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Handwashing and respiratory illness


Bandolier 67 and 82 examined the impact of handwashing on hospital acquired infection. Keeping hands washed reduces respiratory illness as well, and a report reinforces the importance of keeping up the pressure to make sure hands are washed [1].


The study took place in the single US Navy training site for enlisted personnel at Great Lakes, Illinois. It was precipitated by withdrawal of an adenovirus vaccine and a review that showed that handwashing and general hygiene were challenges for recruits. The intervention was called Operation Stop Cough. It had six main elements:

Weekly rates of illness were compared for the year before and two years after introduction of the programme. A control group of advanced students on the same base but not in the programme was used.

A stratified random sample of recruits was chosen at the end of basic training to answer a questionnaire on handwashing, respiratory symptoms, use of medical resources and time lost through illness.


In each year there were about 45,000 recruits, with about 10,000 advanced students. There was no real difference between the periods other than a higher percentage of women and higher ambient temperatures in 1998 compared with earlier years.

The number of outpatient visits because of respiratory illness fell by about half for recruits in 1997 and 1998 after introducing the handwashing programme. Control advanced students saw no change in their lower rate of respiratory illness (Figure 1). Admission to hospital for respiratory illness was the same before and after the programme, and for recruits and advanced students at about 3.5 admissions per 1000 recruits per year.

Figure 1: Outpatient visits before the intervention (1996) and after (1997, 1998)

More than 99% of 1445 recruits filled in the anonymous questionnaire. It showed that only about half washed their hands five times a day, with about 40% washing three to five times a day and 12% washing their hands fewer than three times a day. Frequent handwashers had less self-reported respiratory illness (3.2 episodes per recruit) than infrequent handwashers (4.7 episodes per recruit); the odds ratio was 1.5 (95% confidence interval 1.2 to 2.8). Infrequent handwashers had significantly more hospital admissions; the odds ratio was 11 (95% confidence interval 2.7 to 46).

Barriers to washing hands were insufficient time, insufficient sinks and insufficient soap.


This is a remarkably open examination of the difficulties of getting people to wash their hands, and some of the institutional tensions between medicine and operational issues shine through. They have an 1861 reference to show that things haven't changed much. There are lessons here about doing the simple things well. Forget the complex messages: just encourage people to wash their hands.


  1. 1 MA Ryan et al. Handwashing and respiratory illness among young adults in military training. American Journal of Preventative Medicine 2001 21: 79-83.
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