. J. Trop. Med. Hyg. 1995;98:469–475. [PubMed] 14. Kaltenthaler EC, Drasar BS, Potter CW. The use of microbiology in the study of hygiene behaviour. Microbios. 1996;88:35–43. [PubMed] 15. Pinfold JV, Horan NJ. Measuring the effect of a hygiene behaviour intervention by indicators of behaviour and diarrhoeal disease. Trans. Roy. Soc. Trop. Med. Hyg. 1996;90:366–371. [PubMed] 16. Barker J, Vipond IB, Bloomfield SF. Effects of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces. J. Hosp. Infect. 2004;58:42–49. [PubMed] 17. Grayson ML, Melvani S, Druce J, Barr IG, Ballard SA, Johnson PD, Mastorakos T, Birch C. Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers. Clin. Infect. Dis. 2009;48:285–291. [PubMed] 18. Curtis V, Sidibe M, Scott BE, lyer P, Sara J. The Handwash Handbook: A Guide for Developing a Hygiene Promotion Program to Increase Handwashing with Soap. The World Bank Group; Washington, DC, USA: 2005. pp. 67–68. 19. Scott BE, Schmidt WP, Aunger R, Garbrah-Aidoo N, Animashaun R. Marketing hygiene behaviours: The impact of different communication channels on reported handwashing behaviour of women in Ghana. Health Educ. Res. 2008;23:392–401. [PubMed] 20. Biran A, Rabie T, Schmidt W, Juvekar S, Hirve S, Curtis V. Comparing the performance of indicators of hand-washing practices in rural Indian households. Trop. Med. Int. Health. 2008;13:278–285. [PubMed] Hygiene: new hopes, new horizons Dr Val Curtis PhDa, , , Wolf Schmidt PhDa, Stephen Luby MDb, Rocio Florezc, Ousmane Touré PhDd and Adam Biran PhDa Summary Although promotion of safe hygiene is the single most cost-effective means of preventing infectious disease, investment in hygiene is low both in the health and in the water and sanitation sectors. Evidence shows the benefit of improved hygiene, especially for improved handwashing and safe stool disposal. A growing understanding of what drives hygiene behaviour and creative partnerships are providing fresh approaches to change behaviour. However, some important gaps in our knowledge exist. For example, almost no trials of the effectiveness of interventions to improve food hygiene in developing countries are available. We also need to figure out how best to make safe hygiene practices matters of daily routine that are sustained by social norms on a mass scale. Full and active involvement of the health sector in getting safe hygiene to all homes, schools, and institutions will bring major gains to public health. Introduction Promotion of hygiene might be the single most cost-effective way of reducing the global burden of infectious disease.1 One might therefore expect hygiene to be the subject of multimillion dollar international initiatives like those for malaria or HIV/AIDS prevention. Perhaps because hygiene does not require clever new technologies or products, or perhaps because it is a domestic and personal issue largely affecting women and children, and perhaps because it concerns the neglected diarrhoeal and respiratory diseases (still the two biggest killers of children), hygiene is still very much overlooked in public health. There are signs that the situation is beginning to improve. Governments and funding agencies increasingly accept that hygiene promotion should play a part in health investments across the wider community, not just in health-care settings. Policy makers are also realising that the health benefits of increased investment in water and sanitation infrastructure are largely delivered through improvements in personal and domestic hygiene.2 Original approaches using new insights are modernising the hygiene sector, making it more attractive to investors. Improved water supplies and sanitation facilities make it easier to practise hygiene, keeping children and adults safe from infection. But even without improved facilities, better hygiene can still make a huge difference to health. Although most sanitation and water supply programme implementers seek to improve hygiene alongside hardware, they rarely have the resources and professional support needed to do this effectively. Health professionals recognise the need for better hygiene, but too few are actually engaged in programmes to promote it. In this Review we gather the facts about the importance of hygiene for public health and explore the scale of the problem. We set out what we know about hygiene and assess its promotion in the service of the Millennium Development Goals (MDGs) and beyond. Growing understanding of what shapes hygiene behaviour and creative partnerships are changing the way improvement is being approached. The evidence for giving hygiene a much higher priority is strong, and, to a large extent, we already know what needs to be done. The most important ingredient still missing is the full and active engagement of the health sector in improving global hygiene. Improvements in hygiene, sanitation, and water can prevent several important infections, in addition to providing other benefits. Among these avoidable infections prevention of diarrhoeal diseases is most important. Because the source of infections is human faecal material, the most important hygiene behaviours are clearly those that keep faecal matter out of the domestic environment. Adequate handwashing after contact with faeces is also crucial (after ones own defecation, after handling the faeces of children, or after contact with a