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Illness Transmission in the Home: A Possible Role for Alcohol-Based Hand Gels

Grace M. Lee, Joshua A. Salomon, Jennifer F. Friedman, Patricia L. Hibberd, Dennis


Ross-Degnan, Eva Zasloff, Sitso Bediako and Donald A. Goldmann
Pediatrics 2005;115;852-860
DOI: 10.1542/peds.2004-0856

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/115/4/852

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly


publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
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rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Illness Transmission in the Home:
A Possible Role for Alcohol-Based Hand Gels

Grace M. Lee, MD, MPH*‡; Joshua A. Salomon, PhD§; Jennifer F. Friedman, MD, MPH㛳;
Patricia L. Hibberd, MD, PhD¶; Dennis Ross-Degnan, ScD*; Eva Zasloff, BA‡; Sitso Bediako, BA‡; and
Donald A. Goldmann, MD‡

ABSTRACT. Objectives. The widespread use of child ported use of alcohol-based hand gels all, most, or some
care has altered the epidemiology of respiratory and gas- of the time; 33% reported always washing their hands
trointestinal (GI) infection in the community. Our pri- after blowing or wiping a nose. In multivariate models,
mary objective was to measure transmission of respira- use of alcohol-based hand gels had a protective effect
tory and GI illnesses among families with children against respiratory illness transmission in the home.
enrolled in child care. We also sought to examine poten- Conclusions. In homes with young children enrolled
tial predictors of reduced illness transmission in the in child care, illness transmission to family members
home in a secondary analysis. occurs frequently. Alcohol-based hand gel use was asso-
Methods. We performed an observational, prospec- ciated with reduced respiratory illness transmission in
tive cohort study to determine transmission rates for the home. Pediatrics 2005;115:852–860; child care, illness
respiratory and GI illnesses within families with at least transmission, respiratory, gastrointestinal, alcohol-based
1 child between 6 months and 5 years of age enrolled in hand gels.
child care. A survey about family beliefs and practices
was mailed at the beginning of the study. Symptom
diaries were provided for families to record the timing ABBREVIATION. GI, gastrointestinal.
and duration of respiratory and GI illnesses. To ensure
the accuracy of symptom diaries, biweekly telephone

I
calls were performed to review illnesses recorded by n 1999, ⬃7.5 million children who were younger
participants. Families with >4 weeks of data recorded than 5 years were enrolled in child care in the
were included in the analysis. Families were recruited United States.1 These numbers continue to rise as
from 5 pediatric practices in the metropolitan Boston women enter the workforce in greater numbers and
area. Of 261 families who agreed to participate in the the number of single-parent homes climbs.2 In turn,
study, 208 were available for analysis. Secondary trans- the widespread use of child care facilities has influ-
mission rates for respiratory and GI illnesses were mea- enced the epidemiology of infectious diseases in the
sured as illnesses per susceptible person-month.
Results. We observed 1545 respiratory and 360 GI
community.3 Viral upper respiratory and gastroin-
illnesses in 208 families from November 2000 to May testinal (GI) infections are the 2 most common ill-
2001. Of these, 1099 (71%) respiratory and 297 (83%) GI nesses that occur among those enrolled in child
illnesses were considered primary illnesses introduced care.4–12 The concentration of young children whose
into the home. The secondary transmission rates for re- developmental status promotes transfer of secretions
spiratory and GI illnesses were 0.63 and 0.35 illnesses per via contaminated hands of caregivers and objects
susceptible person-month, respectively. Only two thirds results in enhanced transmission of these infections
of respondents correctly believed that contact transmis- within the child care setting.13,14
sion was important in the spread of colds, and fewer than
An illness in a child may affect not only that child
half believed that it was important in the spread of
stomach flus. Twenty-two percent of respondents re- but also parents, who may miss work to care for a
sick child, or any family member because of second-
ary illness transmission.3,15–20 Within families, sec-
From the *Center for Child Health Care Studies, Department of Ambulatory
ondary attack rates can be as high as 27% for respi-
Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical ratory illnesses and 70% for gastroenteritis.21–24 In
School, Boston, Massachusetts; ‡Division of Infectious Diseases, Children’s addition, intrafamilial spread compounds the eco-
Hospital Boston, Boston, Massachusetts; §Department of Population and nomic impact of child care–associated infections.25–27
International Health, Harvard Center for Population and Development
Studies, Harvard School of Public Health, Boston, Massachusetts; 㛳Interna-
Previous studies have focused on interrupting the
tional Health Institute and Department of Pediatrics, Brown University, spread of transmission of infection through im-
Providence, Rhode Island; and ¶Clinical Research Institute, Tufts–New proved hand hygiene within child care facilities and
England Medical Center, Boston, Massachusetts. elementary schools.28–36 However, few studies have
Accepted for publication Aug 19, 2004.
doi:10.1542/peds.2004-0856
focused on potential hand hygiene interventions in
No conflict of interest declared. the home setting. In 1979, Hendley et al37 studied 22
Reprint requests to (G.M.L.) Center for Child Health Care Studies, Depart- families in a crossover study using iodine to disinfect
ment of Ambulatory Care and Prevention, Harvard Pilgrim Health Care hands. When a person was sick at home, the mother
and Harvard Medical School, 133 Brookline Ave, 6th Floor, Boston, MA
02215. E-mail: grace㛭lee@hphc.org
was instructed to dip her hands in iodine every 3 to
PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Acad- 4 hours. The secondary attack rate was 7% in the
emy of Pediatrics. iodine group compared with 20% in the control

