1. Association Between Intensive Handwashing Promotion and Child Development in Karachi, Pakistan: A Cluster Randomized Controlled Trial Bowen A, Agboatwalla M, Luby S, Tobery T, Ayers T, Hoekstra RM. Association between intensive handwashing promotion and child development in Karachi, Pakistan: a cluster randomized controlled trial. Arch Pediatr Adolesc Med. Published online September 17, 2012. doi:10.1001/archpediatrics.2012.1181. Copyright restrictions may apply

2. Background –Approximately 200 million children are at risk for impaired development due to environmental and social conditions. –The determinants of child development are complex and multifactorial, but include diarrhea and stunting. –Handwashing promotion has been associated with substantial reductions in diarrheal and respiratory disease burdens among children. Effects of handwashing on child growth and development are unknown. Study Objective –To evaluate associations between handwashing promotion and child growth and development. Copyright restrictions may apply Introduction

3. Setting –Informal settlements in Karachi, Pakistan, that typically receive at least 2 hours of running water per week. Study Design –Neighborhoods were randomized to control (n = 9), handwashing promotion (n = 9), or handwashing and drinking water treatment (n = 10) during original trial in 2003. –Handwashing promotion consisted of weekly handwashing education and provision of free soap as needed for 9 months. Outcomes/Analyses –Developmental quotients and anthropometric measurements of children at ages 5-7 years (several years after the original trial). –Analyses were design adjusted and by intent to treat. Copyright restrictions may apply Photo courtesy of HOPE Methods

4. Limitations –16% of the eligible households were lost to follow-up. –Battelle Developmental Inventory II was not validated for use in Pakistan, but: The instrument was translated and adapted carefully for the study population. Effect size is reported relative to controls measured with the same instrument. –Study population resided in an area with a large burden of diarrheal disease and extensive environmental contamination. Results may not be generalizable to other settings. –Study was not designed to assess mechanisms underlying growth or developmental effects. Copyright restrictions may apply Methods

5. Participants –Households 461 households enrolled. Households that reenrolled were similar to those that did not. –Derived from 391 eligible households (84%). –Children One child in target age range was randomly selected from each household: –Control160 children –Handwashing141 children –Handwashing + water treatment160 children Parental literacy, household size and income, breastfeeding exposure, and school exposure of the reenrolled children were similar across study groups. Copyright restrictions may apply Results

6. Results Developmental Quotients by Study Group (Control Group and Combined Handwashing Groups) Copyright restrictions may apply Domain GroupEffect Size P Value ControlHandwashingAbsoluteSD Mean (95% CI) Global98.3 (93.1 to 103.4)104.4 (101.9 to 107.0)6.1 (0.4 to 11.8)0.4.04 Adaptive107.9 (102.7 to 113.1)112.0 (110.0 to 114.1)4.1 (-1.4 to 9.7)0.3.14 Personal-social106.6 (103.2 to 110.0)110.3 (108.3 to 112.2)3.7 (-0.2 to 7.5)0.2.06 Communication99.7 (95.1 to 104.4)105.7 (103.5 to 107.8)5.9 (0.9 to 11.0)0.4.02 Cognitive91.1 (85.0 to 97.3)97.4 (94.1 to 100.7)6.2 (-0.7 to 13.2)0.4.08 Motor90.3 (84.7 to 96.0)96.2 (92.9 to 99.5)5.9 (-0.6 to 12.4)0.4.08

7. Copyright restrictions may apply Z Score Control (n = 9 Clusters and 160 Participants) Mean (95% CI) Handwashing (n = 9 Clusters and 141 Participants) Mean (95% CI) Handwashing + Water Treatment (n = 10 Clusters and 160 Participants) Mean (95% CI) P Value Height for age-1.09 (-1.46 to -0.72)-1.12 (-1.40 to -0.84)-1.22 (-1.44 to -1.01).46 Weight for age-1.55 (-1.85 to -1.26)-1.52 (-1.79 to -1.26)-1.69 (-1.90 to -1.47).39 Body mass index for age -1.29 (-1.54 to -1.04)-1.19 (-1.35 to -1.03)-1.34 (-1.57 to -1.10).75 Results Anthropometric Measurements by Study Group

8. In this study, children randomized to intensive handwashing promotion early in life had global developmental quotients 0.4 SD higher than control children at ages 5-7 years. –Similar improvements were found across adaptive, personal-social, communication, cognitive, and motor domains. –This effect size is comparable to those reported for early intervention programs for premature infants and a publicly funded preschool program in the United States. Undernutrition was common, and anthropometric measurements were not associated with handwashing intervention. Copyright restrictions may apply Comment

9. The mechanisms underpinning these findings are unclear but may be related to the following: –Decreased exposure to pathogens and less immune stimulation. Intervention children experienced less than half the diarrhea of control children in 2003. –Greater interaction with the environment resulting from: Less time spent ill. Parents engaging children to wash hands throughout each day. Additional efforts should be undertaken to understand the processes described and to promote handwashing quickly and efficiently. Copyright restrictions may apply Comment

10. If you have questions, please contact the corresponding author: –Anna Bowen, MD, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS C-09, Atlanta, GA 30333 (abowen@cdc.gov). Copyright restrictions may apply Photo courtesy of Stephen Luby The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Contact Information