Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Acute respiratory infection (ARI) is a leading cause of morbidity and mortality globally, with 83% of ARI mortality occurring in low-income and middle-income countries (LMICs) before the COVID-19 pandemic. We aimed to estimate the effect of interventions promoting handwashing with soap on ARI in LMICs. METHODS: In our systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, Global Health, and Global Index Medicus for studies of handwashing with soap interventions in LMICs from inception to May 25, 2021. We included randomised and non-randomised controlled studies of interventions conducted in domestic, school, or childcare settings. Interventions promoting hand hygiene methods other than handwashing with soap were excluded, as were interventions in health-care facilities or the workplace. The primary outcome was ARI morbidity arising from any pathogen for participants of any age. Secondary outcomes were lower respiratory infection, upper respiratory infection, influenza confirmed by diagnostic test, COVID-19 confirmed by diagnostic test, and all-cause mortality. We extracted relative risks (RRs), using random-effects meta-analysis to analyse study results, and metaregression to evaluate heterogeneity. We assessed risk of bias in individual studies using an adapted Newcastle-Ottawa scale, and assessed the overall body of evidence using a Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The study is registered with PROSPERO, CRD42021231414. FINDINGS: 26 studies with 161 659 participants met inclusion criteria, providing 27 comparisons (21 randomised). Interventions promoting handwashing with soap reduced any ARI compared with no handwashing intervention (RR 0·83 [95% CI 0·76-0·90], I2 88%; 27 comparisons). Interventions also reduced lower respiratory infections (0·78 [0·64-0·94], I2 64%; 12 comparisons) and upper respiratory infections (0·74 [0·59-0·93], I2 91%; seven comparisons), but not test-confirmed influenza (0·94 [0·42-2·11], I2 90%; three comparisons), test-confirmed COVID-19 (no comparisons), or all-cause mortality (prevalence ratio 0·95 [95% CI 0·71-1·27]; one comparison). For ARI, no heterogeneity covariates were significant at p<0·1 and the GRADE rating was moderate certainty evidence. INTERPRETATION: Interventions promoting handwashing with soap can reduce ARI in LMICs, and could help to prevent the large burden of respiratory disease. FUNDING: Bill & Melinda Gates Foundation, Reckitt Global Hygiene Institute, and UK FCDO.

Reduced norovirus epidemic follows increased sales of hand hygiene products in Japan, 2020-2021.

During the recent emergence of COVID-19, an increased practice of hand hygiene coincided with the reduced incidence of the norovirus epidemic in Japan, which is similar to experience with the pandemic flu in 2009. We investigated the relationship between the sales of hand hygiene products, including liquid hand soap and alcohol-based hand sanitizer, and the trend of norovirus epidemic. We used national gastroenteritis surveillance data across Japan in 2020 and 2021 and compared the base statistics of incidence of these two years with the average of the previous 10 years (2010-2019). We calculated the correlations (Spearman's Rho) between monthly sales of hand hygiene products and monthly norovirus cases and fitted them to a regression model. In 2020, there was no epidemic, and the incidence peak was the lowest in recent norovirus epidemics. In 2021, the incidence peak was delayed for five weeks to the usual epidemic seasons. Correlation coefficients between monthly sales of liquid hand soap and skin antiseptics and norovirus incidence showed a significantly negative correlation (Spearman's Rho = -0.88 and p = 0.002 for liquid hand soap; Spearman's Rho = -0.81 and p = 0.007 for skin antiseptics). Exponential regression models were fitted between the sales of each hand hygiene product and norovirus cases, respectively. The results suggest hand hygiene using these products is a potentially useful prevention method against norovirus epidemics. Effective ways of hand hygiene for increasing the prevention of norovirus should therefore be studied.

Understanding the gap between knowledge and practice of handwashing in rural India: evidence from a cross-sectional study.

Limited studies in India had captured the gap in knowledge and practice of handwashing in the community. This study assesses the gap in knowledge and practice of handwashing in rural India. The study was conducted across 10 districts in five states of India - Andhra Pradesh, Assam, Maharashtra, Odisha and West Bengal from December 2021 to January 2022 by the SIGMA Foundation, Kolkata in collaboration with UNICEF India. Descriptive statistics, bivariate analysis, creation of indices and multinomial logistic regression were employed. Findings demonstrated that both knowledge of different aspects of hand hygiene and practice of handwashing with soap and water (HWWS) at critical times varied by socio-economic groups and also across the districts/states. Half of the respondents used only water to wash their hands after taking meals, before serving food, whenever their hands seemed dirty and before eating or cooking. Overall, the 'HWWS knowledge index' was 0.46, whereas the 'HWWS practice index' was 0.36. The correlation coefficient between the two was 0.36. The HWWS practice index was lower than the HWWS knowledge index for 50% of the sampled households. Both HWWS knowledge and practice indices were higher among females, higher educated and younger population. The gap between handwashing practice and knowledge was also higher among females and higher educated.

Mask-Wearing and Handwashing Behaviors of Chinese Rural Residents during the Pandemic of COVID-19: A Cross-Sectional Survey.