852 PEDIATRICS Vol. 115 No. 4 April 2005


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group. It was an effective but intensive intervention Those who agreed to participate were mailed a survey and a
for which compliance rates may have been excep- symptom diary at the beginning of the study. The survey asked
questions about demographic information, beliefs about illness
tionally high (96%) because study nurses observed transmission, and practices regarding hand hygiene in the home.
practices in the home. Although not a practical inter- Completed surveys were mailed back to study investigators at the
vention, this study provided important “proof of beginning of the study. Structured symptom diaries also were
concept” for the potential role of hand antisepsis in provided so that families could record the timing and duration of
respiratory and GI illnesses that occurred among family members
reducing the risk for transmission in the home. More in the home. In biweekly telephone calls, we reviewed the illnesses
recently, Larson et al38 conducted a randomized, recorded by participants. In addition, 7 families with computer
double-blind, clinical trial that examined the effect of and Internet access were selected to record illness data by hand-
antibacterial handwashing and cleaning products on held personal digital assistants (PDAs). These families synchro-
infectious disease symptoms in the home. The au- nized the information via Internet with a secure database at Chil-
dren’s Hospital Boston every 2 weeks rather than receiving
thors found no significant difference between the telephone calls. All written materials were available in English
intervention group that received antibacterial prod- and Spanish. Telephone interviews were also conducted in En-
ucts and the control group, although these products glish and Spanish.
may not have had optimal antiviral efficacy.
Waterless alcohol-based hand gels are consider- Respiratory Illnesses
ably more convenient than traditional sink-based A 7-member expert panel that was composed of pediatric in-
hand hygiene. Use of these gels is now widely advo- fectious disease and study design experts from academia and
industry was convened in June 2000 to determine definitions of
cated in health care settings because studies have illness and illness transmission for this study (see Acknowledg-
demonstrated virucidal activity and reduced antimi- ments). On the basis of consensus of our expert panel and litera-
crobial counts on hands of health care workers who ture review, a respiratory illness was defined as 2 of the following
use these agents.39,40 Alcohol-based hand gels also symptoms for 1 day or 1 of the following symptoms for 2 consec-
utive days, not including 2 consecutive days of cough alone,
are associated with reduced illness and absenteeism sneezing alone, or fever alone: (1) runny nose, (2) stuffy or blocked
in schools.36,41,42 Finally, these hand gels have been nose or noisy breathing, (3) cough, (4) feeling hot or feverish or
associated with improved compliance likely as a re- having chills, (5) sore throat, or (6) sneezing.37 A new or separate
sult of ease of use,43–45 which may be particularly respiratory illness was defined as 1 of the following: (1) the oc-
important for busy caregivers, whether in child care, currence of a respiratory illness (as defined above) after a period
of 3 illness-free days or (2) if the caregiver stated that the child or
school, or home. other household member had a new illness.37,46 A secondary
Unless other effective prevention strategies be- illness was defined as an illness that occurred in a household
come available, such as vaccines for colds and gas- member no sooner than 2 days after the onset in the index case
troenteritis, hand hygiene will continue to play a key and no later than 7 days after the onset in the index case.21,37,46
role in preventing transmission of infections in the
home setting. Our objective was to perform a de- GI Illnesses
scriptive study to measure secondary illness trans- A GI illness in adults and children ⱖ6 years was defined as 1 or
both of the following on the basis of our expert panel and litera-
mission among families with children in child care. ture review: (1) any episode of watery or much looser than normal
In addition, we explored potential predictors of re- bowel movements or stools or (2) vomiting. In children 0 to 5 years
duced illness transmission in the home. of age, a GI illness was defined as 1 or both of the following: (1) 2
or more watery or much looser than normal bowel movements or
stools over a 24-hour period or (2) any episode of vomiting or
METHODS forceful expulsion of stomach contents, not including spit-ups for
infants or young children.29,30,47–50 New or separate GI illnesses
Study Design and Study Population were defined as 1 of the following: (1) the occurrence of a GI
We performed an observational, prospective cohort study to illness (as defined above) after a period of 3 illness-free days or (2)