faeces-contaminated environment). Other ways of preventing the faecal–oral transmission of infections include keeping water, foods, and surfaces free of faecal contamination and preventing carriage by flies. Safe food handling and preparation is also important, especially for children, as is the avoidance of animal faeces and the safe storage and use of water.3 Other diseases that can be prevented by adequate hygiene include respiratory infections, trachoma, and skin infections. Endoparasites, such as roundworm and hookworm, and ectoparasites including scabies and fleas, can also be avoided. Hygiene and health: the evidence Public health practitioners commonly use information from four sources when weighing up the risk of infectious disease. First, they can assess the biological likelihood that a particular practice will place individuals at risk of infection. Second, they can use risk mapping—for example, modelling of the transfer of microbes between surfaces and hosts in homes and hospitals4 or use of the hazard analysis critical control points method for assessing risk in food preparation.5 However, these approaches depend on access to good estimates of environmental contamination, which are largely unavailable for developing countries. Third, health practitioners can use correlations between recorded practices and disease incidence from observational studies. These data are more readily available, but can be misleading.6 Hygiene behaviour is commonly associated with socioeconomic factors, such as wealth, education, access to water, and modern lifestyle attitudes,7 all of which influence the risk of infectious disease. Such strong socioeconomic confounding is difficult, if not impossible, to address analytically.8 The fourth source of information for public health policy making is randomised controlled trials (RCTs), which control for confounding. However, very few RCTs of hygiene promotion programmes have been undertaken in developing countries, and those that have been done have several methodological flaws. For example, the masking of participants to the intervention is difficult, and as a result, mothers who are grateful for an intervention may be less likely to report disease in their children, leading to inflated effect sizes.9 Bias is thus a serious issue in unblinded studies on diarrhoea.10 Given these caveats, what can we say about the prevention of diarrhoeal disease through hygiene? Table 1 draws together our assessment of the available evidence, from reviews and other key papers, concerning the four sources of information: biological plausibility, risk modelling, observational studies, and RCTs. The best studied hygiene practice in developing countries is that of handwashing. Evidence from all four types of source is consistent, with RCTs of handwashing interventions showing reductions in diarrhoea of around 30%, and of 43–47% if soap is used.[11] and [12] Handwashing can also reduce other infections; one review suggested it could reduce respiratory infection by 16%,13 and a more recent cluster-randomised trial in Pakistan reported a reduction in acute lower respiratory tract infections of 50%.14 SP Luby, M Agboatwalla and DR Feikin et al., Effect of handwashing on child health: a randomised controlled trial, Lancet 366 (2005), pp. 225–233. Article | PDF (125 K) | View Record in Scopus | Cited By in Scopus (149)14 Handwashing also reduces neonatal mortality,15 trachoma,16 and parasitic worm infections.17 Face or whole-body washing are less well researched but might help to control skin infections and trachoma.18 An unclean face is associated with increased risk of trachoma,[19] and [20] and a randomised trial suggested that face washing reduces the risk of severe trachoma infection substantially.21 Handwashing with soap mitigated the severe acute respiratory syndrome epidemic22 and is one of the key practices recommended to counter possible influenza pandemics.23 Although food-borne infection is the main route of transmission of gastrointestinal infections in developed countries, their contribution to the burden of diarrhoea in low-income settings is unclear. Hot climates, poor storage facilities, and faecal contamination of the environment all make food-borne infection more likely. Therefore, food-borne infections are likely to play a major part in diarrhoeal disease transmission in low-income settings.24 Microbiological studies have shown the ability of many pathogens to grow quickly in food, especially in hot climates.[24] and [25] Contaminated weaning food, in particular, has been suggested as a major contributor to diarrhoea in low-income settings,26 although observational studies gave inconclusive results.24 Most of what we assume about food-borne infections in low-income settings is based on expert opinion and biological plausibility, rather than field data (eg, WHOs manual Five Keys to Safer Food).27 Several trials have assessed the effect of promoting exclusive breastfeeding on food-borne infections, with equivocal results.