Why is domestic hygiene so important? Each day more than 27,000 children under the age of 5 die, mainly from preventable infections and almost all in countries with limited resources (Black et al. (2003), in Pitett, 2005). Three quarters of this number occurs in sub-Saharan Africa and south Asia and are due to pneumonia and diarrheal diseases.

The intake of unsafe water, the unavailability of water for hygiene and lack of access to sanitation are the causes of approximately 1.5 million child deaths and 88% of deaths from diarrhea. (Black, Morris & Bryce, 2003). Figure 3 shows which the distribution of child deaths by cause. Diarrhea is the responsible disease for 22% of child deaths.

According to Curtis et al. (2000), improving domestic hygiene practices is potentially one of the most effective means of reducing global burden of diarrhoeal disease in children. Diarrheal diseases account for over a quarter of the deaths of children each year (WHO 1993), mostly for children under the age of 5. Moreover, the WHO calculated that there are 4 billion of diarrhoeal cases each year, from which 2.2 million people die from these diseases. Furthermore, Murray & Lopez (1992) estimated that 10% of the people in the developing world are severly infected with intestinal worms related to improper waste and excreta management.

Research into hygiene education programs has concluded that safe disposal of fecal matter and hand washing after contact with adult and child stools should be priorities. Most transmissions occur in the domestic habitat, and can be prevented by changes in domestic hygiene behavior (Cairncross, 1990).

Water, sanitation (e.g. excreta disposal) and hygiene account for the second highest risk factor in disability adjusted life years (DALY) described by Global Burden of Disease (GBD), behind malnutrition.

Table 1 shows the results of a study by Esrey et al. (1991) on the reduction of diarheae morbildiy as a consequence of several water and sanitation measures. According to Esrey et al., diahhrea mortality and child mortality was reduced by respectively 65% and 55% when improved water and sanitation measures were introduced.

Type of water and sanitation measure
Table 1. Reduction in diarrhoeal morbidity from specified water and sanitation improvements based on rigorous studies (Esrey et al. 1991)

Percentage reduction in diarrhoea morbidity

Sanitation (improved excreta disposal) 36
Improved hygiene 33
Water and sanitation 30
Water quantity 20
Water quality and quantity 17
Water quality 15

What is the value of handwashing and soap?

Frequent handwashing can interrupt the transmission routes of several bacteria. It is important to distinguish handwashing as a primary barrier (after handling fecal matter) and a secondary barrier (before preparing food, handling fluids, feeding, eating, etc.) for the transmission of bacterias. There are many epidemiological studies on handwashing which claim substantial reductions in diarrheal morbidity, however, few studies make distinctions between it as a primary or secondary barrier.

There has been several studies on the effect of handwashing on reducing diarrhoeal diseases. Wilson et al. (1989) found a reduction of 89% of diarrhea incidence through promotion of hand washing after 4 different circumstances, one of which is after defecation in Indonesia. Furthermore, Han and Hlaing (1989) claim a 30% reduction by encouraging hand washing in Burma. In 1982, Khan found a reduced incidence of shigellois by 84% and diarrhea by 37% by hand-washing with soap after defecation and before ingesting food. Stanton and Clemens (1987) and Alam (1989) showed that hand-washing was one of the factors which lowered incidence of diarrhea in Bangladesh. Pinfold (1996) showed a significant reduction in hand contamination and in diarrheal disease by an intervention to promote hand washing in Thailand.

Soap and hand washing education reduces impetigo by 34%, diarrhea by 53% and pneumonia by 50% (Pittet, 2005). Reducing the incidence of pneumonia and severe diarrheal disease would save millions of lives on a larger scale in high-risk populations (Black et al 2003, Curtis et al 2003). Cost-effectiveness and sustainability are important elements to any hand-hygiene promotion (Boyce et al 2002, Pittet et al 2000, Pittet et al 2004).

Curtis and Cairncross (2003) conducted a systematic review on the effect of washing hands with soap on diarrhea risk. They concluded that on current evidence, washing hands with soap can reduce the risk of diarrheal diseases by 42-47%. They support the idea that interventions to promote hand washing might save a million lives. The World Health Report stated in 2000 that diarrheal diseases are amongst the top three killers of children in the world today. Interventions are needed to prevent faecal material to enter the domestic environment. Hand washing plays an important role in preventing those diseases to transmit. People's hands have contact with faecal material during anal cleansing of adults and children, and diarrheal diseases can be transmitted by unwashed hands to drinks, foodstuffs and the mouth.

It is unethical to conduct a study on the impact of hand washing on diarrhea mortality. The report suggests that interventions to reduce diarrheal diseases may lead to the same or even a bigger reduction of diarrheal deaths. Diarrheal deaths are mostly associated with persistent diarrhea and dysentery.
Table 3 gives estimates of the number of people that could be saved when hand washing is universally adopted.

Promoting hand-washing with soap after defaecation and before contact with food seems to be the simplest, fastest and most cost-effective method of reducing the major cause of childhood death and adult morbidity in an underprivileged society, as has been showed in a study conducted in Indonesia (Wilson et al., 1991). In a village in central Lombock, Indonesia, mothers were told the importance of using soap for hygiene and against diarrhea. Additionally free soap was distributed. The number of diarrhea cases in a time span before and after the distribution was counted. The cases decreased by 89%.

Water availability?

The availability of water has an impact on the frequency of handwashing. According to Cairncross (1997), mothers tend to restrict their handwashing when water is further than 1km from home, while when water is freely available at close range hand-washing becomes more frequent. This partly explains why increasing the availability of local water supplies decreases the risk on diarrhoeal diseases. Furthermore, the water used for drinking and hand washing in underdeveloped countries is heavily contaminated with faecal organisms (Pittet, 2005).

Two and a half billion people do not have access to improved sanitation worldwide, as is illustrated by Figure 1 (WHO 2000a).

Sanitation coverage

Figure 1. Global coverage of sanitation by world region in 2000 (WHO 2000a).

How can we promote hygiene?

Hygiene promotion is increasingly favored by policymakers because of its potential to deliver reductions in diarrheal disease at low cost. Many hygenical practices are present in educational material. It is important for public health planners to make decisions about which hygiene practices should be promoted.

Handwashing appears to be both highly effective (between 27-87% reduction in diarrheal disease) and feasible. Efforts to increase domestic hygiene should concentrate on hand-washing after stool contact, especially after defecation or after cleaning up a child.

(The World Health Organisation (WHO) provides guidelines on hand hygiene in health care (2005). Th WHO states that hand hygiene, a very simple action, reduces infection and enhances patient safety across all settings, from advanced health-care systems in industrialized countries to local dispensaries in developing countries. Hand hygiene remains the primary measure to reduce health-care associated infections. 4384 children die everyday from health care-associated infections in developing countries.
The report provides health-care workers, hospital administrators and health authorities a review of different aspects of hand hygiene and in-depth information to overcome barriers, as it focuses on a lot of soap-based/cleaner strategies. )

WHO's Water for Life 2005-2015 initiative (International Decade for Action 2005) makes access to water and sanitation an international priority. Clean Care is Safe Care is the slogan of first Global Patient Safety Challenge (GPSC), a core component of the WHO's World Alliance for Patient Safety launched in 2004 (WHO, 2005). The GPSC targets prevention in health-care related infections and hand hygiene improvement.


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