determine transmission rates for respiratory and GI illnesses if the caregiver stated that the household member had a new
within families with children enrolled in child care. The study was illness.30 A secondary illness was defined as an illness in a house-
reviewed and approved by the Institutional Review Boards of hold member that began no sooner than 2 days after the onset in
Children’s Hospital Boston and Harvard Pilgrim Health Care. the index case and no later than 7 days after the onset in the index
Families were recruited from 5 pediatric practices in the metro- case.21,51
politan Boston area. We chose 3 urban practices and 2 suburban
practices to include a diverse study population with respect to Outcome Measures
socioeconomic status and race/ethnicity. A random-number gen-
Our primary outcome measures were the rates of secondary
erator was used to identify 250 families from each practice for a
illness transmission, defined as the number of illnesses per sus-
total of 1250 families. Subjects were sent recruitment letters and
ceptible person-month, for respiratory and GI illnesses. The sus-
subsequently screened for eligibility and recruited by telephone to
ceptibility period for a healthy family member was defined as the
participate in the study.
period 2 to 7 days after a primary illness was introduced into the
Inclusion criteria for the families were (1) at least 1 child 6
home. We examined potential predictors of secondary illness
months to 5 years of age, (2) at least 1 child in child care with at
transmission in the home in a secondary analysis.
least 5 other children for ⱖ10 hours per week anticipated for the
duration of the study, (3) family planned to reside in the metro-
politan Boston area for the duration of study, (4) family had access Data Analysis
to a telephone, and (5) primary caregiver could speak English or Families with ⱖ4 weeks of data recorded were included in the
Spanish. Families were excluded when their homes also func- analysis of secondary illness transmission. Because our data col-
tioned as family child care centers for 5 or more children or when lection methods were different for the handheld PDA group, we
a household member’s occupation included working with chil- excluded from additional analysis the 7 families who used PDAs.
dren 6 months to 5 years of age for ⱖ10 hours per week. Because To measure secondary illness transmission, we calculated the
the primary objective of this study was descriptive, a sample size number of primary illnesses introduced in each family, deter-
of 250 families was considered sufficient to provide reasonable mined the susceptibility period of each family member after ex-
confidence intervals (CIs) for calculated illness transmission rates. posure to illness, and then measured the number of secondary
Thus, we considered study enrollment to be complete when at illnesses that occurred during each susceptibility period. The in-
least 50 families were enrolled per pediatric practice. cidence rate for secondary illnesses was defined as the number of

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secondary illnesses divided by the total number of susceptible
person-months within a family. The 95% confidence intervals
were calculated for incidence rates assuming a Poisson distribu-
tion.
To examine potential predictors of reduced illness transmis-
sion, we performed Poisson regression at the family level. The
outcome was the number of secondary illnesses that occurred
within a family; the denominator was the number of susceptible
person-days within the family. We initially conducted bivariate
analyses to examine the association between clinically relevant
variables available from the survey, such as family characteristics
and hand hygiene practices, and secondary illness transmission
rates. Site of enrollment was included as a fixed effect to account
for potential differences between families who attended different
health care centers. Variables regarding frequency of hand hy-
giene product use (water, plain soap, antibacterial soap, and alco-
hol-based hand gels) and hand hygiene practices (after wiping or
blowing a nose, changing a diaper, and using the bathroom) were
examined as ordinal variables in bivariate analyses. Predictors
were considered significant at P ⬍ .05.
Multivariate analyses were performed using forward and back-
ward stepwise Poisson regression models with ␣ set at ⱕ.15 to
enter and remove terms from the model to identify significant
independent predictors of secondary illness transmission rates in
the home. Because of small cell sizes for hand hygiene practices,
variables were dichotomized as frequent users (all, most, or some
of the time) versus infrequent users (a little or none of the time) for
the multivariate model. As before, site of enrollment was included
as a fixed effect in multivariate models to account for potential
differences as a result of enrollment methods. All analyses were
performed in Stata Intercooled 7.0.52