OBJECTIVE: To understand mask-wearing and handwashing behaviors of Chinese rural residents during the COVID-19 pandemic and to analyze the associated factors. METHODS: This study used a multi-stage random sampling method to conduct a cross-sectional questionnaire survey during the period of July to December of 2021, in six counties located in Shandong, Shanxi, and Yunnan provinces representing the eastern, central, and western regions of China, respectively. A total of 3864 villagers were surveyed with a questionnaire, and 3832 valid questionnaires were finally analyzed. Descriptive statistics and logistic regression analysis were used for statistical analysis. RESULTS: Around ninety-four percent (93.6%) of rural residents reported mask-wearing during the COVID-19 pandemic, but only 44.5% of them could replace masks in time. Multivariate logistic regression analysis showed that those who were female, aged 15-59, had an education level of high school and above, were divorced/widowed, worked as farmers (workers), or were rural residents in Shandong Province were more likely to wear masks. Furthermore, those who were female, aged 15-59, had an education level of high school and above, were unmarried and married, were business and service workers, or were rural residents in Shandong and Shanxi Province replaced masks more timely. Around seventy percent (69.7%) of rural residents reported using soap when washing their hands, but only 38.0% of rural residents could wash their hands properly. Multivariate logistic regression analysis showed that rural residents who were aged 35-59, had an education of high school and above, or lived in Shandong Province and Shanxi Province were more likely to wash their hands with soap. Those who were aged 15-59, had an education of high school and above, worked as farmers (workers), were employees of governmental departments and retirees, were business and service workers, or were students had higher proper handwashing rates. CONCLUSION: During the COVID-19 pandemic, the proportion of Chinese rural residents wearing masks reached 93.6%, but only 44.5% were able to replace masks in time, gender, age, education level, marital status, occupation, and living place had an impact on mask-wearing. The proportion of Chinese rural residents who could wash hands with soap reached 69.7%, but only 38.0% could wash their hands properly. Age and education level were influencing factors for both washing-hand with soap and proper handwashing.

Changes in water treatment, hygiene practices, household floors, and child health in times of Covid-19: A longitudinal cross-sectional survey in Surkhet District, Nepal.

INTRODUCTION: Consistent and effective practice of water treatment, sanitation, and hygiene (WASH) behaviour is an indispensable requisite for realizing health improvements among children living in low-income areas with challenging hygienic conditions. Sustainably achieving such a behaviour change is challenging but more likely to be realized during epidemics, when health threats are high and the dissemination of information on preventative measures is intense. Our study conducted cross-sectional surveys in Surkhet District Nepal, before and during the Covid-19 pandemic to assess the impact of water safety interventions and hygiene training implemented before and during the pandemic on WASH conditions and practices and to assess the association of these changes with child health. METHODS: Information on WASH infrastructure, WASH behaviour, nutrition, and child health, including on parasitic infections, was obtained before and during the Covid-19 pandemic in spring 2018 and spring 2021, from 589 children aged between 6 months and 10 years and their caregivers. Data was collected through quantitative, structured face-to-face interviews, observations, health examinations of children including anthropometric measurements, analysis of children's stool, and water quality analysis. The association of changes in WASH factors with changes in child health was analysed using multivariate generalized estimating equations for repeated measures. RESULTS: Water safety management was significantly improved by the introduction of chlorination to piped water supply systems, which served 40% of households. In addition, the percentage of households using a ceramic water filter increased from 12.2% to 34.8%. Large and significant changes were observed in handwashing behaviour (frequency, use of soap and washing at critical times) and infrastructure: 35% of households constructed a new handwashing station. Kitchen and household hygiene also improved. An additional 22% of households improved the cleanliness of the toilet. The number of houses with a cemented floor increased by 20%. WASH changes were significantly associated with improved child health: the chlorination of piped water supply reduced odds ratios for diarrhoea (OR = 0.36, 95% CI = 0.15-0.88, p = 0.025), respiratory difficulties (OR = 0.39, 95% CI = 0.16-0.92, p = 0.033), fever (OR = 0.42, 95% CI = 0.26-0.71, p = 0.001) and cough (OR = 0.58, 95% CI = 0.36-0.93, p = 0.024), and. The frequency of handwashing with soap was associated with significantly reduced odds ratios for infections with Giardia lamblia (OR = 0.68, 95% CI = 0.50-0.91, p = 0.011), stunting and wasting (OR = 0.75, 95% CI = 0.66-0.92, p = 0.003) and fever (OR = 0.85, 95% CI = 0.75-0.96, p = 0.008),. The presence of a handwashing station at baseline was associated with significantly reduced odds ratios for respiratory difficulties (OR = 0.45, 95% CI = 0.26-0.78, p = 0.004). The construction of a handwashing station between baseline and endline was significantly associated with reduced odds ratios for pale conjunctiva (OR = 0.32, 95% CI = 0.17-0.60, p < 0.001), which is a clinical sign of iron deficiency and anaemia, respiratory difficulties (OR = 0.39, 95% CI = 0.17-0.89, p = 0.026) and cough (OR = 0.44, 95% CI = 0.26-0.76, p = 0.003). Using a clean container for the transport of drinking water was significantly associated with reduced odds ratios for infections with Giardia lamblia (OR = 0.39, 95% CI = 0.16-0.93, p = 0.033) and diarrhoea (OR = 0.48, 95% CI = 0.24-0.96, p = 0.038). Similarly, a cemented floor in the household was significantly associated with reduced odd ratios for diarrhoea (OR = 0.38, 95% CI = 0.16-0.87, p = 0.022) and infections with Giardia lamblia (OR = 0.44, 95% CI = 0.19-1.02, p = 0.056). CONCLUSION: WASH training and the promotion of preventative measures during the Covid-19 pandemic supported improved water safety management and hygiene behaviour, which resulted in a reduction in infectious diseases among children in the study area.