[28] and [29] Food hygiene interventions have rarely been systematically tested. In one of the very few intervention studies of improving childhood feeding practices, which included some food-hygiene education, Bhandari and colleagues30 found little effect on the nutritional status of children in rural India. The results of a recent trial done in Mali suggested that the microbiological safety of weaning food could be significantly improved with hazard-control principles in homes.31 Other routes of infection that could be removed by better hygiene are related to contact with child[7], [32] and [33] and animal faeces.34 A meta-analysis of observational studies of hygiene practices associated with child faeces found that failure to remove child faeces and unhygienic handling practices were associated with a 23% increased risk of diarrhoea.35 Other observational studies have reported that animals kept in shared outdoor living spaces (compounds) increase the risk of diarrhoea by over 50%.[36], [37] and [38] However, no studies that we know of have quantified the risks associated with the use of cow dung for fuel or in house maintenance. So far no intervention trials have aimed to reduce animal faecal contamination in domestic spaces. Neither are there any reports of trials of improving the disposal of child faeces by use of potties, nappies, or child-friendly toilets. Household surfaces seem to play a major part in disease transmission, although most evidence is from developed countries,[39], [40] and [41] and few intervention studies have tested whether surface cleansing can reduce transmission in any setting. Larson and colleagues42 in the USA compared use of antibacterial cleaning products with similar products without an antibacterial agent, and found no additional benefit. However, a small study in a school setting suggested that regular cleaning of desks and other classroom surfaces reduces the risk of gastrointestinal illness.43 Epidemiological evidence of the health risk associated with solid-waste disposal in low-income settings is scarce. Observational studies have shown a strong link between environmental exposure to solid waste and diarrhoea,44 perhaps because waste heaps are sometimes used for open defecation and disposal of excreta. In addition to attracting insect vectors and flies, waste is associated with Lassa fever infection which is transmitted by rats.45 In some settings fly control might reduce diarrhoea risk by around 25%,[46], [47] and [48] and lessen the risk of trachoma. Because there are multiple routes for the transmission of gastroenteric pathogens, many hygiene intervention studies have targeted several behaviours at once. Such an approach can dilute the effect of the intervention. For example, Haggerty and co-workers49 did a large cluster-randomised trial to test the effect of promoting four different hygiene behaviours (handwashing after faecal contact, handwashing before food contact, disposal of animal faeces, and disposal of child faeces). No effect on diarrhoea was reported in this study, perhaps suggesting that changing four distinct hygiene practices over a short time is unrealistic. The biological plausibility of most hygiene interventions is high (table 1); there is, however, a major shortage of evidence from trials. Trials on this topic can be complex and the results misleading; it is hard to mask participants to the nature of the intervention, which can lead to bias in outcome reporting. One way to improve this situation is to use more objective outcome measures, such as health-care seeking, assessments by health-care workers masked to intervention status, or mortality. Future hygiene trials need to be larger to model full-scale programme implementation and more intensive (and therefore costly) than previous trials to objectively assess outcomes. Large, adequately funded trials are urgently needed to assess the effects of intervening to improve three key practices in particular: handwashing, safe disposal of child stools, and promotion of food hygiene. The immediate question is what public health actions should be taken now? Whether an intervention can be recommended for implementation depends not only on the evidence of disease reduction, but also on its scalability, acceptability, and the risk of adverse effects.50 The weight of evidence suggests that hygiene promotion is effective in reducing disease, can be promoted both directly and by mass media programmes with relatively low expenditure per person targeted,[1] and [51] and has few adverse effects. Even if the true effect on disease in low-income settings is smaller than studies suggest, hygiene improvements will likely have an effect on disease control at large scale. Although additional intervention trials using improved outcome measures are urgently needed to confirm previous findings, hygiene promotion can already be recommended for large-scale implementation. Hygiene behaviour While surveys such as multiple indicator cluster surveys and demographic and health surveys systematically collect data on key health indicators, only recently have they begun to include data on hygiene practices. One reason for this is that questionnaire-based surveys are inadequate for gathering data about private and morally bound issues such as food and hand hygiene because they overestimate rates of handwashing, for example, by two to three times.52 V Curtis, S Cousens, T Mertens, E Traoré, B Kanki and I Diallo, Structured observations of hygiene behaviours in Burkina Faso, validity, variability and utility, Bull World Health Organ 71 (1993), pp. 23–32. View Record in Scopus | Cited By in Scopus (55)52 Efforts are continuing to identify indicators of hygiene practice that are both valid and simple to collect.