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Handwashing in schoolchildren


Bandolier 91 reported that encouraging handwashing in military recruits reduced outpatient visits for respiratory conditions. Another target for improving washing of hands is schoolchildren, and a study in Detroit [1] showed handwashing to be effective in reducing absence through illness in elementary school children.


A single school with 305 children aged 5-12 years in 14 classes was chosen, and classes were divided into experimental and control without formal randomisation. Six classrooms with 143 children formed the experimental group and eight with 162 children the control group.

The intervention was that children in the handwashing classes were required by their teachers to wash their hands after arrival at school, before eating lunch, after the lunch break and before going home. This was done as a class activity. Children in the control group had no required hand washing.

The outcome was absence from school, recorded daily and monitored by telephone contact with parents to investigate the nature of any illness. Illness was regarded as respiratory if it included cough, sneeze, sinus trouble etc, and gastrointestinal if it included abdominal pain or diarrhoea or vomiting. Both were used, and total days of absence for illness. Children with both respiratory and gastrointestinal reasons for absence were included in both groups, so the total may be less than the sum of these two reasons.


Absences were recorded as a percentage of the total number of possible days of attendance. Absences were lower in the handwashing than in the control group (Figure 1). The relative risk for each reason is given in Table 1. For total illness absence and gastrointestinal reasons, the reduction was statistically significant.

Figure 1: Days absent, total and by cause, for children washing hands regularly, and control

Table 1: Relative risks for absence, total and by cause, for handwashing compared with control


Relative risk (95% CI)

All illness 0.75 (0.60 to 0.95)
Respiratory illness 0.79 (0.61 to 1.02)
Gastrointestinal illness 0.43 (0.25 to 0.73)


This study was not randomised, nor was it blind. Both these defects could have contributed to a result that might be biased. But there is so little evidence for the effectiveness of handwashing in the community that this study is worth a look. It also reports that it performed a literature review, though no details are given. There are perhaps three other studies in children, usually in special circumstances. Mostly they showed reduction in illness, and we know that in other settings washing hands frequently makes a difference.

What is surprising is that there is so little information about so basic an activity. Where are the trials, and where are the reviews of trials that can help us determine how and where washing hands can help, both in the community, as here with schoolchildren, and in healthcare to reduce infections?

Bandolier has started a special handwashing section on its Internet pages, to begin to draw together the evidence we have about handwashing. Searching electronic databases reveals few trials. Perhaps it is because there are few academic brownie points in so simple an issue.

Readers could help by telling Bandolier about studies they know of, and email or fax references, or better still the papers if they are in uncommon journals. We would also like to hear from those who have successfully implemented handwashing schemes.


  1. D Master et al. Scheduled hand washing in an elementary school population. Family Medicine 1997 29: 336-339.
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