Does use of an instant hand sanitizer reduce elementary school illness absenteeism?

Journal of Family Practice, Jan, 2001 by Johnathan Gore, Jerry A. Lambert

Dyer DL, Shinder A, Shinder F. Alcohol-free instant hand sanitizer reduces elementary school illness absenteeism. Fam Med 2000; 32:633-68.

* BACKGROUND Hand washing is generally considered to be beneficial in fighting the plethora of viral and bacterial pathogens in school settings. Many antimicrobial rinse-free hand-sanitizing formulas are available. The one chosen for this study (CleanHands) contains surfactants, allantoin, and benzalkonium chloride. Unlike alcohol- or triclosan-based products, this one has persistent antiviral and antimicrobial properties and does not irritate or dry the skin.

* POPULATION STUDIED All 420 students from a private elementary school were included. Their ages ranged from 5 to 12 years (all grades from kindergarten through sixth grade).

* STUDY DESIGN AND VALIDITY This was a 10-week crossover study of hand sanitizer use in conjunction with at-will soap and water hand washing. The subjects were not formally randomized; they were grouped by school class into 2 similar groups. There was no blinding. All of the students received education on the importance of hand washing before the study started. Seven classes then received instant hand sanitizer, and 7 were assigned to the control group. In addition to at-will hand washing with soap and water, children in the study group used the hand cleaner under teacher supervision immediately after entering the classroom, before eating, after sneezing or coughing, and after using the restroom. Children in the control group were only told to wash before eating and after going to the restroom but were not monitored for hand washing. The initial study group was evaluated for 4 weeks. After a 2-week washout period the 2 groups switched roles.

Use of crossover method reduces the likelihood that the outcome difference is due to differences in the groups. Amazingly, all of the students were involved with no exclusions or dropouts. These students attended a private school, however, so socioeconomic diversity may have been limited. The monitoring of hand washing with sanitizer in the study group but not the control group raises questions about the true benefit of the specific sanitizer use versus that of supervised hand washing with any product.

* OUTCOMES MEASURED The teachers recorded days absent, and parents provided the reasons for the absence, which if due to illness were then broken down into gastrointestinal (GI) illness versus respiratory illness.

* RESULTS During the study period the number of absences caused by a communicable acute illness was reduced by 33.6% (P=.001) in the first group and 55.7% (P=-.001) in the second group compared with their respective control groups. Absences for all causes were reduced by 48% (P=.001) and 43% (P=.05) in the 2 groups. GI illnesses in the 2 groups were significantly reduced by 37.5% (P=.001) in the first group but not in the second group. Absences for respiratory illnesses were reduced 30.9% (P=.02) and 76% (P=.001) during the 2 time periods. During the 2-week washout period the absences were statistically similar between the 2 groups. No adverse events were reported.

RECOMMENDATIONS FOR CLINICAL PRACTICE

This study demonstrated something mothers have always known: the benefit of clean hands. Clearly, having the teacher frequently tell children to clean their hands (and watching them do so) is more efficacious than giving them hall passes to go to the restroom unsupervised. Problems with this intervention include adding more responsibilities to teachers, adding training to institute this practice in public schools, and losing teaching time. This inexpensive, easy-to-use intervention could have an astounding impact, however, since the diverse effects of school absenteeism include effects on funding of public schools, remediation for absent students, and parents' loss of work to stay home and care for sick children. As primary care providers, we should educate our young patients and their parents about the importance of clean hands.

Johnathan Gore, MD Jerry A. Lambert, MD Medical College of Georgia Augusta E-mail: jlambert@mail.mcg.edu