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Helminth and protozoan infections affect more than 1 billion children globally. Improving water quality, sanitation, handwashing, and nutrition could be more sustainable control strategies for parasite infections than mass drug administration, while providing other quality of life benefits. We enrolled geographic clusters of pregnant women in rural western Kenya into a cluster-randomized controlled trial (ClinicalTrials.gov NCT01704105) that tested 6 interventions: water treatment, improved sanitation, handwashing with soap, combined water treatment, sanitation, and handwashing (WSH), improved nutrition, and combined WSH and nutrition (WSHN). We assessed intervention effects on parasite infections by measuring Ascaris lumbricoides, Trichuris trichiura, hookworm, and Giardia duodenalis among children born to the enrolled pregnant women (index children) and their older siblings. After 2 years of intervention exposure, we collected stool specimens from 9,077 total children aged 2 to 15 years in 622 clusters, including 2,346 children in an active control group (received household visits but no interventions), 1,117 in the water treatment arm, 1,160 in the sanitation arm, 1,141 in the handwashing arm, 1,064 in the WSH arm, 1,072 in the nutrition arm, and 1,177 in the WSHN arm. In the control group, 23% of children were infected with A. lumbricoides, 1% with T. trichiura, 2% with hookworm, and 39% with G. duodenalis. The analysis included 4,928 index children (median age in years: 2) and 4,149 older siblings (median age in years: 5); study households had an average of 5 people, <10% had electricity access, and >90% had dirt floors. Compared to the control group, Ascaris infection prevalence was lower in the water treatment arm (prevalence ratio [PR]: 0.82 [95% CI 0.67, 1.00], p = 0.056), the WSH arm (PR: 0.78 [95% CI 0.63, 0.96], p = 0.021), and the WSHN arm (PR: 0.78 [95% CI 0.64, 0.96], p = 0.017). We did not observe differences in Ascaris infection prevalence between the control group and the arms with the individual interventions sanitation (PR: 0.89 [95% CI 0.73, 1.08], p = 0.228), handwashing (PR: 0.89 [95% CI 0.73, 1.09], p = 0.277), or nutrition (PR: 86 [95% CI 0.71, 1.05], p = 0.148). Integrating nutrition with WSH did not provide additional benefit. Trichuris and hookworm were rarely detected, resulting in imprecise effect estimates. No intervention reduced Giardia. Reanalysis of stool samples by quantitative polymerase chain reaction confirmed the reductions in Ascaris infections measured by microscopy in the WSH and WSHN groups. Trial limitations included imperfect uptake of targeted intervention behaviors, limited power to detect effects on rare parasite infections, and that it was not feasible to blind participants and sample collectors to treatment status. However, lab technicians and data analysts were blinded to treatment status. The trial was funded by the Bill & Melinda Gates Foundation and the United States Agency for International Development. Integration of improved water quality, sanitation, and handwashing could contribute to sustainable control strategies for Ascaris infections, particularly in similar settings with recent or ongoing deworming programs. Combining nutrition with WSH did not provide further benefits, and water treatment alone was similarly effective to integrated WSH. Our findings provide new evidence that drinking water should be given increased attention as a transmission pathway for Ascaris. ClinicalTrials.gov NCT01704105.