RESULTS
Study Participants
Of the 1250 families randomly selected (Fig 1), 49%
did not meet eligibility criteria, 22% were eligible
and contacted for study participation, and 29% were
not contacted because study enrollment was com-
plete for each pediatric practice. Of the 278 eligible
families who were contacted, 17 families refused to Fig 1. Study enrollment.
participate and 261 (94%) families were enrolled in
the study from November 2000 to May 2001. A total
of 215 (82%) families completed at least 4 weeks of age age of respondents was 34.6 years (range: 20 –50
illness transmission data for the study either by tele- years).
phone follow-up (208) or handheld PDA (7). Forty-
six families were withdrawn from the study for the Survey Responses
following reasons: study team unable to reach par- We asked individuals about their beliefs regarding
ticipants for 4 consecutive weeks (19), participants illness transmission for “colds” and “stomach flus”
did not have time to complete study (9), telephone (Table 2). Almost all respondents believed that colds
disconnected (3), parent left area (1), child no longer could be transmitted by kissing a sick person or
in child care (1), other (3), and unknown (10). having someone cough or sneeze on them (large
A total of 208 families had 105 352 person-days of droplet transmission). Approximately two thirds of
observation. The total study population consisted of respondents believed that colds could be transmitted
837 people (287 children ⱕ5 years of age including by shaking hands with a sick person or touching
those enrolled in child care, 152 children 6 –17 years objects that a sick person touched (transmission by
of age, 395 adults ⱖ18 years of age, and 3 whose ages direct and indirect contact). However, fewer than
are unknown). Families were observed for an aver- half of the respondents believed that stomach flus
age of 128 days (range: 29 –174 days). A total of 185 were transmitted by direct or indirect contact or the
(89%) families returned completed surveys. Informa- fecal-oral route.
tion about education, income, race/ethnicity, family When asked about household practices regarding
size, household density, and site of enrollment is hand hygiene, respondents reported using the fol-
described in Table 1. Hispanic or Latino families lowing all, most, or some of the time: water alone
described themselves as Puerto Rican (12), Domini- (30%), soap (90%), antibacterial soap (75%), and al-
can (17), Mexican (1), Central or South American (6), cohol-based hand gels (22%; Fig 2). Use of antibacte-
and Puerto Rican/Dominican (1). Other families in- rial soaps and alcohol-based hand gels was posi-
cluded in the study were Asian or Pacific Islander tively correlated (r ⫽ 0.417, P ⬍ .001), whereas use of
(13), Black Caribbean (6), and Black Caribbean/ antibacterial soaps and plain soaps was negatively
American Indian (1) or Alaskan Native (1). Primary correlated (r ⫽ ⫺0.198. P ⫽ .009). Most respondents
caregivers were mostly female (96%), and the aver- reported washing their hands all of the time after