Effects of a social norm-based handwashing intervention including handwashing stations, and a handwashing station-only intervention on handwashing with soap in urban Côte d'Ivoire: a cluster randomised controlled trial.

BACKGROUND: Diarrhoeal diseases are an important cause of mortality in children younger than 5 years in sub-Saharan Africa. We aimed to evaluate the effect of three handwashing interventions on handwashing with soap (HWWS) after toilet use. METHODS: In this cluster randomised trial in Abidjan, Côte d'Ivoire, we randomly assigned communal housing compounds (1:1:1) to receive one of three interventions: a theory of normative social behaviour (TNSB) intervention, including provision of handwashing stations; handwashing stations only; and no intervention. The TNSB intervention was designed to shift the outcome expectation associated with HWWS from health to riddance of faeces-related disgust, and to increase the perceived descriptive norm and perceived handwashing publicness. Participants and fieldworkers were masked to the study objectives. The primary outcome was HWWS after toilet use, assessed at 1 month and 5 months follow-ups. Analysis was by intention to treat. This trial is registered at the Pan African Clinical Trial Registry, PACTR201501000892239. FINDINGS: Between April 10 and May 22, 2014, we identified 92 eligible compounds, of which 75 compounds were included. Follow-up data on HWWS were available for 23 compounds for the TNSB group, 25 compounds for the handwashing station-only group, and 25 compounds for the control group. The study ended in April, 2017. Compared with a frequency of 5% (29 of 604 occasions) in the control group, HWWS after toilet use increased to 9% (49 of 557 occasions; adjusted risk ratio 1·89, 95% CI 1·16-3·08) in the handwashing station-only group, and 24% (143 of 588 occasions; 4·82, 3·06-7·59) in the TNSB group, at the 1-month follow-up. The intervention effect was only sustained in the TNSB group (98 [22%] of 450 compounds; 2·68, 1·65-4·34). INTERPRETATION: A social norm-based handwashing intervention combined with disgust-inducing messages, with provision of handwashing stations, was effective at increasing HWWS after toilet use. The provision of handwashing stations alone had little effect. Future studies should investigate whether the same approach, when delivered via mass media, can have a similar effect to the face-to-face delivery used in this study. FUNDING: None.

Adherence to Covid-19 preventive measures among high school students in Jimma town, South-West Ethiopia: Institutional-based cross-sectional study.

BACKGROUND: Corona (COVID-19) is an infectious disease caused by a newly discovered corona virus. The World Health Organization has recommended several preventive measures for COVID-19 and African countries, including Ethiopia had accepted and engaged in the recommended preventive measures. Adherence to COVID-19 prevention measure is still a big problem; however, the level of adherence to preventive measures had not reported in Ethiopia among students and there is an information gap, therefore, this study conducted to fill the information gap on level of adherence to COVID-19 preventive measures among students. OBJECTIVE: This study aimed to assess the level of adherence to COVID-19 preventive measures and its associated factors among high school students in Jimma Town public High Schools in southwest Ethiopia, 2021. METHODS SAND MATERIALS: An institution-based cross-sectional study was conducted among 404 systematically selected high school students from Jimma town from July 15 to August 2, 2021. The sample size was determined using a single-population proportion formula, and data were collected through face-to-face interviews using a structured and pretested questionnaire. Data were entered into Epi-data manager 4.4.2.1 then exported to Stata 14 for cleaning and analysis. Bivariate and multivariable ordinal logistic regression analyses were declared to identify significant variables. Finally; significant factors were determined at a significance level of <0.05. RESULTS: Of 388 students included in the analysis, approximately 14.7% (95%CI: 11.51-18.60) of students had good level of adherence to COVID-19 preventive measures.Only 6.9%of participants had good knowledge where as approximately half of the respondents had favorable attitude toward COVID-19 preventive measures. Factors such as Female gender (AOR = 1.03(95%CI: 1.01-1.74), access to water and soap (AOR = 2.11(95%CI: 1.06-4.19) andattitude (AOR = 4.36(95%CI: 2.69-7.08)) were found to have a statistically significant association with level of adherence to COVID-19 preventive measures. CONCLUSION: Adherence to COVID-19preventive measures among students wasunexpectedly lower than in other studies. Female gender, lack of access to water and soap, and attitudes were factors associated with adherence to COVID-19 preventive measures. Therefore, to ensure maximal adherence to preventive measures for COVID-19, special messages and efforts targeting males, increasing access to water and soap, trainingto improve attitude toward COVID-19 preventive measures should be implemented at schools.

