Munn Zachary, Tufanaru Catalin, Lockwood Craig, Stern Cindy, McAneney Helen, Barker Timothy H
The University of Adelaide, Joanna Briggs Institute, Faculty of Health Sciences, 55 King William Road, Adelaide, South Australia, Australia, 5005.
Macquarie University, Australian Institute of Health Innovation, 75 Talavera Rd, Sydney, New South Wales (NSW), Australia, 2113.
Cochrane Database Syst Rev. 2020 Apr 9;4(4):CD012566. doi: 10.1002/14651858.CD012566.pub2.
Illness-related absenteeism is an important problem among preschool and school children for low-, middle- and high- income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse-free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness-related absenteeism in preschool and school children.
In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied.
Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse-free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions.
Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings.
This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day-care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most-notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse-free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low-certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse-free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse-free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low-certainty evidence), which indicates rinse-free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse-free' group (eight days absent per 1000). There may be little to no difference between rinse-free hand washing and 'no rinse-free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low-certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very-low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse-free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very-low certainty evidence).
AUTHORS' CONCLUSIONS: The findings of this review may have identified a small yet potentially beneficial effect of rinse-free hand washing regimes on illness-related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse-free hand washing regimens in order to provide more conclusive, higher-certainty evidence regarding its impact. When considering the use of a rinse-free hand washing program in a local setting, there needs to be consideration of the current rates of illness-related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings.
在低收入、中等收入和高收入国家，因病缺勤是学龄前儿童和在校儿童中存在的一个重要问题。适当的手部卫生是一项常用的、经过研究并实施的策略，旨在减少疾病传播，进而减少缺勤天数。大多数手部卫生策略包括用肥皂和水洗手，然而，这与一些阻碍其使用的因素有关，比如需要自来水，以及洗手后需要擦干双手。另一种方法是使用免冲洗洗手液洗手。与传统的手部卫生策略相比，这种技术有许多优点，并且可能在减少学龄前儿童和在校儿童因病缺勤方面被证明是有益的。
2020年2月，我们检索了Cochrane系统评价数据库、医学期刊数据库、Embase数据库、护理学与健康领域数据库、其他12个数据库以及三个临床试验注册库。我们还查阅了纳入研究的参考文献列表，并根据需要直接联系研究的主要作者以收集更多信息。检索没有设置日期或语言限制。
随机对照试验（RCT），无论其发表状态如何，比较任何形式的免冲洗洗手（洗手液、手部消毒剂、凝胶、泡沫等）与用肥皂和水进行的传统洗手、其他手部卫生计划（如仅进行教育）或不进行干预。研究对象为年龄在2至18岁之间，就读于学前班（托儿所、日托中心、幼儿园等）或学校（小学、初中、小学等）的儿童。主要结局包括儿童或学生因任何原因缺勤、因病缺勤以及皮肤不良反应。
按照Cochrane的标准方法，两位综述作者（ZM、CT、CL、CS、TB中的两位）独立选择纳入研究，评估偏倚风险并提取相关数据。缺勤数据以缺勤学生天数占总天数的比例形式提取。有时以原始数字报告，有时以发病率比（IRR）报告，我们也提取了这些数据。对于不良事件数据，我们计算效应量作为风险比（RRs），并给出95%置信区间（CIs）。我们使用Cochrane预期的标准方法程序进行数据分析，并遵循GRADE方法确定研究结果的确定性。
本综述纳入了19项研究，共30747名参与者。大多数研究在美国进行（8项研究），两项在西班牙进行，中国、哥伦比亚、芬兰、法国、肯尼亚、孟加拉国、新西兰、瑞典和泰国各进行了一项。6项研究在学前班或日托中心进行（年龄从出生到小于5岁的儿童），其余13项在小学进行（年龄在5至14岁的儿童）。纳入研究在几个领域被判定为存在高偏倚风险，最明显的是在实施和检测偏倚领域，因为难以对实施干预的人员或评估结果的人员进行盲法处理。此外，每个感兴趣的结局的证据确定性等级为低或极低，主要原因是高偏倚风险，以及效应估计的不精确性和汇总数据之间的不一致性。对于因任何原因缺勤的结局，免冲洗洗手的汇总估计IRR为0.91（95%CI 0.82至1.01；2项研究；极低确定性证据），这表明两组之间可能几乎没有差异。对于因病缺勤，汇总IRR为0.82（95%CI 0.69至0.97；6项研究；极低确定性证据），这表明与“无免冲洗”组相比，免冲洗洗手可能会减少缺勤（每1000人中有13天缺勤）（“无免冲洗”组每1000人中有16天缺勤）。对于急性呼吸道疾病缺勤的结局，汇总IRR为0.79（95%CI 0.68至0.92；6项研究；极低确定性证据），这表明与“无免冲洗”组相比，免冲洗洗手可能会减少缺勤（每1000人中有33天缺勤）（“无免冲洗”组每1000人中有42天缺勤）。在评估急性胃肠道疾病缺勤时，汇总估计发现IRR为0.79（95%CI 0.73至0.85；4项研究；低确定性证据），这表明与“无免冲洗”组相比，免冲洗洗手可能会减少缺勤（每1000人中有6天缺勤）（“无免冲洗”组每1000人中有8天缺勤）。在皮肤不良反应方面，免冲洗洗手与“无免冲洗”组之间可能几乎没有差异，RR为1.03（95%CI 0.8至1.32；3项研究，4365名参与者；极低确定性证据）。总体而言，干预措施的依从性似乎从中度到高度不等（9项研究，10749名参与者；极低确定性证据）；从叙述来看，没有作者报告依从性方面的重大问题。总体而言，大多数纳入了关于认知数据的研究报告称，教师和学生对免冲洗洗手持积极看法，并愿意继续使用（3项研究，1229名参与者；极低确定性证据）。
本综述的结果可能已经确定免冲洗洗手方案对因病缺勤有微小但潜在有益的影响。然而，根据GRADE方法，得出这一结论的证据确定性低或极低，因此尚不确定。需要在各级学校进行进一步研究，以评估免冲洗洗手方案，以便提供更具决定性、更高确定性的证据，说明其影响。在考虑在当地环境中使用免冲洗洗手方案时，需要考虑当前因病缺勤的发生率，以及此处看到的微小有益效果是否会在其环境中转化为有意义的减少。