854 ILLNESS TRANSMISSION IN THE HOME


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TABLE 1. Demographic and Household Characteristics of In bivariate analyses (Table 3), only reported use of
Families alcohol-based hand gels was associated with reduced
Variable n (%) respiratory illness transmission. In the multivariate
Site of enrollment (N ⫽ 208)
model, frequent use (all, most, or some of the time) of
1 43 (21) alcohol-based hand gels was associated with lower
2 44 (21) rates of secondary illness transmission in the home
3 44 (21) (Table 4).
4 40 (19)
5 37 (18) GI Illness Transmission
Family size (N ⫽ 208)
2 people 14 (7) The total number of GI illnesses was 360 during
3 people 49 (24) 105 352 person-days of observation, or 0.1 GI ill-
4 people 95 (46) nesses per person-month. Of these, 297 were primary
5 people 29 (14)
ⱖ6 people 21 (10)
GI illnesses. A total of 123 children ⱕ5 years intro-
Race/ethnicity of respondent (N ⫽ 182) duced 171 (58%) illnesses into the home, 39 children
White non-Hispanic 81 (45) 6 to 17 years of age introduced 47 (16%) new GI
Black/African-American non-Hispanic 44 (24) illnesses into the home, and 63 adults were respon-
Hispanic/Latino 37 (20) sible for 79 (27%) primary GI illnesses. Sixty-three
Other 20 (11)
Educational level of respondent (N ⫽ 175) secondary illnesses (22 [35%] in children ⱕ5 years, 7
ⱕHigh school graduate 31 (18) [11%] in children 6 –17 years, 34 [54%] in adults, 17
ⱕCollege graduate 86 (49) [50%] of whom were considered primary caregivers)
⬎College graduate 58 (33) occurred over 5500 susceptible person-days of obser-
Household income (N ⫽ 174)
⬍$20 000 30 (17)
vation, or 0.35 GI illnesses per susceptible person-
$20 000–$39 999 24 (14) month (95% CI: 0.27– 0.45). There were no significant
$40 000–$59 999 26 (15) differences in rates of secondary GI illness transmis-
$60 000–$79 999 25 (14) sion in families with and without diapered children
ⱖ$80 000 69 (40) in the home.
Insurance (N ⫽ 179)
Individual or employee-sponsored 131 (73) Bivariate analyses revealed that higher educational
Medicaid 43 (24) level and Medicaid insurance were significantly as-
Other or uninsured 5 (3) sociated with increased rates of secondary transmis-
Household density (N ⫽ 182) sion for GI illnesses (Table 3). Use of alcohol-based
0.0–1.0 person/sleeping room 55 (30)
1.1–2.0 persons/sleeping room 116 (64)
hand gels seemed to reduce secondary GI illness
2.1–3.0 persons/sleeping room 9 (5) transmission; however, this trend was not signifi-
3.1–4.0 persons/sleeping room 2 (1) cant. In multivariate analyses, only Medicaid insur-
ance remained a significant predictor of increased
secondary illness transmission in the home (Table 4).
changing a diaper (72%) or using the bathroom
(84%). However, only 33% reported always washing DISCUSSION
their hands after blowing or wiping a nose. Of note, Our study is one of the few longitudinal studies to
parents who reported frequent alcohol-based hand examine illness transmission rates in the home since
gel use were also more likely to report frequent use of child care facilities became widespread in the
handwashing after blowing or wiping a nose (r ⫽ United States. We found an average of 0.45 respira-
0.215, P ⫽ .004). tory illnesses per person-month and 0.1 GI illnesses
per person-month from November 2000 to May 2001.
Respiratory Illness Transmission In earlier longitudinal studies such as the Tecumseh
The total number of respiratory illnesses in 208 study (1976 –1981) and the Seattle Virus Watch
families (287 children ⱕ5 years, 152 children 6 –17 (1965–1969), only 0.16 to 0.29 respiratory illnesses per
years, 392 adults, and 2 unknown age) was 1545 person-month were reported.53,54 In the well-known
illnesses over 105 352 person-days of observation, or Cleveland Family Study (1948 –1957) that followed
0.45 respiratory illnesses per person-month. Of these 86 families over a 10-year period, Dingle et al21 es-
illnesses, 1099 (71%) were introduced into families as tablished the overall incidence of common respira-
primary illnesses. A total of 239 children ⱕ5 years tory and GI illnesses to be 0.47 and 0.13 per person-
were responsible for 592 (54%) primary illnesses, month, respectively. Although our illness rates were
whereas 76 children 6 to 17 years of age were respon- measured during the peak season for respiratory and
sible for 135 (12%) primary illnesses. Among adults, GI illnesses, they seem comparable to these previous
234 people introduced 371 (34%) primary illnesses studies. In addition, we chose to focus on secondary
into the family. One person who had a primary transmission because these infections are potentially
illness was of unknown age. A total of 446 secondary preventable episodes through household interven-
respiratory illnesses occurred over 21 452 susceptible tion. In our study, ⬃0.63 respiratory and 0.35 GI
person-days of observation, or 0.63 illnesses per sus- illnesses per susceptible person-month occurred in
ceptible person-month (95% CI: 0.58 – 0.69). Among households with children enrolled in child care.
those whose age was known, 168 (38%) secondary Young children were most likely to introduce respi-
illnesses occurred in children ⱕ5 years, 51 (11%) in ratory and GI illnesses into the household, although
children 6 to 17 years, and 225 (50%) in adults, 147 adults were also unexpectedly responsible for a sub-
(65%) of whom were primary caregivers. stantial number of primary respiratory illnesses.

