CDC Hygiene-related Programs and Projects

Washing Your Hands: Measuring Factors Associated with Respiratory Disease Prevention through Technology

There is evidence that handwashing with soap can reduce respiratory disease incidence overall, but its role for prevention of clinically-confirmed disease is uncertain in resource-poor countries like Bangladesh.

CDC’s Respiratory Diseases Branch (RDB) and CDC’s Influenza Division have partnered with the International Centre for Diarrhoeal Disease Research, Bangladesh and the University at Buffalo’s School of Public Health and Health Professions on a case-control study to measure the associations between handwashing with soap and influenza and radiologically-confirmed pneumonia among young children living in an urban area of the capital city, Dhaka, Bangladesh.

The study relies on a community-based surveillance system that tracks influenza and pneumonia in a defined population and provides medical care for households that participate in surveillance.

Handwashing behavior is being measured using strategies designed to accurately record handwashing events and other pertinent data. Field research assistants begin household visits by administering a questionnaire on demographics and illness histories, knowledge of acute respiratory infections, handwashing knowledge, and socioeconomic status. Next, the research assistants conduct a series of observations in the home, recording water availability, sanitation facilities, and handwashing behaviors.

Use of technology is also an important part of the study. Soap use events are detected using bars of soap with a motion sensor (accelerometer) and an embedded data logging device. The soaps are designed to closely resemble actual soaps that are available locally (see photo). The study will examine associations between these behavioral factors and the rates of respiratory diseases. The project completed data collection in April 2010. Data analysis and interpretation are currently underway.

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Handwashing in the Developing World

Diarrhea and respiratory infections remain leading killers of young children in the developing world, and claim approximately 3.5 million young lives each year. The Centers for Disease Control and Prevention (CDC) has been studying the role of handwashing in preventing these diseases in developing world settings. In a series of randomized, controlled studies of intensive handwashing promotion in Pakistan, CDC researchers found about 50% fewer diarrheal and respiratory infections among young children in low-income households that received weekly handwashing promotion and a supply of soap for about a year, compared with households that did not receive these interventions. The disease reductions were similar whether households were given antibacterial or plain soap ^{1, 2}.

These studies helped demonstrate that handwashing can prevent spread of two of the leading killers of young children in the developing world. However, although handwashing seems outwardly simple, the habit of washing hands consistently and at the key times can be difficult to form. Additionally, handwashing does require some basic infrastructure: a water source and a hand cleanser like soap, ideally placed somewhere convenient to access during the most important times to wash hands, such as after using the toilet and before preparing or eating food. Establishing and maintaining such infrastructure may be challenging in some settings. Thus, while the type of intensive handwashing promotion used in these studies can be very effective in reducing disease, it is probably not something that can be delivered efficiently to large numbers of people. Furthermore, it is unclear whether handwashing behavior change or health impacts are sustained after such promotion ends ³.

As a result, CDC began investigating models of promoting handwashing behavior change more efficiently in developing countries. Because hygiene habits generally evolve through childhood, and large numbers of children are concentrated in schools, this strategy included studying schools as a site for handwashing promotion. In one randomized, controlled study, investigators compared absenteeism among three groups of first grade students for 5 months in China. One group was exposed to a simple, commercially-developed handwashing promotion program; a second group received the same program, plus a supply of soap for the school sinks, and one child in each classroom served as a handwashing role model for his or her peers; the third group received hygiene education that was typical for the region. Students in the group that received the handwashing promotion program, soap, and peer hygiene role models were absent substantially less than students who continued to receive standard hygiene education ⁴.

Additional research is underway to further clarify the role of school-based handwashing promotion in reducing illness among students and their families in several countries, and to explore the long-term impacts on child development of intensive handwashing promotion.

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Hand Hygiene Saves Lives: Patient Admission Video

The mission of CDC’s Division of Healthcare Quality Promotion (DHQP) is to protect patients, protect healthcare personnel, and promote safety, quality, and value in the healthcare delivery system.

Protecting patients from the transmission of infectious diseases and from conditions attributable to the care they receive is key to an effective infection prevention and control program. One way DHQP has worked to protect the health of patients is by the creation of the Hand Hygiene Saves Lives Patient Admission Video.

This video, available in English and Spanish, teaches two key points to hospital patients and visitors to help prevent infections: the importance of practicing hand hygiene while in the hospital, and that it is appropriate to ask or remind their healthcare providers to practice hand hygiene as well.

Modeled after the video that airline passengers are required to view prior to take-off on a flight, this new video is intended to be shown to patients upon admission to the hospital. The goal is that the video will inform patients at the beginning of their hospital stay about what they can do to help prevent infections throughout the duration of their stay. Posters and brochures for patients have been developed to accompany the video and reinforce the messages about hand hygiene.

Please visit CDC’s Guideline for Hand Hygiene in Healthcare Settings home page for more information.

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Division of Oral Health Water Fluoridation Leadership

Today, CDC’s Division of Oral Health in the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) provides national leadership in water fluoridation practice to state programs. CDC also collaborates with many national associations and organizations to further water fluoridation practice. The CDC leadership includes training of state officials, assistance in management of water fluoridation activities, technical and engineering support, and information on health effects. In 1998, NCCDPHP developed the Water Fluoridation Reporting System in partnership with the Association of State and Territorial Dental Directors (ASTDD) to collect data about water fluoridation management across the United States. The Water Fluoridation Reporting System has a dual role, both supporting state program management as well as acting as the principal national surveillance tool for water fluoridation. An important use of the system is the biannual water fluoridation report, providing statistics on the extent of water fluoridation within the United States. Extensive information on water fluoridation, including benefits, safety, data, technical resources and current guidelines and recommendations, is available to state programs and the public at CDC’s community water fluoridation website.

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1. Luby SP, et al. Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: A randomized controlled trial. JAMA 2005;291(21):2547-54.
2. Luby SP, et al . Effect of handwashing on child health: A randomised controlled trial. Lancet 2005;366(9481):225-33.
3. Luby SP, et al. Difficulties in maintaining improved handwashing behavior, Karachi, Pakistan. Am J Trop Med Hyg 2009;81(1):140–45.
4. Bowen A, et al. A cluster-randomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools. Am J Trop Med Hyg 2007;76(6):1166-73.