Characterizing changes in behaviors associated with chemical exposures during the COVID-19 pandemic.

The COVID-19 pandemic-and its associated restrictions-have changed many behaviors that can influence environmental exposures including chemicals found in commercial products, packaging and those resulting from pollution. The pandemic also constitutes a stressful life event, leading to symptoms of acute traumatic stress. Data indicate that the combination of environmental exposure and psychological stress jointly contribute to adverse child health outcomes. Within the Environmental influences on Child Health Outcomes (ECHO)-wide Cohort, a national consortium initiated to understand the effects of environmental exposures on child health and development, our objective was to assess whether there were pandemic-related changes in behavior that may be associated with environmental exposures. A total of 1535 participants from nine cohorts completed a survey via RedCap from December 2020 through May 2021. The questionnaire identified behavioral changes associated with the COVID-19 pandemic in expected directions, providing evidence of construct validity. Behavior changes reported by at least a quarter of the respondents include eating less fast food and using fewer ultra-processed foods, hair products, and cosmetics. At least a quarter of respondents reported eating more home cooked meals and using more antibacterial soaps, liquid soaps, hand sanitizers, antibacterial and bleach cleaners. Most frequent predictors of behavior change included Hispanic ethnicity and older age (35 years and older). Respondents experiencing greater COVID-related stress altered their behaviors more than those not reporting stress. These findings highlight that behavior change associated with the pandemic, and pandemic-related psychological stress often co-occur. Thus, prevention strategies and campaigns that limit environmental exposures, support stress reduction, and facilitate behavioral change may lead to the largest health benefits in the context of a pandemic. Analyzing biomarker data in these participants will be helpful to determine if behavior changes reported associate with measured changes in exposure.

COVID-19 and its prevention in internally displaced person (IDP) camps in Somalia: impact on livelihood, food security and mental health.

BACKGROUND: Somalia has over 2.6 million internally displaced people (IDP) that depend on daily wages and humanitarian assistance for their livelihoods. This study investigated the impact of COVID-19 on livelihoods, food security and mental health of Somalia's IDPs. METHODS: A questionnaire was conducted with "breadwinners" (n = 585) residing in 15 randomly selected IDP camps. Mental health was assessed using the 5-item World Health Organization Wellbeing Index (WHO-5) and the Patient Health Questionnaire-9 (PHQ-9). Multivariable regression was used to explore the effect of depressive symptoms on soap use and ability to pay for food/medicine/rent. RESULTS: Knowledge of COVID-19 symptoms, transmission and prevention was relatively high, however only 55% reported using soap for hand washing. Around one third perceived that prohibition of public gatherings had negatively impacted weekly earnings. Participants reported difficulty buying food (85%), medicine (82%) and paying rent (51%) because of COVID-19. The majority were assessed as having low wellbeing and high depressive symptoms (mean WHO-5 = 44.2/100; mean PHQ-9 = 18.6/27), with most (74%) indicating that they felt worse than before the pandemic. Compared to people with low depressive symptoms, people with high depressive symptoms were less likely to use soap (aOR = 0.3, 95% CI = 0.2, 0.7; P < 0.001) and more likely to report difficulty buying food (aOR = 2.2; 95% CI = 1.1, 4.3; P = 0.02). CONCLUSION: COVID-19 and associated restrictions have negatively impacted Somalia's internally displaced population. Livelihood and mental health support is urgently needed in the recovery phase of the pandemic and should be factored into future pandemic planning.

Application of the Capability, Opportunity, Motivation and Behavior (COM-B) model to identify predictors of two self-reported hand hygiene behaviors (handwashing and hand sanitizer use) to prevent COVID-19 infection among U.S. adults, Fall 2020.

