title: Impact of Intensive Handwashing Promotion on Secondary Household Influenza-Like Illness in Rural Bangladesh: Findings from a Randomized Controlled Trial.
abstract: BACKGROUND
  There is little evidence for the efficacy of handwashing for prevention of influenza transmission in resource-poor settings. We tested the impact of intensive handwashing promotion on household transmission of influenza-like illness and influenza in rural Bangladesh.
  
  
  METHODS
  In 2009-10, we identified index case-patients with influenza-like illness (fever with cough or sore throat) who were the only symptomatic person in their household. Household compounds of index case-patients were randomized to control or intervention (soap and daily handwashing promotion). We conducted daily surveillance and collected oropharyngeal specimens. Secondary attack ratios (SAR) were calculated for influenza and ILI in each arm. Among controls, we investigated individual risk factors for ILI among household contacts of index case-patients.
  
  
  RESULTS
  Among 377 index case-patients, the mean number of days between fever onset and study enrollment was 2.1 (SD 1.7) among the 184 controls and 2.6 (SD 2.9) among 193 intervention case-patients. Influenza infection was confirmed in 20% of controls and 12% of intervention index case-patients. The SAR for influenza-like illness among household contacts was 9.5% among intervention (158/1661) and 7.7% among control households (115/1498) (SAR ratio 1.24, 95% CI 0.92-1.65). The SAR ratio for influenza was 2.40 (95% CI 0.68-8.47). In the control arm, susceptible contacts <2 years old (RRadj 5.51, 95% CI 3.43-8.85), those living with an index case-patient enrolled ≤24 hours after symptom onset (RRadj 1.91, 95% CI 1.18-3.10), and those who reported multiple daily interactions with the index case-patient (RRadj 1.94, 95% CI 1.71-3.26) were at increased risk of influenza-like illness.
  
  
  CONCLUSIONS
  Handwashing promotion initiated after illness onset in a household member did not protect against influenza-like illness or influenza. Behavior may not have changed rapidly enough to curb transmission between household members. A reactive approach to reduce household influenza transmission through handwashing promotion may be ineffective in the context of rural Bangladesh.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT00880659.
authors.affiliation: Department of Epidemiology and Environmental Health, State University of New York at Buffalo, Buffalo, NY, United States of America.
authors.forename: Pavani K
authors.initials: PK
authors.lastname: Ram
authors.affiliation: Department of Epidemiology and Environmental Health, State University of New York at Buffalo, Buffalo, NY, United States of America.
authors.forename: Margaret A
authors.initials: MA
authors.lastname: DiVita
authors.affiliation: Centre for Communicable Diseases, International Centre for Diarrhoeal Diseases Research, Bangladesh, Dhaka, Bangladesh.
authors.forename: Kaniz
authors.initials: K
authors.lastname: Khatun-e-Jannat
authors.affiliation: Centre for Communicable Diseases, International Centre for Diarrhoeal Diseases Research, Bangladesh, Dhaka, Bangladesh.
authors.forename: Manoshi
authors.initials: M
authors.lastname: Islam
authors.affiliation: Department of Epidemiology and Environmental Health, State University of New York at Buffalo, Buffalo, NY, United States of America.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Krytus
authors.affiliation: Department of Epidemiology and Environmental Health, State University of New York at Buffalo, Buffalo, NY, United States of America.
authors.forename: Emily
authors.initials: E
authors.lastname: Cercone
authors.affiliation: Centre for Communicable Diseases, International Centre for Diarrhoeal Diseases Research, Bangladesh, Dhaka, Bangladesh.
authors.forename: Badrul Munir
authors.initials: BM
authors.lastname: Sohel
authors.affiliation: Centre for Communicable Diseases, International Centre for Diarrhoeal Diseases Research, Bangladesh, Dhaka, Bangladesh.
authors.forename: Makhdum
authors.initials: M
authors.lastname: Ahmed
authors.affiliation: Centre for Communicable Diseases, International Centre for Diarrhoeal Diseases Research, Bangladesh, Dhaka, Bangladesh.
authors.forename: Abid Mahmud Quaiyum
authors.initials: AM
authors.lastname: Rahman
authors.affiliation: Centre for Communicable Diseases, International Centre for Diarrhoeal Diseases Research, Bangladesh, Dhaka, Bangladesh.
authors.forename: Mustafizur
authors.initials: M
authors.lastname: Rahman
authors.affiliation: Department of Biostatistics, State University of New York at Buffalo, Buffalo, NY, United States of America.
authors.forename: Jihnhee
authors.initials: J
authors.lastname: Yu
authors.affiliation: Centre for Communicable Diseases, International Centre for Diarrhoeal Diseases Research, Bangladesh, Dhaka, Bangladesh.
authors.forename: W Abdullah
authors.initials: WA
authors.lastname: Brooks
authors.affiliation: Centre for Communicable Diseases, International Centre for Diarrhoeal Diseases Research, Bangladesh, Dhaka, Bangladesh.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Azziz-Baumgartner
authors.affiliation: Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, United States of America.
authors.forename: Alicia M
authors.initials: AM
authors.lastname: Fry
authors.affiliation: Centre for Communicable Diseases, International Centre for Diarrhoeal Diseases Research, Bangladesh, Dhaka, Bangladesh.
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Luby
mesh_terms: D001459:Bangladesh / Q000453:epidemiology; D002675:Child, Preschool; D005191:Family Characteristics; D005260:Female; D006235:Hand Disinfection / Q000379:methods*; D006801:Humans; D007223:Infant; D007251:Influenza, Human / Q000175:diagnosis / Q000517:prevention & control* / Q000635:transmission*; D008297:Male; D009960:Oropharynx / Q000821:virology*; D012424:Rural Population