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Hand washing for preventing diarrhoea (Review)
Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA 
Thisisareprint of aCochrane review, preparedandmaintained byThe Cochrane Collaboration andpublishedin
TheCochrane Library 
2008, Issue 4http://www.thecochranelibrary.com
Hand washing for preventing diarrhoea (Review)Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Analysis 1.1. Comparison 1 Institutional-based trials: hand washing promotion vs no intervention, Outcome 1Incidence of diarrhoea: cluster-adjusted rate ratios. . . . . . . . . . . . . . . . . . . . . .38 Analysis 1.2. Comparison 1 Institutional-based trials: hand washing promotion vs no intervention, Outcome 2Incidence of diarrhoea: not cluster-adjusted rate ratios. . . . . . . . . . . . . . . . . . . . .38 Analysis 2.1. Comparison 2 Community-based trials: hand washing promotion vs no intervention, Outcome 1Incidence of diarrhoea: cluster-adjusted rate ratios. . . . . . . . . . . . . . . . . . . . . .38 Analysis 2.2. Comparison 2 Community-based trials: hand washing promotion vs no intervention, Outcome 2Incidence of diarrhoea: not cluster-adjusted rate ratios. . . . . . . . . . . . . . . . . . . . .40 Analysis 2.3. Comparison 2 Community-based trials: hand washing promotion vs no intervention, Outcome 3Incidence of diarrhoea: stratified by soap provision and type of intervention. . . . . . . . . . . . .42 Analysis 2.4. Comparison 2 Community-based trials: hand washing promotion vs no intervention, Outcome 4Episodes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .43INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iHand washing for preventing diarrhoea (Review)Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 
[Intervention review]
Hand washing for preventing diarrhoea
Regina I Ejemot
1
, John E Ehiri
2
, Martin M Meremikwu
3
, Julia A Critchley 
41
Department of Public Health, College of Medical Sciences, University of Calabar, Calabar, Nigeria.
2
Maternal and Child Health,School of Public Health, University of Alabama at Birmingham, Birmingham, USA.
3
Department of Paediatrics, University of CalabarTeaching Hospital, Calabar, Nigeria.
4
Institute of Health and Society, Newcastle University, Newcastle, UK Contact address: Regina I Ejemot, Department of Public Health, College of Medical Sciences, University of Calabar, Calabar, Nigeria.reginaejemot@yahoo.com.idulove@yahoo.com. (Editorial group: Cochrane Infectious Diseases Group.)
Cochrane Database of Systematic Reviews 
, Issue 4, 2008 (Status in this issue:
Edited 
)Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.DOI: 10.1002/14651858.CD004265.pub2
This version first published online:
23 January 2008 in Issue 1, 2008. Re-published online with edits: 8 October 2008 in Issue 4,2008.
Last assessed as up-to-date:
4 November 2007. (Dates and statuses?)
This record should be cited as:
Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea.
Cochrane Database of Systematic Reviews 
2008, Issue 1. Art. No.: CD004265. DOI: 10.1002/14651858.CD004265.pub2.
A B S T R A C T
Background 
Diarrhoea is a common cause of morbidity and a leading cause of death among children aged less than five years, particularly inlow- and middle-income countries. It is transmitted by ingesting contaminated food or drink, by direct person-to-person contact, orfrom contaminated hands. Hand washing is one of a range of hygiene promotion interventions that can interrupt the transmission of diarrhoea-causing pathogens.
Objectives
To evaluate the effects of interventions to promote hand washing on diarrhoeal episodes in children and adults.
Search strategy 
In May 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (
The Cochrane Library 
2007,Issue 2), MEDLINE, EMBASE, LILACS, PsycINFO, Science Citation Index and Social Science Citation Index, ERIC, SPECTR,Bibliomap, RoRe, The Grey Literature, and reference lists of articles. We also contacted researchers and organizations in the field.
Selection criteria 
Randomized controlled trials, where the unit of randomization is an institution (eg day-care centre), household, or community, thatcomparedinterventions topromotehandwashingorahygienepromotionthatincludedhandwashing withnointerventiontopromotehand washing.
Data collection and analysis
Two authors independently assessed trial eligibility and risk of bias. We stratified the analyses for cluster adjusted and non-adjustedtrials. Where appropriate, incidence rate ratios (IRR) were pooled using the generic inverse variance method and random-effects model with 95% confidence intervals (CI).
Main results
Fourteen randomized controlled trials met the inclusion criteria. Eight trials were institution-based in high-income countries, five werecommunity-based in low or middle-income countries, and one was in a high-risk group (people with acquired immune deficiency 
1Hand washing for preventing diarrhoea (Review)Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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