BACKGROUND: Handwashing with soap and water is an important way to prevent transmission of viruses and bacteria and worldwide it is estimated handwashing can prevent 1 in 5 viral respiratory infections. Frequent handwashing is associated with a decreased risk for infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Using a hand sanitizer with at least 60% alcohol when handwashing is not feasible can also help prevent the transmission of viruses and bacteria. OBJECTIVE: Since early 2020, the public has been encouraged to handwash frequently with soap and water and use alcohol-based hand sanitizer when soap and water are not available to reduce COVID-19 transmission. This study's objectives were to assess U.S. adults' perceptions of components of the Capability, Opportunity, Motivation and Behavior (COM-B) Model in relation to these two hand hygiene behaviors and to identify relationships between these components and hand hygiene behaviors. METHODS: Items assessing capability, opportunity, motivation, and hand hygiene behaviors were included in FallStyles, a survey completed by 3,625 adults in the fall of 2020 through an online panel representative of the U.S. POPULATION: We calculated composite capability, opportunity, and motivation measures and descriptive statistics for all measures. Finally, we conducted multiple logistic regressions to identify predictors of handwashing and hand sanitizer use. RESULTS: Most respondents reported frequently washing hands with soap and water (89%) and using alcohol-based hand sanitizer (72%) to prevent coronavirus. For capability, over 90% of respondents said that neither behavior takes a lot of effort, but fewer agreed that they knew when, or how, they should engage in handwashing (67%; 74%) and hand sanitizer use (62%; 64%). For opportunity, over 95% of respondents said lack of time didn't make it hard to engage in either behavior; fewer said visual cues reminded them to engage in the behaviors (handwashing: 30%; sanitizer use: 48%). For motivation, the majority believed the two behaviors were good ways to prevent coronavirus illness (handwashing: 76%; sanitizer use: 59%). Regressions indicated that capability, opportunity, and particularly motivation were positively associated with both hand hygiene behaviors. CONCLUSIONS: The COM-B model was a helpful framework for increasing understanding of hand hygiene behavior; it identified capability, opportunity, and motivation as predictors of both handwashing and hand sanitizer use.

The need of an updated culture of "occupational" atopic hand dermatitis in children at the time of COVID-19.

During the COVID-19 outbreak, handwashing emerged as an essential tool to prevent the spread of SARS-CoV-2 virus. It can put into practice using warm water and soap or, if not available, alcohol-based hand sanitizers (ABHS). Anyway, the use of warm water and soap is not always possible. On the contrary, ABHS are frequently used for their versatility, but can represent a risk factor for atopic dermatitis exacerbations in the pediatric age. At the same time, the Italian Ministry of Health established a school regulation, asking the students to periodically disinfect hands with sanitizing gel, or soap and water, especially before entering classrooms and laboratories, immediately after contact with everyday objects, after using the toilet, after throwing away the handkerchief and before and after eating. No rules have been personalized in this statement for children affected by atopic dermatitis attending the school. Based on this observation, we reported two case reports, involving children with a known diagnosis of atopic dermatitis, who attended our Pediatric Allergy Unit in Mantua, Italy. They experienced a worsening of symptoms related to AD on their hands in the last year for an intensive handwashing with ABHS before entering all classrooms and laboratories every day at school. Avoiding ABHS at school and washing their hands with a non-alcohol and additives soap and water solved their problem and brought their atopic dermatitis back to good control. So, it seems appropriate to consider ABHS as a "school trigger" and the low-controlled atopic dermatitis of these two patients as an "occupational dermatitis". An adequate pediatric culture of atopic dermatitis at the time of COVID 19 is needed.

Compliance with COVID-19 preventive measures among chronic disease patients in Wolaita and Dawuro zones, Southern Ethiopia: A proportional odds model.

INTRODUCTION: So far, shreds of evidence have shown that COVID-19 related hospitalization, serious outcomes, and mortality were high among individuals with chronic medical conditions. However, strict compliance with basic public health measures such as hand washing with soap, social distancing, and wearing masks has been recommended and proven effective in preventing transmission of the infection. Therefore, this study aimed to determine the level of compliance with COVID-19 preventive measures and identify its predictors among patients with common chronic diseases in public hospitals of Southern Ethiopia by applying the proportional odds model. METHODS: A facility-based cross-sectional study was employed in public hospitals of Southern Ethiopia between February and March 2021. Using a systematic random sampling technique, 419 patients with common chronic diseases were recruited. Data were collected using an Open Data Kit and then submitted to the online server. The proportional odds model was employed, and the level of significance was declared at a p-value of less than 0.05. RESULTS: This study revealed that 55.2% (95%CI: 50.4%-59.9%) of the study participants had low compliance levels with COVID-19 preventive measures. The final proportional odds model identified that perceived susceptibility (AOR: 0.91, 95%CI: 0.84, 0.97), cues to action (AOR: 0.89, 95%CI: 0.85, 0.94), having access to drinking water piped into the dwelling (AOR: 0.52, 95%CI: 0.32, 0.84), having no access to any internet (AOR: 0.62, 95%CI: 0.42, 0.92), having no functional refrigerator (AOR: 2.17, 95%CI: 1.26, 3.74), and having poor knowledge (AOR: 1.42, 95%CI: 1.02, 1.98) were the independent predictors of low compliance level with COVID-19 preventive measures. CONCLUSION: In the study area, more than half of the participants had low compliance levels with COVID-19 preventive measures. Thus, the identified factors should be considered when designing, planning, and implementing new interventional strategies, so as to improve the participants' compliance level.

Factors predicting proper handwashing practice amidst the COVID-19 pandemic in India: a field-based cross-sectional study.