[53], [54] and [55] An article56 published in 2009 collated data about directly observed handwashing in 11 countries, and we identified another survey57 from Bangladesh in 2008 (table 2). Handwashing with soap by child carers at key moments, such as after using the toilet, was rare, varying from 3% in Ghana to 42% in Kerala, India. Handwashing with water alone happens on a further 45% of occasions, on average. Handwashing with soap was also rare after cleaning up children and before handling food. If these figures are a good guide, less than one in six children in developing countries is protected from disease by handwashing with soap at key moments. This contributes perhaps a million unnecessary deaths to the global toll.61 Policy issues—what the health sector needs to do Far more is known about hygiene now than a decade ago. We understand the need to invest in hygiene and the key practices that require change, and we have appealing new ways of promoting hygiene. If hygiene promotion is truly the most cost-effective intervention for preventing disease in developing countries,1 then it is extraordinary that hygiene features so seldom in international public health efforts. What then holds back major investment in the improvement of hygiene? The health sector needs to address four major challenges for hygiene to take its rightful place as a major issue within global public health. First, governments and ministries have to stop merely talking about the need for hygiene and instead act, investing in programmes that can actually change hygiene behaviour in villages and towns where children are dying from neglected diseases. Second, hygiene promotion has to figure in the job description for health agents, from the heads of health services to the most remote rural community health worker. Third, massive efforts need to be made to train health workers in the skills of hygiene promotion. This is important because otherwise they will continue to use outdated methods and health education approaches that are demotivating because they are ineffective. Fourth, although we know enough to act now, gaps in our knowledge exist. Health research funders need to make up for some of the decades of underinvestment in hygiene. Support is needed for the research that will allow us to say with more certainty how to change hygiene behaviour on a large scale, what improved hygiene will cost, and what the financial returns will be. There are encouraging signs that, although investment still remains low, the topic of hygiene is moving up the political agenda. As pointed out by the former director of the World Bank Jim Wolfenson, hygiene is no longer seen as a joke. Inspired advocacy events, such as the Global Handwashing Day organised by the Global PPP-HW, have enhanced the global profile of hygiene. Celebrated every year on October 15, the day involves imaginative high-profile activities organised by public and private players from around the world. To become the focus of real investment, rather than good intentions, hygiene needs champions at all levels: from global, right through to village, and especially national ministries of health. Hygiene needs to find a place in national health plans and in poverty reduction strategies. Donors need to actively solicit hygiene promotion programmes and bring companies interested in promoting hygiene into the public health fold, rather than treating them with suspicion, as is sometimes the case. Coordination is a key issue in hygiene improvement; each country needs to designate a focal point to provide effective management of diverse efforts. Greater impact could be achieved if the many agencies, donors, non-governmental organisations, companies, and government and citizen institutions with hygiene in their mandates could agree upon a few simple principles and harmonise their approaches. Every mother who has contact with a health worker during pregnancy or in the neonatal period needs to learn about the importance of hygiene, and handwashing in particular. Similarly, every family member who prepares food needs to know a few basic rules of food hygiene. If the coordination of outreach to the community is seen as crucial to efforts to combat HIV and malaria, the same should also be true for hygiene promotion. In increasingly decentralised countries, policy building work needs to take place at national, regional, and provincial level. Creating this framework is challenging given competition for attention in the relevant ministries, their limited human and logistic resources, and shortage of skills. These problems are often worst in the remote and poverty-stricken areas that would benefit most from improved hygiene. Global leaders need to get involved to help show that hygiene is not a dirty contaminated topic, but one that can be attractive and popular, increasing votes, attention, and resources. For action on hygiene to become part of the remit of health workers, greatly increased investment in the development of capacity is needed. Training in up-to-date methods of communication is lacking at all levels in health ministries. Tertiary institutions that can provide this training need training themselves, and this is an area that could be addressed by external funders; although for some reason funding such skills development has, unfortunately, not been a priority for donors