Student hand cleaning rates (% of toileting events) and duration captured by in-person structured observation <i>versus</i> video observation.

<p>*p<0.05.</p>φ<p>Rate-ratios (RR) and p-values reported for Poisson regression analysis of rate differences between video and in-person data, while controlling for the individual school at which the data were collected.</p

Hand cleaning rates (% of toileting events) when the subject was observed to be alone in the video frame <i>versus</i> when other students were present in the frame, as captured by video surveillance.

<p>Hand cleaning rates (% of toileting events) when the subject was observed to be alone in the video frame <i>versus</i> when other students were present in the frame, as captured by video surveillance.</p

Hand cleaning rates (% of toileting events) captured by video surveillance data (left), and by in-person observation (right).

<p>Simultaneous monitoring refers periods when in-person observation and video surveillance were conducted concurrently.</p><p>*p<0.05.</p>φ<p>Rate-ratios (RR) and p-values reported for Poisson regression analysis of rate differences between simultaneous and independent monitoring, while controlling for the individual school at which the data were collected.</p

Average rate of hand cleaning (% of toileting events) captured by video surveillance preceding and during in-person observation (days with concurrent video/in-person observation only).

<p>Average rate of hand cleaning (% of toileting events) captured by video surveillance preceding and during in-person observation (days with concurrent video/in-person observation only).</p

Proportion of student toileting events followed by hand cleaning, shown by number of other people present at the hand cleaning station (visible within the camera view frame).

<p>Error bars show standard error of the mean.</p

Schematic of study design.

<p>Number of toileting events captured on video surveillance (N_V) and through in-person observation (N_P), during independent (single-method) <i>versus</i> simultaneous monitoring periods.</p

Still frame from a camera positioned above a handwashing with soap station next to a latrine (door is open).

<p>Still frame from a camera positioned above a handwashing with soap station next to a latrine (door is open).</p

Impact of Intensive Handwashing Promotion on Secondary Household Influenza-Like Illness in Rural Bangladesh: Findings from a Randomized Controlled Trial

<div><p>Rationale</p><p>There is little evidence for the efficacy of handwashing for prevention of influenza transmission in resource-poor settings. We tested the impact of intensive handwashing promotion on household transmission of influenza-like illness and influenza in rural Bangladesh.</p><p>Methods</p><p>In 2009–10, we identified index case-patients with influenza-like illness (fever with cough or sore throat) who were the only symptomatic person in their household. Household compounds of index case-patients were randomized to control or intervention (soap and daily handwashing promotion). We conducted daily surveillance and collected oropharyngeal specimens. Secondary attack ratios (SAR) were calculated for influenza and ILI in each arm. Among controls, we investigated individual risk factors for ILI among household contacts of index case-patients.</p><p>Results</p><p>Among 377 index case-patients, the mean number of days between fever onset and study enrollment was 2.1 (SD 1.7) among the 184 controls and 2.6 (SD 2.9) among 193 intervention case-patients. Influenza infection was confirmed in 20% of controls and 12% of intervention index case-patients. The SAR for influenza-like illness among household contacts was 9.5% among intervention (158/1661) and 7.7% among control households (115/1498) (SAR ratio 1.24, 95% CI 0.92–1.65). The SAR ratio for influenza was 2.40 (95% CI 0.68–8.47). In the control arm, susceptible contacts <2 years old (RR_adj 5.51, 95% CI 3.43–8.85), those living with an index case-patient enrolled ≤24 hours after symptom onset (RR_adj 1.91, 95% CI 1.18–3.10), and those who reported multiple daily interactions with the index case-patient (RR_adj 1.94, 95% CI 1.71–3.26) were at increased risk of influenza-like illness.</p><p>Discussion</p><p>Handwashing promotion initiated after illness onset in a household member did not protect against influenza-like illness or influenza. Behavior may not have changed rapidly enough to curb transmission between household members. A reactive approach to reduce household influenza transmission through handwashing promotion may be ineffective in the context of rural Bangladesh.</p><p>Trial Registration</p><p>ClinicalTrials.gov <a href="http://clinicaltrials.gov/ct2/show/NCT00880659?term=NCT00880659&rank=1" target="_blank">NCT00880659</a></p></div

Impact of intensive handwashing promotion on secondary attack risks (SAR) of influenza-like illness, and influenza, among household compound members of index case-patients, Kishoregonj, Bangladesh, 2009–2010.

<p>*All susceptible contacts in both index case-patient and secondary households included.</p><p>**Confidence intervals and P-values generated using log binomial regression model with generalized estimating equations to estimate significance of ratio of secondary attack risks in treatment arms.</p><p>Impact of intensive handwashing promotion on secondary attack risks (SAR) of influenza-like illness, and influenza, among household compound members of index case-patients, Kishoregonj, Bangladesh, 2009–2010.</p

Multivariable analysis of impact of intensive handwashing promotion on secondary attack risks (SAR) of influenza-like illness, and influenza, among household compound members of index case-patients, Kishoregonj, Bangladesh, 2009–2010.

<p>Multivariable analysis of impact of intensive handwashing promotion on secondary attack risks (SAR) of influenza-like illness, and influenza, among household compound members of index case-patients, Kishoregonj, Bangladesh, 2009–2010.</p