Proper handwashing is one of the effective ways to prevent many communicable diseases, including COVID-19. We explored the handwashing practices in a rural Indian population before the probable third wave of the COVID-19 pandemic. A data collection schedule was administered to eligible adult members of a rural community, selected by multi-stage sampling, to assess their pattern and practice of handwashing. All 176 respondents washed their hands after defecation, 82.4 and 80.7% washed hands after urination and before taking food, respectively, while 68.2% of respondents washed hands after coming back from outdoors. Among those who handwashed, 82.9% used soap water after defecation; 46.2, 45.8 and 50.8% washed hands with soap water after urination, before taking food and after visiting outdoors, respectively. Only a quarter (24.4%) of all the participants used soap water for handwashing consistently after defecation, after urination, before taking food and after coming home. The more educated, those coming from higher socioeconomic stratum and working from home, were more likely to report proper handwashing practice. Handwashing, as recommended by health agencies, for restraining COVID-19 infection, was not noticed in the majority of the participants. Better awareness of handwashing is recommended to help restrain COVID-19 in the Indian population.

Investigation of a COVID-19 outbreak at a regional prison, Northern Uganda, September 2020.

Despite implementing measures to prevent introduction of COVID-19 in prisons, a COVID-19 outbreak occurred at Moroto Prison, northern Uganda in September 2020. We investigated factors associated with the introduction and spread of COVID-19 in the prison. A case was PCR-confirmed SARS-CoV-2 infection in a prisoner/staff at Moroto Prison during August-September 2020. We reviewed prison medical records to identify case-patients and interviewed prison and hospital staff to understand possible infection mechanisms for the index case-patient and opportunities for spread. In a retrospective cohort study, we interviewed all prisoners and available staff to identify risk factors. Data were analyzed using log-binomial regression. On September 1, 2020, a recently-hospitalized prisoner with unrecognized SARS-CoV-2 infection was admitted to Moroto Prison quarantine. He had become infected while sharing a hospital ward with a subsequently-diagnosed COVID-19 patient. A sample taken from the hospitalized prisoner on August 20 tested positive on September 3. Mass reactive testing at the prison on September 6, 14, and 15 revealed infection among 202/692 prisoners and 8/90 staff (overall attack rate=27%). One prison staff and one prisoner who cared for the sick prisoner while at the hospital re-entered the main prison without quarantining. Both tested positive on September 6. Food and cleaning service providers also regularly transited between quarantine and unrestricted prison areas. Using facemasks >50% of the time (adjusted risk ratio [aRR]=0.26; 95%CI: 0.13-0.54), or in combination with handwashing after touching surfaces (aRR=0.25; 95%CI: 0.14-0.46) were protective. Prisoners recently transferred from other facilities to Moroto Prison had an increased risk of infection (aRR=1.50; 95%CI: 1.02-2.22). COVID-19 was likely introduced into Moroto Prison quarantine by a prisoner with hospital-acquired infection and delayed test results, and/or by caretakers who were not quarantined after hospital exposures. The outbreak may have amplified via shared food/cleaning service providers who transited between quarantined and non-quarantined prisoners. Facemasks and handwashing were protective. Reduced test turnaround time for the hospitalized prisoner could have averted this outbreak. Testing incoming prisoners for SARS-CoV-2 before quarantine, providing unrestricted soap/water for handwashing, and universal facemask use in prisons could mitigate risk of future outbreaks.

Evaluation of quality and antimicrobial efficacy of locally manufactured alcohol-based hand sanitizers marketed in Addis Ababa, Ethiopia in the era of COVID-19.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has been rapidly spreading across the globe since the World Health Organization (WHO) has declared the disease outbreak as a global pandemic on March 11, 2020. Hand hygiene, via either regular handwashing with soap and water or using hand sanitizers, is among the various measures that need to be followed to control the outbreak of the disease. Alcohol-based hand sanitizers (ABHS) are the "gold standard" for hand disinfection because of their broad antimicrobial spectrum of activity, easy availability, better safety profile, and general acceptability to users. This study aimed at evaluating the physicochemical quality and antimicrobial efficacy of the locally manufactured ABHS marketed in Addis Ababa, Ethiopia. METHODS: A cross-sectional survey was used to collect ABHS from Addis Ababa marketplaces. A total of 25 sample products were randomly selected from different categories of hand sanitizer manufacturers. The physicochemical evaluation of the products was carried out as per the United States Pharmacopoeia and WHO standards. Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, Staphylococcus aureus, Salmonella spp., and Shigella spp clinical isolates were used for the antimicrobial efficacy test. RESULTS: The Fourier Transform Infrared result confirmed that all the test products met the identification test for ethanol. The majority (68%) of ABHS complied with the test for ethanol content (75-85% v/v). However, only 3 products fulfilled the hydrogen peroxide content (0.112-0.137% v/v). LPC307 showed the maximum zone of inhibition of 12 mm against Escherichia coli whereas MPC204 exhibited only 3 mm. LPC101 was found to be more sensitive to Shigella and Klebsiella Spp with minimum inhibitory concentration values of 20% and 10%, respectively. The sample product LPC101 showed a minimum bactericidal concentration of 20% against Escherichia coli, Pseudomonas aeruginosa, and Klebsiella spp. CONCLUSION: One-third of the tested ABHS did not comply with the WHO ethanol content limit and the majority of the products failed to meet the label claim for hydrogen peroxide content. Besides, nearly all products proved that they have activity against all the tested pathogenic microorganisms at a minimum concentration from 10 to 80%; though, they did not show 99.9% bacteriostatic or bactericidal activities as claimed. The study findings suggested regular monitoring of the quality of marketed ABHS considering the current wide use of these products.