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TABLE 2. Parental Beliefs Regarding Illness Transmission for Respiratory and GI Illnesses
Among Survey Respondents
Beliefs Regarding Transmission Via Colds, Stomach Flus,
% Agree % Agree
Direct contact
Shaking hands with a sick person 66 46
Indirect contact
Touching objects that a sick person touched 70 42
Large droplet
Talking closely with a sick person (⬍3 ft) 57 27
Having someone cough/sneeze on you (⬍3 ft) 90 N/A
Airborne
Sitting ⬎3 ft away from a sick person 20 5
Fecal-oral route
Eating food prepared by a sick person N/A 43
Changing the diapers of a sick child N/A 35
Kissing a sick person 94 N/A

Fig 2. Reported household practices regarding hand hygiene.

We found that several misconceptions may exist the majority believed in large droplet and contact
regarding mechanisms of illness transmission. Only spread of cold viruses. It may be that parents are
two thirds of respondents correctly believed that likely to overreport the frequency of behaviors such
contact transmission was important for the spread of as handwashing after bathroom use because of per-
colds, and fewer than half believed that it was im- ceived social expectations.56–58 It may also be that
portant in the spread of stomach flus. Almost all parents wash their hands for reasons other than re-
families shared the common misconception that kiss- ducing the spread of germs—for example, to remove
ing was an efficient means of spreading colds.55 Per- dirt. Regardless, we would have expected the more
haps more surprising, fewer than half stated that likely predictor of transmission to be actual practices
changing a diaper or eating food prepared by a per- rather than beliefs.
son with gastroenteritis (fecal-oral transmission) Reported hand hygiene practices in the home re-
were important in spreading stomach flus. lied principally on soap and water, with approxi-
It is interesting that parents reported washing their mately half of respondents using antibacterial soaps
hands very frequently after changing a diaper or all or most of the time and another quarter using
using the bathroom, although they did not necessar- these agents some of the time. Such frequent use of
ily believe that fecal-oral transmission was impor- antibacterial products is not surprising given that
tant. Conversely, fewer parents reported washing 75% of liquid and 29% of bar soaps that are available
their hands after blowing or wiping a nose, although to US consumers contain antibacterial ingredients.59

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TABLE 3. Bivariate Predictors of Secondary Illness Transmission in the Home
Variable Respiratory Illnesses GI Illnesses
IRR Adjusted for Site, 95% CI* P Value IRR Adjusted for Site, 95% CI* P Value
Race/ethnicity of respondent
White 1.0 — 1.0 —
Black 1.0 (0.6–1.6) .995 0.6 (0.2–2.0) .397
Hispanic 0.9 (0.5–1.6) .709 0.3 (0.0–2.6) .265
Other 1.1 (0.8–1.5) .431 0.3 (0.1–1.1) .067
Educational level of respondent
Some high school or high school graduate 0.8 (0.5–1.1) .117 0.2 (0.1–0.8) .024
Some college or college graduate 0.8 (0.7–1.0) .072 0.6 (0.3–1.2) .170
Some graduate/professional school 1.0 — 1.0 —
Household income
⬍$59 999 1.0 — 1.0 —
ⱖ$60 000 0.9 (0.6–1.2) .415 1.0 (0.3–3.8) .951
Insurance
Individual or employee-sponsored 1.0 — 1.0 —
Medicaid 1.2 (0.7–2.0) .442 4.0 (1.2–13.0) .023
Other or uninsured 1.3 (0.6–2.9) .458 † —
Household density (persons/sleeping room) 1.0 (0.8–1.2) .970 0.9 (0.5–1.6) .742
Handwashing using water alone
All of the time 0.8 (0.3–2.7) .758 ‡ ‡
Most of the time 0.9 (0.6–1.4) .747 0.5 (0.1–2.2) .367
Some of the time 1.1 (0.9–1.5) .327 1.1 (0.5–2.3) .896
A little of the time 1.2 (1.0–1.5) .121 1.5 (0.8–2.8) .159
None of the time 1.0 — 1.0 —
Handwashing using plain soap
All of the time 1.0 (0.7–1.3) .842 0.7 (0.3–1.7) .383
Most of the time 1.0 (0.8–1.3) .979 1.0 —
Some of the time 1.0 — 1.0 (0.5–1.8) .984
A little of the time 0.7 (0.4–1.2) .211 1.7 (0.6–4.7) .270
None of the time 1.3 (0.8–2.0) .246 1.5 (0.5–5.2) .493
Handwashing using antibacterial soap
All of the time 1.0 (0.7–1.3) .845 0.6 (0.2–1.5) .267
Most of the time 1.0 — 1.0 —
Some of the time 0.8 (0.6–1.1) .218 0.7 (0.3–1.4) .292
A little of the time 1.0 (0.7–1.4) .988 1.2 (0.5–2.8) .658
None of the time 1.1 (0.9–1.5) .340 0.9 (0.4–2.0) .771
Using alcohol-based hand gels
All of the time 1.0 (0.5–2.1) .955 ‡ ‡
Most of the time 0.9 (0.5–1.7) .683 0.4 (0.1–2.8) .342
Some of the time 0.6 (0.4–0.9) .014 0.3 (0.1–1.2) .091
A little of the time 1.2 (1.0–1.5) .101 0.7 (0.4–1.3) .260
None of the time 1.0 — 1.0 —
Handwashing after blowing/wiping nose
All of the time 1.0 — — —
Most of the time 1.0 (0.8–1.4) .800 — —
Some of the time 1.1 (0.8–1.5) .402 — —
A little of the time 1.1 (0.8–1.5) .694 — —
None of the time 1.0 (0.5–1.8) .923 — —
Handwashing after diaper change
All of the time — — 1.0 —
Most of the time — — 0.4 (0.2–1.1) .086
Some of the time — — 1.4 (0.7–2.9) .347
Handwashing after bathroom use
All of the time — — 1.0 —
Most of the time — — 0.6 (0.2–1.3) .180
Some of the time — — ‡ ‡
IRR indicates incidence rate ratio.
* IRR is the ratio of number of secondary illnesses occurring per susceptible person-days. The reference group for each variable is
indicated by an IRR of 1.0.
† Dropped because of collinearity.
‡ Numbers too small to produce an estimate.