Intensive care units (ICUs) are high-risk areas for transmission of antimicrobial-resistant bacteria, but no controlled study has tested the effect of rapid screening and isolation of carriers on transmission in settings with best-standard precautions. We assessed interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in European ICUs. We did this study in three phases at 13 ICUs. After a 6 month baseline period (phase 1), we did an interrupted time series study of universal chlorhexidine body-washing combined with hand hygiene improvement for 6 months (phase 2), followed by a 12–15 month cluster randomised trial (phase 3). ICUs were randomly assigned by computer generated randomisation schedule to either conventional screening (chromogenic screening for meticillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant enterococci [VRE]) or rapid screening (PCR testing for MRSA and VRE and chromogenic screening for highly resistant Enterobacteriaceae [HRE]); with contact precautions for identified carriers. The primary outcome was acquisition of resistant bacteria per 100 patient-days at risk, for which we calculated step changes and changes in trends after the introduction of each intervention. We assessed acquisition by microbiological surveillance and analysed it with a multilevel Poisson segmented regression model. We compared screening groups with a likelihood ratio test that combined step changes and changes to trend. This study is registered with ClinicalTrials.gov, number NCT00976638. Seven ICUs were assigned to rapid screening and six to conventional screening. Mean hand hygiene compliance improved from 52% in phase 1 to 69% in phase 2, and 77% in phase 3. Median proportions of patients receiving chlorhexidine body-washing increased from 0% to 100% at the start of phase 2. For trends in acquisition of antimicrobial-resistant bacteria, weekly incidence rate ratio (IRR) was 0·976 (0·954–0·999) for phase 2 and 1·015 (0·998–1·032) for phase 3. For step changes, weekly IRR was 0·955 (0·676–1·348) for phase 2 and 0·634 (0·349–1·153) for phase 3. The decrease in trend in phase 2 was largely caused by changes in acquisition of MRSA (weekly IRR 0·925, 95% CI 0·890–0·962). Acquisition was lower in the conventional screening group than in the rapid screening group, but did not differ significantly (p=0·06). Improved hand hygiene plus unit-wide chlorhexidine body-washing reduced acquisition of antimicrobial-resistant bacteria, particularly MRSA. In the context of a sustained high level of compliance to hand hygiene and chlorhexidine bathings, screening and isolation of carriers do not reduce acquisition rates of multidrug-resistant bacteria, whether or not screening is done with rapid testing or conventional testing. European Commission.

The gold standard for hand hygiene (HH) while wearing gloves requires removing gloves, performing HH, and donning new gloves between WHO moments. The novel strategy of applying alcohol-based hand rub (ABHR) directly to gloved hands might be effective and efficient. A mixed-method, multicenter, 3-arm, randomized trial. Adult and pediatric medical-surgical, intermediate, and intensive care units at 4 hospitals. Healthcare personnel (HCP). HCP were randomized to 3 groups: ABHR applied directly to gloved hands, the current standard, or usual care. Gloved hands were sampled via direct imprint. Gold-standard and usual-care arms were compared with the ABHR intervention. Bacteria were identified on gloved hands after 432 (67.4%) of 641 observations in the gold-standard arm versus 548 (82.8%) of 662 observations in the intervention arm ( < .01). HH required a mean of 14 seconds in the intervention and a mean of 28.7 seconds in the gold-standard arm ( < .01). Bacteria were identified on gloved hands after 133 (98.5%) of 135 observations in the usual-care arm versus 173 (76.6%) of 226 observations in the intervention arm ( < .01). Of 331 gloves tested 6 (1.8%) were found to have microperforations; all were identified in the intervention arm [6 (2.9%) of 205]. Compared with usual care, contamination of gloved hands was significantly reduced by applying ABHR directly to gloved hands but statistically higher than the gold standard. Given time savings and microbiological benefit over usual care and lack of feasibility of adhering to the gold standard, the Centers for Disease Control and Prevention and the World Health Organization should consider advising HCP to decontaminate gloved hands with ABHR when HH moments arise during single-patient encounters. NCT03445676.

