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Schoolchildren are commonly linked to influenza transmission. Handwashing with soap has been shown to decrease infections; however, improving handwashing practices using soap and water is difficult in low-resource settings. In these settings, alternative hygiene options, such as hand sanitizer, could improve handwashing promotion to reduce influenza virus infections. We conducted a cluster randomized control trial in 24 primary schools in Dhaka to assess the effectiveness of hand sanitizer and a respiratory hygiene education intervention in reducing influenza-like illness (ILI) and laboratory-confirmed influenza during June–September 2015. Twelve schools were randomly selected to receive hand sanitizer and respiratory hygiene education, and 12 schools received no intervention. Field staff actively followed children daily to monitor for new ILI episodes (cough with fever) through school visits and by phone if a child was absent. When an illness episode was identified, medical technologists collected nasal swabs to test for influenza viruses. During the 10-week follow-up period, the incidence of ILI per 1,000 student-weeks was 22 in the intervention group versus 27 in the control group (P-value = 0.4). The incidence of laboratory-confirmed influenza was 53% lower in the intervention schools (3/1,000 person-weeks) than in the control schools (6/1,000 person-weeks) (P-value = 0.01). Hand sanitizer and respiratory hygiene education can help to reduce the risk of influenza virus transmission in schools.

BackgroundDiarrhea prevalence increases from around the time that complementary foods are introduced. Improving caregiver’s hand hygiene during food preparation could reduce complementary food contamination and enteric pathogen transmission. Washing hands with soap is more common when water and soap are together at a convenient location. We conducted a three-month pilot intervention to evaluate two options for setting up handwashing stations: i) provide a handwashing station, or ii) help the family to make their own from available materials. Additionally, we assessed the feasibility of this intervention to be integrated with a child feeding program.MethodsWe conducted the intervention among two groups; 40 households received a free of cost handwashing station and another 40 households were motivated to place their own soap/soapy-water and water vessel near the food preparation and child feeding area. Community health workers encouraged caregivers to wash hands with soap/soapy-water before food preparation and feeding a child. They either assisted study participants to install the study-provided handwashing station at the recommended place or encouraged caregivers to develop their own. Field researchers assessed placement and composition of handwashing stations and the feasibility of integrating handwashing and nutrition messages.ResultsBy end of the trial, 39/40 households developed their own handwashing station, comprising a bucket, mug and bar soap/soapy-water of which 60% (6/10) households were observed with a functional and complete handwashing station set. Observed handwashing with soap was detected among 8/10 households from the study-provided handwashing station group and 5/10 among households who had made their own handwashing station. Sixty-seven of the 76 caregivers recalled integrated intervention messages on social and health benefits of infant and young child feeding correctly; and all recalled key handwashing with soap times, before food preparation and feeding a child.ConclusionEncouraging households to develop their own handwashing station with soap and water to place at a food preparation/child feeding location is feasible over the short term. In the absence of large-scale provision of handwashing stations, caregivers can be encouraged to create and use their own. Integrating handwashing with soap into a nutrition intervention was feasible and acceptable and should be considered by policy makers.

Background Acute diarrhoeal disease management often requires rehydration alone without antibiotics. However, non-indicated antibiotics are frequently ordered and this is an important driver of antimicrobial resistance. The mHealth Diarrhoea Management (mHDM) trial aimed to establish whether electronic decision support improves rehydration and antibiotic guideline adherence in resource-limited settings.Methods A cluster randomised controlled trial was done at ten district hospitals in Bangladesh. Inclusion criteria were patients aged 2 months or older with uncomplicated acute diarrhoea. Admission orders were observed without intervention in the pre-intervention period, followed by randomisation to electronic (rehydration calculator) or paper formatted WHO guidelines for the intervention period. The primary outcome was rate of intravenous fluid ordered as a binary variable. Generalised linear mixed-effect models, accounting for hospital clustering, served as the analytical framework; the analysis was intention to treat. The trial is registered with ClinicalTrials.gov (NCT03154229) and is completed. Findings From March 11 to Sept 10, 2018, 4975 patients (75•6%) of 6577 screened patients were enrolled. The intervention effect for the primary outcome showed no significant differences in rates of intravenous fluids ordered as a function of decision-support type. Intravenous fluid orders decreased by 0•9 percentage points for paper electronic decision support and 4•2 percentage points for electronic decision support, with a 4•2-point difference between decision-support types in the intervention period (paper 98•7% [95% CI 91•8-99•8] vs electronic 94•5% [72•2-99•1]; p interaction =0•31). Adverse events such as complications and mortality events were uncommon and could not be statistically estimated. Interpretation Although intravenous fluid orders did not change, electronic decision support was associated with increases in the volume of intravenous fluid ordered and decreases in antibiotics ordered, which are consistent with WHO guidelines.

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