By Philip R. Fischer, MD, DTM&H

Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN

Dr. Fischer reports no financial relationships relevant to this field of study.

SYNOPSIS: In day care settings, the implementation of hand hygiene programs reduced respiratory illness, absenteeism, and antibiotic use in children 0 to 3 years of age. Using hand sanitizer was more effective than washing with soap and water.

SOURCE: Azor-Martinez E, Yui-Hifume R, Munoz-Vico FJ, et al. Effectiveness of a hand hygiene program at child care centers: A cluster randomized trial. Pediatrics 2018;142:e20181245.

Respiratory tract infections are a major cause of illness, medical office visits, and antibiotic prescriptions for preschool-age children. Attendance at day care centers is a significant risk factor for becoming ill with respiratory tract infections, and children in day care have six to 10 respiratory tract infections each year. In school-age children, implementation of hand hygiene interventions reduces infections and school absenteeism. However, there are not many data about the effectiveness of hand hygiene programs in preschoolers in day care settings.

Thus, Azor-Martinez and colleagues randomized day care centers (and the children attending those centers) to either hand hygiene (with groups randomized to use soap and water or hand sanitizer) or control groups. There were 25 state-registered day care centers in the area of a single city in Spain included in the study. Researchers included families of children 0 to 3 years of age who attended day care for at least 15 hours per week. Children with chronic illnesses and medication use that might alter the risk of respiratory tract infection were excluded.

Prior to the study period, parents and day care center staff who were randomized to an intervention group attended a one-hour workshop about hand hygiene. Participants were encouraged not to alter their usual post-toileting cleaning or the manner by which they cleaned visibly dirty hands. However, they were instructed to use the intervention (soap-and-water washing or sanitizer use) before and after lunch, after outdoor play, prior to leaving school for home, after diapering, and after sneezing, coughing, or blowing their noses.

Sanitizer (70% alcohol) or soap (not specifically bactericidal) was provided for the schools and homes. Informational brochures about hand hygiene were available in the intervention day care centers. All day care centers, both in the intervention and control groups, provided informational sessions about respiratory infections and fever. Children were followed carefully for eight months.

The study included 960 children (82% of those who were eligible; the others did not have parental authorization for participation) from the 25 day care centers. One child in the sanitizer group had worsened atopic dermatitis; no other adverse effects were noted.

In this study, more than three-fourths of children received a 13-valent pneumococcal vaccine. Receipt of this bacterial vaccine did not significantly alter the risk of contracting a respiratory illness.

Overall, the 960 children had 5,211 respiratory illnesses during the eight-month study period. Children received antibiotics for 39% of those illnesses. The rate of respiratory infection was 21% lower in the sanitizer group than in the soap-and-water group, and 23% lower than in the control group. Day care absenteeism was significantly lower in the intervention groups (3.3% with sanitizer, 3.9% with soap and water) than in the control group (4.2%). The rate of antibiotic use was 31% lower in the sanitizer group than in the control group (which was similar to the soap-and-water group in terms of antibiotic use).

In summary, the Spanish team found that hand hygiene education and practice (whether with sanitizer or soap and water) reduced day care center absenteeism. Interestingly, children assigned to use sanitizer had significantly less infection, absenteeism, and antibiotic use than those who used soap and water for hand hygiene.


What seems right is right — hand hygiene is effective in reducing illness and missed activity in preschool-age children. This is congruent with experience in older school-age children, but the availability of hand hygiene materials must be supplemented by instruction that promotes helpful behaviors.1 Even though the impact of hand hygiene programs varies between settings,2 many medical and education professionals are aware of the value of hand hygiene, and hand hygiene is increasingly implemented in many child care settings.

As we think back over the past two decades, we realize that hand hygiene in hospitals became a standard not just because of knowledge about the value of hand hygiene. Rather, people started cleaning their hands on entering and exiting hospital rooms when hand hygiene became easy and convenient. A systematic review suggests that multimodal strategies are needed to improve compliance with hand hygiene most effectively.3,4 Similarly, hand hygiene should become easy and convenient in day care centers and schools.

Why was sanitizing more effective than hand washing in this study? There are several potential explanations. First, sanitizer kills germs while soap and water “just” removes germs from hands. Future studies could compare the use of regular and bactericidal soaps in preventing infection in day care settings.

Second, the authors did not measure compliance with the implementation of sanitizing programs. It could be that hand washing was implemented less in the day care centers assigned to that intervention because it was not as easy or convenient. Hand washing requires sinks, a means of drying, and a longer pause at the sink. Sanitizing simply requires a quick hand motion while passing a dispenser and some hand rubbing while moving on toward the next activity. Whatever means of hand hygiene is suggested, success depends on effective implementation.

Third, the authors did not mention the means of drying in the soap and water group. Hand washing is most effective in reducing bacterial colonization when accompanied by the use of a sterile (rather than non-sterile) towel.5 If wet towels were reused repeatedly, the towels might have served as reservoirs of infection to facilitate ongoing microbial transmission.

Sanitizer use in hospitals might be facilitated by programs that have patients remind care providers to use sanitizer before and after patient contact.6 Similarly, parents and even children can be empowered to ensure that sanitizer is available conveniently in day care settings and for individual student use. By whatever means, hand hygiene can prevent illness in preschool-age children, decrease absence from planned activities, and reduce costs of medical care. It is time for implementation; faced with new data from Spain, don’t just analyze, sanitize!


  1. Lau CH, Springston EE, Sohn MW, et al. Hand hygiene instruction decreases illness-related absenteeism in elementary schools: A prospective cohort study. BMC Pediatr 2012;12:52.
  2. McGuinness SL, Barker SF, O’Toole J, et al. Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: A systematic review. Trop Med Int Health 2018;23:816-833.
  3. Gould DJ, Moralejo D, Drey N, et al. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev 2017;9:CD005186.
  4. Alshehari AA, Park S, Rashid H. Strategies to improve hand hygiene compliance among healthcare workers in adult intensive care units: A mini systematic review. J Hosp Infect 2018;100:152-158.
  5. Siddiqui N, Friedman Z, McGeer A, et al. Optimal hand washing technique to minimize bacterial contamination before neuraxial anesthesia: A randomized control trial. Int J Obstet Anesthes 2017;29:39-44.
  6. Alzyood M, Jackson D, Brooke J, Aveyard H. An integrative review exploring the perceptions of patients and healthcare professionals towards patient involvement in promoting hand hygiene compliance in the hospital setting. J Clin Nurs 2018;27:1329-1345.