A previous cluster-randomized controlled trial in Bangladesh found that individual or combined water, handwashing, sanitation, and nutrition interventions during pregnancy and after birth improved developmental outcomes of children at 1 and 2 years of age. In this study, we aimed to determine if these intervention effects were sustained for children at school age. Clusters of pregnant women were enrolled between May 31, 2012 and July 7, 2013 and block-randomized into chlorinated drinking water (W); improved sanitation (S); handwashing with soap (H); combined WSH; nutrition counseling and provision of lipid-based supplements (N); combined WSH + N, or a double-sized passive control arm (C) with no intervention visits (N = 5,551). The primary outcomes of the main trial after the 2-year intervention were 7-day diarrhea prevalence and length-for-age z-score, measured in 4,584 children of enrolled pregnant women. We conducted a post hoc, follow-up of all initially enrolled mothers and their children 5 years after intervention completion, when children were 7 years old. Primary outcomes were child cognition assessed using the Wechsler Pre and Primary Scale of Intelligence (WPPSI-IV), along with assessments of fine motor abilities, behavior, school achievement, and executive function; secondary outcomes were maternal mental health and stimulation in the home environment. We conducted intention-to-treat analyses using generalized linear models to calculate unadjusted and adjusted comparisons between each arm and the control group, accounting for block-level clustering. Between September 2019 and February 2021, we re-enrolled 4,175 households from all 720 original clusters, with the full set of child development assessments conducted on 3,833 children across 718 clusters. Children in the WSH + N, N, and S arms had improved cognitive scores on one or more domains compared to the control arm, with adjusted effect sizes between 0.10 (95%CI: 0.00, 0.20) and 0.15 (0.03, 0.27). Children in the W, H, N, WSH, and WSH + N arms demonstrated improved prosocial behaviors (adjusted effect sizes between 0.20 (0.07, 0.33) and 0.31 (0.16, 0.46)) and reduced difficult behaviors (adjusted effect sizes between -0.15 (-0.28, -0.01) and -0.31 (-0.45, -0.17)). No intervention effects were observed for fine motor, executive functioning, or school achievement outcomes. Maternal depressive symptoms were improved in the WSH + N, H, and N arms (adjusted effect sizes between -0.14 (-0.24, -0.03) and -0.21 (-0.31, -0.11)), and the stimulating home environment was improved in all intervention arms (adjusted effect sizes between 0.17 (0.01, 0.33) and 0.40 (0.25, 0.56)). Children whose families had higher wealth at baseline and those who were male tended to have larger effect sizes on the FSIQ. Data collection for this study was interrupted by a 6-month pause at the start of the COVID-19 pandemic. The main limitation of this study is loss to follow-up. At 7 years of age, we found small, sustained benefits of early water, sanitation, handwashing, and nutrition interventions on child cognitive and socioemotional outcomes, the stimulating home environment, and maternal mental health. Future work to determine the mechanisms underlying these intervention effects will further inform the design of early interventions to improve child health and development. Trial registration: Follow-up trial: ClinicalTrials.gov, NCT04443855. Original WASH-Benefits Bangladesh (WASH-B): ClinicalTrials.gov, NCT01590095.

Intestinal parasitic infections are highly endemic among school-aged children in resource-limited settings. To lower their impact, preventive measures should be implemented that are sustainable with available resources. The aim of this study was to assess the impact of handwashing with soap and nail clipping on the prevention of intestinal parasite reinfections. In this trial, 367 parasite-negative school-aged children (aged 6-15 y) were randomly assigned to receive both, one or the other, or neither of the interventions in a 2 × 2 factorial design. Assignment sequence was concealed. After 6 mo of follow-up, stool samples were examined using direct, concentration, and Kato-Katz methods. Hemoglobin levels were determined using a HemoCue spectrometer. The primary study outcomes were prevalence of intestinal parasite reinfection and infection intensity. The secondary outcome was anemia prevalence. Analysis was by intention to treat. Main effects were adjusted for sex, age, drinking water source, latrine use, pre-treatment parasites, handwashing with soap and nail clipping at baseline, and the other factor in the additive model. Fourteen percent (95% CI: 9% to 19%) of the children in the handwashing with soap intervention group were reinfected versus 29% (95% CI: 22% to 36%) in the groups with no handwashing with soap (adjusted odds ratio [AOR] 0.32, 95% CI: 0.17 to 0.62). Similarly, 17% (95% CI: 12% to 22%) of the children in the nail clipping intervention group were reinfected versus 26% (95% CI: 20% to 32%) in the groups with no nail clipping (AOR 0.51, 95% CI: 0.27 to 0.95). Likewise, following the intervention, 13% (95% CI: 8% to 18%) of the children in the handwashing group were anemic versus 23% (95% CI: 17% to 29%) in the groups with no handwashing with soap (AOR 0.39, 95% CI: 0.20 to 0.78). The prevalence of anemia did not differ significantly between children in the nail clipping group and those in the groups with no nail clipping (AOR 0.53, 95% CI: 0.27 to 1.04). The intensive follow-up and monitoring during this study made it such that the assessment of the observed intervention benefits was under rather ideal circumstances, and hence the study could possibly overestimate the effects when compared to usual conditions. Handwashing with soap at key times and weekly nail clipping significantly decreased intestinal parasite reinfection rates. Furthermore, the handwashing intervention significantly reduced anemia prevalence in children. The next essential step should be implementing pragmatic studies and developing more effective approaches to promote and implement handwashing with soap and nail clipping at larger scales.