In contrast, only 8% reported use of alcohol-based In multivariate models, we found that reported
hand gels all or most of the time, and 14% used these alcohol-based hand gel use was associated with re-
products some of the time. Given the convenience, duced secondary transmission of respiratory ill-
tolerability, and rapid virucidal activity of alcohol- nesses. Our findings are supported by a recent study
based products,39,45,60–64 we might expect increased in which use of an alcohol gel hand sanitizer in the
use of these products in the home over time, similar classroom was found to decrease absenteeism as a
to the rise that we have seen in the hospital setting result of respiratory, flu, and GI illnesses in elemen-
over the past 5 years.43,45,62 tary school students.36 Another study by Fendler et

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TABLE 4. Independent Predictors of Secondary Transmission of Respiratory and GI Illnesses in the Home on Multivariate Analysis
Variable Respiratory Illnesses, IRR GI Illnesses, IRR P Value
Adjusted for Site Adjusted for Site
(95% CI) (95% CI)
Using alcohol-based hand gels 0.6 (0.4–0.9) .010
Educational level of respondent
Some high school or high school graduate 0.1 (0.0–1.0) .054
Some college or college graduate 0.6 (0.3–1.2) .138
Some graduate/professional school 1.0 —
Insurance
Individual or employee-sponsored 1.0 —
Medicaid 4.3 (1.2–15.2) .023
Insurance (Medicaid) ⫻ education 3.1 (0.2–43.8) .397
(some high school or high school graduate)

