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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
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
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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
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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
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
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.
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