My 5 moments (M5M) was used less frequently among cleaning staff members, suggesting that a poor compliance score in this group may not indicate deficient handwashing. This quasi-experimental study compared hand hygiene compliance (HHC), hand hygiene (HH) moments, and HH time distribution in the control group (no HH intervention; n = 21), case group 1 (normal M5M intervention; n = 26), case group 2 (extensive novel six moments (NSM) training; n = 24), and case group 3 (refined NSM training; n = 18). The intervention’s effect was evaluated after 3 months. The HHC gap among the four groups gradually increased in the second intervention month (control group, 31.43%; case group 1, 38.74%; case group 2, 40.19%; case group 3, 52.21%; p < 0.05). After the intervention period, the HHC of case groups 2 and 3 improved significantly from the baseline (23.85% vs. 59.22%, 27.41% vs. 83.62%, respectively; p < 0.05). ‘After transferring medical waste from the site’ had the highest HHC in case group 3, 90.72% (95% confidence interval, 0.1926–0.3967). HH peak hours were from 6 AM to 9 AM and 2 PM to 3 PM. The study showed that the implementation of an NSM practice can serve as an HHC monitoring indicator and direct relevant training interventions to improve HH among hospital cleaning staff.

Background. Hand hygiene is a key measure in preventing infections. We evaluated healthcare worker (HCW) hand hygiene with the use of remote video auditing with and without feedback. Methods. The study was conducted in an 17-bed intensive care unit from June 2008 through June 2010. We placed cameras with views of every sink and hand sanitizer dispenser to record hand hygiene of HCWs. Sensors in doorways identified when an individual(s) entered/exited. When video auditors observed a HCW performing hand hygiene upon entering/exiting, they assigned a pass; if not, a fail was assigned. Hand hygiene was measured during a 16-week period of remote video auditing without feedback and a 91-week period with feedback of data. Performance feedback was continuously displayed on electronic boards mounted within the hallways, and summary reports were delivered to supervisors by electronic mail. Results. During the 16-week prefeedback period, hand hygiene rates were less than 10% (3933/60 542) and in the 16-week postfeedback period it was 81.6% (59 627/73 080). The increase was maintained through 75 weeks at 87.9% (262 826/298 860). Conclusions. The data suggest that remote video auditing combined with feedback produced a significant and sustained improvement in hand hygiene.

Soil transmitted helminths (STH) infect >1.5 billion people. Mass drug administration (MDA) effectively reduces infection; however, there is evidence for rapid reinfection and risk of potential drug resistance. We conducted a randomized controlled trial in Bangladesh (WASH Benefits, NCT01590095) to assess whether water, sanitation, hygiene and nutrition interventions, alone and combined, reduce STH in a setting with ongoing MDA. In 2012-2013, we randomized 720 clusters of 5551 pregnant women into water treatment, sanitation, handwashing, combined water+sanitation+handwashing (WSH), nutrition, nutrition+WSH (N+WSH) or control arms. In 2015-2016, we enrolled 7795 children, aged 2-12 years, of 4102 available women for STH follow-up and collected stool from 7187. We enumerated STH infections with Kato-Katz. We estimated intention-to-treat intervention effects on infection prevalence and intensity. Participants and field staff were not blinded; laboratory technicians and data analysts were blinded. Prevalence among controls was 36.8% for A. lumbricoides, 9.2% for hookworm and 7.5% for T. trichiura. Most infections were low-intensity. Compared to controls, the water intervention reduced hookworm by 31% (prevalence ratio [PR] = 0.69 (0.50,0.95), prevalence difference [PD] = -2.83 (-5.16,-0.50)) but did not affect other STH. Sanitation improvements reduced T. trichiura by 29% (PR = 0.71 (0.52,0.98), PD = -2.17 (-4.03,-0.38)), had a similar borderline effect on hookworm and no effect on A. lumbricoides. Handwashing and nutrition interventions did not reduce any STH. WSH and N+WSH reduced hookworm prevalence by 29-33% (WSH: PR = 0.71 (0.52,0.99), PD = -2.63 (-4.95,-0.31); N+WSH: PR = 0.67 (0.50,0.91), PD = -3.00 (-5.14,-0.85)) and marginally reduced A. lumbricoides. Effects on infection intensity were similar. In a low-intensity infection setting with MDA, we found modest but sustained hookworm reduction from water treatment and combined WSH interventions. Impacts were more pronounced on STH species with short vs. long-term environmental survival. Our findings suggest possible waterborne transmission for hookworm. Water treatment and sanitation improvements can augment MDA to interrupt STH transmission. NCT01590095.