Handwashing Practice among Elementary Schoolchildren in Urban Setting, Mongolia: A School-Based Cross-Sectional Survey.

Objectives: Handwashing with soap is the simplest, most affordable, and cost-effective preventative intervention for reducing the burden of communicable diseases, including the COVID-19. This study was aimed at investigating elementary schoolchildren's handwashing practice at two critical moments, namely, before eating and after using the toilet and its associated factors. Methods: The cross-sectional study was conducted at ten public secondary schools in Ulaanbaatar, Mongolia, between February and March 2019. Data were collected from all fifth-grade children's parents at the selected schools by using a self-reported questionnaire. Descriptive and multiple regression analyses were conducted using STATA/MP version 13.0. Results: A total of 1507 parents/guardians of 5th-grade school children participated. Reported schoolchildren's handwashing practice for both critical moments was 50.1%. It was significantly associated with female gender (adjusted odds ratio [AOR] = 0.56 (95%CI = 0.45, 0.70)), number of siblings (AOR = 0.72 (95%CI = 0.61, 0.80)), and availability of handwashing amenity at school (AOR = 1.1595%CI = 0.86, 1.42)). Only 34% of children wash their hands with soap at school, and the most common reasons for skipping handwashing were an absence of soap (23.9%), lack of sink (14.5%), and the use of hand sanitizer (19.7%). Conclusions: The school children's handwashing practice at two critical moments is considerably low. The main disabling factors of regular handwashing at school included insufficient handwashing facility and soap. Therefore, promoting HW facilities and innovative and participatory education for elementary schoolchildren should be prioritized.

Remote infection control assessments in long-term care facilities during COVID-19 pandemic in Texas, 2020.

BACKGROUND: The Texas Department of State Health Services (DSHS) Healthcare Safety Unit (HCSU) conducts remote infection control assessments (tele-ICARs) in long-term care facilities (LTCFs) to evaluate COVID-19 infection prevention and control (IPC) knowledge and practices using a standardized assessment tool. Tele-ICARs are used to gauge different IPC measures specific to SARS-CoV-2 and are either proactive--conducted prior to identified cases--or responsive to an outbreak, which is defined as a new SARS-CoV-2 infection in any staff or any facility-onset infection in a resident. State and local partners use findings from the assessments to aid LTCFs by providing targeted and timely resources and support to mitigate identified gaps. METHODS: Data from tele-ICARs conducted between March 1 and October 30, 2020 were analyzed to assess major gaps across LTCF types. A major gap was defined as 10% or more of facilities not satisfying a specific IPC measure, excluding missing data. Gaps were also assessed by tele-ICAR type: proactive or responsive. Fisher's exact tests and univariate logistic regression were used to characterize significant associations between major IPC gaps and LTCF or tele-ICAR type. RESULTS: DSHS conducted tele-ICARs in 438 LTCFs in Texas during 8 months; 191 were nursing homes/skilled nursing facilities (NH/SNFs), 206 were assisted living facilities (ALFs) and 41 were other settings. Of the assessments, 264 were proactive and 174 responsive. Major gaps identified were: (1) 22% did not have a preference for alcohol-based hand sanitizer (ABHS) over soap and water; (2) 18.1% were not aware of the contact time for disinfectants in use; (3) 17.9% had not stopped resident communal dining; (4) 16.8% did not audit hand hygiene and PPE compliance; and (5) 11.8% had not stopped inter-facility group activities and extra-facility field trips. When restricting analyses to proactive tele-ICARs, one additional gap was identified: 11.1% of facilities lacked a dedicated space to care for or cohort residents with confirmed SARS-CoV-2 infection. Significantly more ALFs than NH/SNFs had not suspended resident communal dining (P < .001) nor identified a dedicated space to cohort residents with confirmed SARS-CoV-2 infection (P < .001). Significantly more LTCFs that received a responsive ICAR compared to a proactive ICAR reported a preference for ABHS over soap and water (P = .008) and reported suspending communal dining (P < .001) and group activities (P < .001). Also, significantly more LTCFs that received a responsive ICAR compared to a proactive ICAR had identified a dedicated space to cohort residents with confirmed SARS-CoV-2 (P = .009). CONCLUSIONS: Increased facility education and awareness of federal and state guidelines for group activities and communal dining is warranted in Texas, emphasizing the importance of social distancing for preventing the transmission of SARS-CoV-2 in LTCFs, particularly ALFs. CDC recommendations for ABHS versus hand washing should be emphasized, as well as the importance of monitoring and auditing HCP hand hygiene and PPE compliance. Facilities may benefit from additional education and resources about disinfection, to ensure proper selection of disinfectants and understanding of the contact time required for efficacy. Analysis by tele-ICAR type suggests facilities may benefit from identifying space for dedicated COVID-19 units in advance of an outbreak in their facility. Conducting tele-ICARs in LTCFs enables public health agencies to provide direct and individualized feedback to facilities and identify state-wide opportunities for effective interventions in response to SARS-CoV-2.