al65 also demonstrated efficacy of alcohol-based There are several limitations to this study that
hand gels in reducing nosocomial respiratory tract should be acknowledged. First, our outcome mea-
infections in extended care facilities. Ours is the first sure was based on reported symptoms or illnesses by
study to suggest that using alcohol-based hand gels the family caregiver. We were unable to validate the
for hand hygiene may reduce secondary respiratory cause of these illnesses by microbiologic diagnoses or
infection rates in the home setting. serologic assays. However, previous work has sug-
In our analysis of secondary GI illness transmis- gested that self-reported symptoms for respiratory
sion, we observed a pattern of reduced transmission and GI illnesses are a valid proxy for physician-
among users of alcohol-based hand gels in bivariate reported symptoms.38,69,70 Second, we relied on pa-
analyses; however, we may not have had the power rental reports of frequency of hand hygiene prac-
in this exploratory analysis to detect a statistically tices. We were unable to validate independently the
significant effect as a result of the relatively small quantity of hand hygiene product used or the fre-
number of GI illnesses seen during this study period. quency of hand hygiene practices after common
In addition, the reported use of alcohol-based hand household events such as using the bathroom. Al-
gels by primary caregivers was used as a proxy for though parents may overreport the frequency of
the family, which may have reduced our ability these hand hygiene practices to conform to social
to detect a significant difference if all family mem- expectations,56–58 the impact of overreporting, if all
bers did not share similar hand hygiene behaviors. else were equal, would be to reduce our ability to
Finally, the lack of a statistically significant effect detect a significant difference in secondary illness
may also be explained by the variable activity of transmission rates through misclassification. The
alcohol against GI pathogens. For example, studies finding that use of alcohol-based hand gels was as-
have demonstrated an excellent virucidal effect of
sociated with reduced secondary transmission in the
alcohol when used for rotavirus-contaminated sur-
home therefore might reflect a conservative estimate
faces, whereas handwashing with plain soap may
of potential impact.
actually further spread the virus.66–68 However,
Finally, use of alcohol-based hand gels may simply
other viral causes of child care–associated GI ill-
serve as a proxy for good hand hygiene behaviors.
nesses such as noroviruses may not be killed effi-
ciently by alcohol-based hand gels.47 Families who use these products may have had in-
One of the strengths of our study is the measure- creased awareness of the importance of hand hy-
ment of the incidence rate of secondary illnesses, giene in the interruption of illness transmission, as
rather than just the total number of illnesses that suggested by the association between alcohol-based
occurred in each family. We believe that this is a hand gel use and handwashing after blowing or
more appropriate measure because we would not wiping a nose. Thus, the product itself may not nec-
predict that a household intervention would neces- essarily be responsible for the observed protective
sarily reduce the number of primary illnesses that effect. Unfortunately, we were not able to answer
occurred in the family, unless home practices were this question definitively through our observational
applied vigorously outside the household. We also study. For determining the true impact of alcohol-
attempted to enroll families from diverse socioeco- based hand gels on illness transmission, a random-
nomic and racial/ethnic backgrounds by recruiting ized controlled trial in the home setting should be
from urban and suburban settings and conducting performed.
the survey and telephone interviews in both English In conclusion, our study demonstrates that fre-
and Spanish. Thus, our population may be more quent transmission of illnesses is occurring in the
representative of illness transmission rates in the home of families with young children enrolled in
community, especially when compared with the child care. Alcohol-based hand gel use was associ-
Cleveland Family Study (1948 –1957), which pur- ated with reduced respiratory illness transmission in
posely selected families who lived in suburban areas, the home. Targeted educational interventions about
had high educational levels, and were recommended the importance of hand hygiene and use of alcohol-
to study investigators by their family physicians or based hand gels should be considered for use in the
pediatricians.21 future.

858 ILLNESS TRANSMISSION IN THE HOME


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ACKNOWLEDGMENTS 23. Rodriguez WJ, Kim HW, Brandt CD, et al. Common exposure outbreak
of gastroenteritis due to type 2 rotavirus with high secondary attack rate
Dr Lee was supported by an Agency for Healthcare Quality within families. J Infect Dis. 1979;140:353–357
and Research training grant (T32 HS 000063), and Dr Friedman 24. Haug KW, Orstavik I, Kvelstad G. Rotavirus infections in families. A
was supported by a Health Research and Services Administration clinical and virological study. Scand J Infect Dis. 1978;10:265–269
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Benckiser, Inc. No promotional product or materials were used burden of non-influenza-related viral respiratory tract infection in the
during this study. United States. Arch Intern Med. 2003;163:487– 494
We gratefully acknowledge the pediatric practices and all of the 26. Liddle JL, Burgess MA, Gilbert GL, et al. Rotavirus gastroenteritis:
families who participated in this study. We also thank our expert impact on young children, their families and the health care system.
panel members for invaluable input: Donald Goldmann, MD; Med J Aust. 1997;167:304 –307
Penelope Dennehy, MD; Girish Dixit, MD; J. Owen Hendley, MD; 27. Haskins R, Kotch J. Day care and illness: evidence, cost, and public
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Illness Transmission in the Home: A Possible Role for Alcohol-Based Hand Gels
Grace M. Lee, Joshua A. Salomon, Jennifer F. Friedman, Patricia L. Hibberd, Dennis
Ross-Degnan, Eva Zasloff, Sitso Bediako and Donald A. Goldmann
Pediatrics 2005;115;852-860
DOI: 10.1542/peds.2004-0856
Updated Information including high-resolution figures, can be found at:
& Services http://www.pediatrics.org/cgi/content/full/115/4/852
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