Early implementation of interventions at a young age fosters behaviour changes and helps to adopt behaviours that promote health. Digital technologies may help to promote the hand hygiene behaviour of children. However, there is a lack of digital feedback interventions focusing on the hand hygiene behaviour of preschool children in childhood education and care settings. This study protocol aims to describe a study that evaluates the effectiveness of a gamified live feedback intervention and explores underlying behavioural theories in achieving better hand hygiene behaviour of preschool children in early childhood education and care settings. This study will be a four-arm cluster randomized controlled trial with three phases and a twelve-month follow-up by country stratification. The sample size is 106 children of which one cluster will have a minimum number of 40 children. During the baseline phase, all groups will have automated monitoring systems installed. In the intervention phase, the control group will have no screen activity. The intervention groups will have feedback displays during the handwashing activity. Intervention A will receive instructions, and intervention B and C groups will receive instructions and a reward. In the post-intervention phase, all the groups will have no screen activity except intervention C which will receive instructions from the screen but no reward. The outcome measures will be hand hygiene behaviour, self-efficacy, and intrinsic motivation. Outcome measures will be collected at baseline, intervention, and post-intervention phases and a 12-month follow-up. The data will be analysed with quantitative and qualitative methods. The findings of the planned study will provide whether this gamified live feedback intervention can be recommended to be used in educational settings to improve the hand hygiene behaviour of preschool children to promote health. The trial is registered with ClinicalTrials.gov (registration number NCT05395988 https://clinicaltrials.gov/ct2/show/NCT05395988?term=NCT05395988&draw=2&rank=1 ).

To prevent Ebola transmission, frequent handwashing is recommended in Ebola Treatment Units and communities. However, little is known about which handwashing protocol is most efficacious. We evaluated six handwashing protocols (soap and water, alcohol-based hand sanitizer (ABHS), and 0.05% sodium dichloroisocyanurate, high-test hypochlorite, and stabilized and non-stabilized sodium hypochlorite solutions) for 1) efficacy of handwashing on the removal and inactivation of non-pathogenic model organisms and, 2) persistence of organisms in rinse water. Model organisms E. coli and bacteriophage Phi6 were used to evaluate handwashing with and without organic load added to simulate bodily fluids. Hands were inoculated with test organisms, washed, and rinsed using a glove juice method to retrieve remaining organisms. Impact was estimated by comparing the log reduction in organisms after handwashing to the log reduction without handwashing. Rinse water was collected to test for persistence of organisms. Handwashing resulted in a 1.94-3.01 log reduction in E. coli concentration without, and 2.18-3.34 with, soil load; and a 2.44-3.06 log reduction in Phi6 without, and 2.71-3.69 with, soil load. HTH performed most consistently well, with significantly greater log reductions than other handwashing protocols in three models. However, the magnitude of handwashing efficacy differences was small, suggesting protocols are similarly efficacious. Rinse water demonstrated a 0.28-4.77 log reduction in remaining E. coli without, and 0.21-4.49 with, soil load and a 1.26-2.02 log reduction in Phi6 without, and 1.30-2.20 with, soil load. Chlorine resulted in significantly less persistence of E. coli in both conditions and Phi6 without soil load in rinse water (p<0.001). Thus, chlorine-based methods may offer a benefit of reducing persistence in rinse water. We recommend responders use the most practical handwashing method to ensure hand hygiene in Ebola contexts, considering the potential benefit of chlorine-based methods in rinse water persistence.