in recent years. Marketing expertise from the private sector has been helping to fill the skills gap, by designing state-of-the-art hygiene communication programmes and helping to train health officials in the techniques of marketing. Links between government health bodies and private organisations could be developed on a wider and more formal basis. The interface between programmes and health research is also problematic, as it is for health development in general. Local universities are the obvious institutions for designing and evaluating hygiene promotion programmes, but very few have that capacity at present. Another question for policy makers is whether hygiene should be promoted alone or in concert with efforts to improve water and sanitation infrastructure. The introduction of a new water supply to a community is a perfect opportunity to raise the issue of hygiene. However, large-scale engineering programmes are rarely equipped to handle what they call the software (ie, the behavioural) side of development. Equally, the most effective use of a hygiene budget might be to cover larger areas by use of mass media, rather than to restrict efforts to villages in the process of acquiring new water facilities. Hygiene messages should always be integral to efforts promoting improved sanitation. Ministries of health can play a part by insisting that it is not acceptable to build toilets in schools, health facilities, workplaces, and homes without appropriate handwashing facilities. Finally, good professional practice requires continual advancement in a feedback loop of learning and knowledge development whilst doing. Much can be done now. Far more could be done with serious investment to fill some of the important knowledge gaps about hygiene that still remain. Panel 4 sets out crucial questions that need answering urgently if we are to be able to deliver better hygiene programming in the future. Panel 4. Research priorities Trials of interventions to change key hygiene practices Randomised controlled trials are needed to test interventions to improve hygiene practices, including handwashing, safe stool disposal and food hygiene. Such studies should use objective outcomes such as clinical infection or mortality. Testing of hygiene interventions Small-scale testing of approaches in a laboratory or community setting, as well as large-scale screening, can provide answers about what works best to change hygiene behaviour and assurance of effectiveness before interventions are rolled out at a large scale. The effectiveness, cost-effectiveness, and differential impact of different channels? An analysis of the different routes of communication used in the Ghana PPP-HW campaign suggested that TV and radio had greater reach and impact than community events. Further analytical studies into the effectiveness and cost-effectiveness of different channels of communication are needed. We need to know more about the differential impact of different approaches on the low-income sections of society, which are at greatest risk of death from diarrhoeal disease and have fewer resources to commit to hygiene.80 We also need data to calculate dose-response curves: how much intervention produces how much behaviour change, and hence what level of investment is most cost effective? Designing effective interventions The process of turning insight about behaviour into effective behaviour-changing communication is still more of an art than a science. More needs to be understood about what makes communications attention-grabbing and memorable, as well as motivating. Habit clearly has an important role in hygiene and many other health behaviours, but the topic of how to create and change habits has been little studied.[6] and [7] Methods and models for hygiene promotion at different scales Proven model approaches to hygiene promotion are badly needed by decentralised authorities and non-government organisations. Such agencies are often willing to implement hygiene promotion, but rarely have the specific expertise or capacity to develop the approaches themselves. Several examples of simple, effective, attractive, and costed activities and materials that have been tested and have been shown to work, are needed so that organisations can adapt these to local circumstances. Sustaining improvements Even when we are successful in changing hygiene behaviours we still do not know how persistent such changes are,[11] and [12] or the sort of investment that is needed to maintain the gains in a given population. Perhaps the most important tasks facing hygiene promoters and soap manufacturers are to work out how to make hygiene a matter of habit and a social norm. Once hygiene is established, improvements in behaviours will be truly sustainable. Measuring hygiene behaviour If we cannot accurately measure changes in hygiene behaviour we cannot measure the effectiveness of interventions in trials or evaluate the delivery of behaviour change in programmes. Because hygiene behaviour is private and morally loaded, simple questionnaire surveys give overestimates of behaviours such as handwashing, whereas direct observation is cumbersome and intrusive, and technological fixes, such as Smart Soap (containing accelerometers that record usage) have drawbacks too.14 Simple, cheap, and widely applicable methods of measuring hygiene behaviour change are still