Effect of New Surfactants on Biological Properties of Liquid Soaps.

Liquid soaps are the basic cosmetics used to clean the skin of the hands. Frequent hand washing prevents viral contamination but may damage the skin's hydro-lipid layer, leading to various types of irritation. Therefore, four liquid soap formulas were developed with three amphoteric surfactants: Cocamidopropyl Betaine (LS II), CocamidopropylHydroxysultaine (LS III), and newly synthesized Evening PrimroseaamidopropylSulfobetaine (LS IV). We evaluated the skin irritating potential (zein number, bovine albumin test) and cytotoxicity (AlamarBlue™, Cell viability, and Cell cycle assays) on HaCaT cell line. We observed lower values of the zein number and bovine albumin tests after adding soaps with surfactants (the highest differences in LS IV) compared to the base soap (LS I). However, LS I and LS II did not differ in cytotoxic assays. Therefore, adding LS III and LS IV seems potentially more dangerous to the cells. However, it should be noted that cells were continuously exposed to liquid soaps for more than 24 h, so its cytotoxic effects after dermal use in humans may be unnoticeable. Concluding, results suggest that the newly synthesized LS IV should improve the safety of liquid hand washing soaps.

Changes in residents' hygiene awareness and behaviors in public toilets before and during the COVID-19 pandemic in Hangzhou, China: a two-round cross-sectional study.

BACKGROUND: Hygiene behaviors in public toilets are important to prevent the transmission of infectious diseases, especially during the pandemic. All through the novel coronavirus (COVID-19) pandemic, governments in many countries published guidance on personal hygiene for the general population to prevent disease transmission. This study aimed to investigate improvements in residents' hygiene awareness and behaviors in public toilets before and during the pandemic. METHODS: We recruited 316 residents between November and December 2018 before the pandemic, and 314 residents between December 2020 and January 2021 during the pandemic in the same study sites in Hangzhou, a well-developed city in China. Residents' hygiene behaviors in public toilets, hygiene awareness, risk perception, and sociodemographic factors were collected. Bivariate analysis and multivariable logistic regressions were used to test the differences between the two rounds. We conducted an observational study to record the provision of hygiene amenities at toilets during the pandemic. RESULTS: After controlling for sociodemographic factors (gender, marital status, age, education level, and monthly household income), compared with respondents recruited before the pandemic, respondents recruited during the pandemic were more likely to perceive the risks of infection when using public toilets (aOR = 1.77, 95%CI [1.20, 2.60]), and were more likely to be aware of the risks of touching contaminated toilet facilities (aOR = 1.72, 95%CI [1.17, 2.54]) and the risks of not using soap to wash one's hands after using the toilet (aOR = 1.93, 95%CI [1.38, 2.72]). They were more likely to always clean their toilet seat with alcohol (aOR = 1.88, 95%CI [1.01, 3.51]), wash hands with soap (aOR = 1.52, 95%CI [1.09, 2.10]) and dry their hands with a dryer (aOR = 1.78, 95%CI [1.16, 2.71]), but they were less likely to always wash their hands after using the toilets (aOR = 0.57, 95%CI [0.32, 1.00]). Among 70 public toilets observed, 9 provided alcohol for toilet seat disinfection, 52 provided soap, 33 provided paper towels, and 41 had working hand dryers. CONCLUSIONS: Despite the overall improvement, residents' hygiene behaviors in public toilets and the supply of hygiene amenities were still suboptimal during the pandemic. Further hygiene education and an adequate supply of hygiene amenities in public toilets are needed to promote residents' hygiene behaviors.

Assessment of Anti-Bacterial Effectiveness of Hand Sanitizers Commonly Used in South Africa.

Hand sanitizers are used as an alternative to hand washing to reduce the number of viable microorganisms when soap and water are not readily available. This study aimed to investigate the anti-bacterial effectiveness of commercially available hand sanitizers and those commonly used in healthcare and community settings. A mapping exercise was done to select and procure different hand sanitizers (n = 18) from retailers. Five microorganisms implicated in hospital-acquired infections were selected and tested against each hand sanitizer: Escherichia coli, Enterococcus faecalis, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus. Twenty-one volunteers were recruited to do a handprint before and after applying the hand sanitizer. Only four out of eighteen hand sanitizers (22%) were effective against all tested bacterial species, and an equal number (22%) were completely ineffective. Seven hand sanitizers with a label claim of 99.99% were only effective against E. coli. Only five hand sanitizers (27%) effectively reduced bacteria on participants' hands. This study showed that only a fifth of hand sanitizers were effective against selected microorganisms. The findings raise a concern about the effectiveness of hand sanitizers and their role in infection, prevention, and control if not well regulated.