Download Comment Handwashing and community management of infections

Comment
THELANCET-D-15-00777
S0140-6736(15)60460-3
Embargo: August 7, 2015—00:01 (BST)
Handwashing and community management of infections
Influenza has a strong potential to transfer from
individual to individual, and encounters in everyday
life play an important part in its diffusion in the
population. Wherever people meet—at work, in shops,
on public transport—there is the risk of transmission,
suggesting that the community is the context in which
protection against further spread has to be orchestrated.
Vaccination, personal hygiene (including handwashing),
and measures against crowding are recommended
measures.1 Primary care is important in influenza
vaccination because it can reach large numbers of people
at high risk of influenza complications and provide them
with effective protection against the virus.2,3 At the same
time, general practitioners and other professionals in
primary care will be the point of contact for those who
have contracted influenza. In this community context,
the home environment has a special place, because
people are together there for lengthy periods, often in
limited space, and with intimate physical contact.
The study by Paul Little and colleagues4 reported
in The Lancet provides important information. The
investigators studied the effects of handwashing in a
trial in more than 16 000 households randomised from
344 UK general practices. Their findings showed a small
but tangible protective effect of handwashing on the
contraction and transfer of infections: after 16 weeks,
4242 (51%) individuals reported one or more episodes
of respiratory-tract infections in the intervention group
compared with 5135 (59%) individuals in the control
group (multivariate risk ratio 0·86, 95% CI 0·83–0·89).
This reduction was accompanied by lower demand for
professional care (617 [6%] vs 535 (6%); 0·83 (0·74–
0·94) and fewer antibiotic prescriptions (1021 (11%) vs
951 (10%); 0·90 (0·82–0·98).
Little and colleagues deserve praise for their ability to
preserve the real-life environment of busy primary care
in the research setting of their trial, which facilitates
the translation of the study into routine practice. Their
use of the internet to reach households, inform and
instruct individuals about handwashing, and maintain
its application is innovative. This approach was founded
on important values of general practice and primary
care: its relation to a defined community population,
with the family and household setting as a key focus,
and empowerment of people to care for their own
health as a core objective.5 Furthermore, the success
of the web-based intervention will have been at least
partly determined by the fact that it was delivered from
a trusted source; innovative approaches in information
technology can be of great value, particularly when
integrated into and built on the strength of primary
care.
A second point is the engagement of individuals
and the population: the study was not only able to
recruit substantial participation, representative of
the primary care population, but also to retain their
commitment to self-care over time. The management
of influenza in the population has no single magic
bullet that can be imposed through professional care.
Protection of individuals (particularly those at highest
risk), prevention of further spread in the community,
and early identification of individuals in need of
intensive treatment each require targeted measures
with incremental effects on the impact of infection
on the population. Additionally, processes that can be
managed by communities and individuals themselves
do not add to the burden of professional health
care—a particular issue during influenza pandemics.
In such a situation, the small effects on individual risk
of infection and decreased demand on primary care
services achieved by Little and colleagues4 could add up
to substantial benefits.
These findings stress the importance of peoplecentred primary health care for population health.6,7
Influenza is only one of the many infectious diseases
that can affect populations, and influenza-related
experience could inform more general efforts in
prevention and management of the spread of infections
in the population. An even more important point to
take from this study4 is therefore the promotion of
handwashing as a generic routine to manage transfer of
infections. This broader applicability is the intervention’s
real attraction, and should be the basis of any costeffectiveness calculation as well. In this context, the
small reduction in antibiotic prescriptions should be
taken into account. The investigators showed improved
management of infections while using fewer antibiotics,
which is in line with policies to counter the threat of
population resistance to antibiotics.8
Little and colleagues’ findings4 strongly support
www.thelancet.com Published online August 7, 2015 http://dx.doi.org/10.1016/S0140-6736(15)60460-3
Published Online
August 7, 2015
http://dx.doi.org/10.1016/
S0140-6736(15)60460-3
See Online/Articles
http://dx.doi.org/10.1016/
S0140-6736(15)60127-1
1
Comment
promotion of handwashing in the socioeconomically
and culturally diverse communities in which primary
health care operates, along with strategies to retain
adherence in the long term. The history of adherence
to handwashing by the health-care profession itself
suggests that this undertaking will not be easy, and
the values attached to handwashing are culturally
determined.9 Engagement of the actual users of
interventions in implementation is an effective
approach to secure the desired effects, and the
knowledge and experience developed in participatory
research10 provides the structure and methodology to
strengthen primary health care further. An exciting
way forward to support communities in coping better
with various infectious diseases might therefore be in
promotion of the intervention through a community
participation approach.
Chris van Weel
1
WHO. Global influenza programme. http://www.who.int/influenza/en/
(accessed Jan 30, 2015).
2 Govaert TM, Thijs CT, Masurel N, Sprenger MJ, Dinant GJ, Knottnerus JA.
The efficacy of influenza vaccination in elderly individuals. A randomized
double-blind placebo-controlled trial. JAMA 1994; 272: 1661–65.
3 Knottnerus JA. Influenza vaccination in the elderly: current evidence and
uncertainties. J Clin Epidemiol 2009; 62: 675–76.
4 Little P, Stuart B, Hobbs FDR, et al. An internet-delivered handwashing
intervention to modify influenza-like illness and respiratory infection
transmission (PRIMIT): a primary care randomised trial. Lancet 2015;
published online Aug 7. http://dx.doi.org/10.1016/
S0140-6736(15)60127-1.
5 WONCA Europe. The European definition of the general practitioner/family
physician. 2011. http://www.woncaeurope.org/sites/default/files/
documents/Definition%203rd%20ed%202011%20with%20revised%20
wonca%20tree.pdf (accessed Feb 2, 2015).
6 The Lancet. Making primary care people-centred: a 21st century blueprint.
Lancet 2014; 384: 281.
7 De Maeseneer J, van Weel C, Daeren L, et al. From “patient” to “person” to
“people”: the need for integrated, people centered health care.
Int J Pers Cent Med 2012; 2: 601–14.
8 Goossens H, Ferech M, Vander Stichele R, Elseviers M, for the ESAC project
group. Outpatient antibiotic use and association with resistance:
a cross-national database study. Lancet 2005; 365: 579–87.
9 Jumaa PA. Hand hygiene: simple and complex. Int J Infect Dis 2005; 9: 3–14.
10 Jagosh J, Macaulay AC, Pluye P, et al. Uncovering the benefits of
participatory research: implications of a realist review for health research
and practice. Milbank Q 201; 90: 311–46.
Department of Primary and Community Care, Radboud University
Medical Center, PO Box 9101, 6500 HB, Netherlands; and
Australian National University, Canberra, Australia
[email protected]
I declare no competing interests
2
www.thelancet.com Published online August 7, 2015 http://dx.doi.org/10.1016/S0140-6736(15)60460-3