needed. Technological, consumer, and business model innovation Although simple technologies, such as water-saving taps, nappies, potties, and child-friendly toilets, can help families to live more hygienically, little effort has been made to develop and market hygiene-helping products that are appropriate for the consumers with low income. Three things are needed: exploration of the design space for the products that the poorest consumers need and want,16 the adaptation or creation of technologies, products, and services that meet those needs, and the development of business models that can operate profitably and be sustained on a large scale. Hygiene: a roadmap to success Though the evidence base is far from complete, the information we do have strongly suggests a need to improve handwashing behaviour, stool disposal practices, and food hygiene in particular when weaning. We know that hygiene can be promoted successfully through conventional health channels, water and sanitation initiatives, schools, and by commercial companies. The first priority for any new resources allocated to hygiene is the design, management, and rigorous evaluation of large-scale hygiene promotion programmes (using randomised trials, where possible). Second, we need more medium-scale programmes, operating at rural or urban district level. Such programmes provide the opportunity to learn more of the basics of hygiene promotion, how to turn insight about hygiene into effective promotional campaigns, how to invest to get the most behavioural change, which channels to use, how best to reach the most vulnerable, how often and how much to intervene and how to sustain behavioural changes. The capacity to implement medium-scale programmes needs to be built through learning by doing. Programmes of research led by local universities, with international support where needed, can begin to tackle these multiple issues. Because there are many different ways to promote hygiene, having more diverse and properly evaluated programmes will build a body of knowledge as to what works best in changing these persistent habitual behaviours. Third, we need more dedicated epidemiological research funded by international donors and research councils. Many RCTs investigating efficacy and effectiveness are needed to provide rigorous evidence of the importance of improving individual hygiene practices. Food hygiene has the best claim to be tackled first, but all of the hygiene practices we have discussed have been neglected relative to the efforts for malaria or HIV research. For example, there is no evidence to indicate whether the practice of using animal dung to smooth floors and walls (common in Asia) is injurious to family health. Fourth, we need to set new and more ambitious targets for the coming decades. It is unacceptable that, in the 21st century, most schools in developing countries still do not have sanitation and hygiene facilities, or that health centres, hospitals, maternity facilities, workplaces, and public institutions still cannot offer water and soap to their users. It is unacceptable that birth attendants and outreach workers are not always trained to wash hands with soap and do not systematically promote handwashing and hygiene to mothers. Handwashing and hygiene should be promoted at least as aggressively as vaccination. For the future every child should have the right to live in a household that is protected from disease by good hygiene. In the next 5–10 years we have a window of opportunity to develop the high impact programmes which will bring about mass scale changes. If these programmes are successful in leading the members of all societies to adopt hygienic habits as a matter of course, then hygiene will be able to take its rightful place as one of the foundation stones of global health. Search strategy and selection criteria We searched Medline, from 1970 to 2009, regardless of language, using the search terms “[diarrh(o)ea AND hygiene]”, “[respiratory AND hygiene]”, “[food AND hygiene]”, “[pneumonia AND hygiene]”, “[stool AND disposal]”, “[waste AND hygiene]”, and “[animal faeces AND diarrh(o)ea]”. We searched the reference lists of relevant articles and contacted authors and experts for further identification of articles. Table 1 draws together our assessment of the available evidence from available reviews (and other key papers) concerning the four sources of evidence, biological plausibility, risk modelling, observational studies, and randomised controlled trials. Contributors VC wrote the first draft and subsequent drafts, revised and finalised the paper. SL made substantial contributions to the content and conclusions of the paper, reviewing and finalising. WS made contributions to the content, reviewing and finalising. RF made contributions to the content, especially concerning policy issues. OT made contributions to the content in the food hygiene section. AB made contributions to the structure of the paper. Pathways to clean hands: highlights of successful hand hygiene implementation strategies in Europe A P Magiorakos ()1, E Leens2, V Drouvot3, L May-Michelangeli3, C Reichardt4, P Gastmeier4, K Wilson5, M Tannahill6, E McFarlane6, A Simon7 United Kingdom - England: My Five Moments for Hand Hygiene and beyond From 2009 to 2010, the cleanyourhands campaign in England and Wales embraced the WHO’s My Five Mo Read More