Journal of Medical Microbiology (2007), 56, 659–663
DOI 10.1099/jmm.0.46867-0
Effect of intensive handwashing in the prevention of diarrhoeal illness among patients with AIDS: a randomized controlled study David B. Huang13 and Jing Zhou2 Correspondence
1
David B. Huang
[email protected]
2
Received 1 August 2006 Accepted 3 January 2007
Division of Infectious Diseases, New Jersey Veterans Affairs Medical Center, East Orange, NJ, USA Division of Infectious Diseases, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, 535EE, Houston, TX 77030, USA
Patients with AIDS frequently develop diarrhoeal illness. In this randomized, controlled study, 260 patients were screened for those who had not had diarrhoea in the preceding 3 months and who had received a stable highly active antiretroviral therapy regimen for at least 6 weeks prior to the study enrolment. A total of 148 patients met the inclusion criteria and were enrolled: 75 patients were randomly assigned to an intensive handwashing intervention (i.e. handwashing after defecation, after cleaning infants who had defecated, before preparing food, before eating, and before and after sex) and 73 patients were randomly assigned to the control group. Patients in both groups were called weekly by telephone to determine compliance with handwashing and to determine the number of diarrhoeal episodes for the preceding week. Patients were observed for 1 year. Patients assigned to the intensive handwashing intervention group washed their hands more frequently compared with the control group (seven vs four times a day, respectively; P ,0.05) and developed fewer episodes of diarrhoeal illness (1.24±0.9 vs 2.92±0.6 new episodes of diarrhoea, respectively; P ,0.001) during the 1 year observation. The most common pathogens identified in both groups in patients who developed diarrhoeal illness were Giardia lamblia, Cryptosporidium, Entamoeba histolytica and Shigella flexneri. These data suggest that intensive handwashing reduces diarrhoeal illness in patients with AIDS.
INTRODUCTION Diarrhoea is one of the most frequent illnesses occurring among patients with AIDS (Smith et al., 1992). The pathogens that cause diarrhoea include bacteria, viruses and parasites. For many of these pathogens, inadequate therapy exists for treatment. Thus diarrhoea prevention strategies that improve hygiene and sanitation are important. A useful prevention strategy may be the promotion of frequent handwashing among patients with AIDS. A meta-analysis of handwashing in a non-AIDS community concluded that handwashing promotion decreased the frequency of diarrhoea by 47 % (Curtis & Cairncross, 2003). Many intensive handwashing promotion studies have been conducted among children, persons in the developing world and health care workers (Haggerty et al., 1994; Luby et al., 2004; Shahid et al., 1996). However, to our knowledge, few if any studies on handwashing promotion have been conducted among patients with AIDS, in 3Present address: Department of Virology, 900 Ridgebury Road, Ridgefield, CT 06877, USA. Abbreviation: HAART, highly active antiretroviral therapy.
46867 G 2007 SGM
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whom diarrhoeal illness leads to significant morbidity and mortality. Thus the objective of this randomized controlled study was to determine the effect of intensive handwashing promotion among patients with AIDS.
METHODS Subjects. A total of 260 patients with AIDS were identified pro-
spectively, based on an institutional review board approved protocol, at a local human immunodeficiency virus (HIV) clinic. Medical information on all patients was available and included demographic characteristics, medical history, physical examination results, prior HIV-related infections, medications prescribed including dose and duration, medication flow sheet, pathology reports, HIV-1 infection verified by both ELISA and Western blot, and laboratory values including CD4 lymphocyte count and plasma HIV RNA level. Of the 260 patients with AIDS screened for inclusion, 148 (57 %) patients did not report having diarrhoeal illness within the past 3 months and had been receiving a stable highly active antiretroviral therapy (HAART) regimen for at least 6 weeks. Consent was obtained and these patients were enrolled in the study. Prior to randomization, all 148 patients were asked to complete a handwashing diary for 1 week to determine the frequency of handwashing per day. Seventy-five patients were randomly assigned to the intensive handwashing intervention group and 73 patients to the control group. 659
D. B. Huang and J. Zhou
Intervention. Three dedicated study nurses educated the patients on the health problems resulting from contaminated hands and provided specific handwashing instructions at enrolment to both the intensive handwashing group and the control group. Thereafter, for the intensive handwashing group, a weekly telephone call was made by the study nurse to determine the number of handwashing episodes per day, to ensure handwashing compliance, to answer any questions, to re-educate the patients on the importance of handwashing and to go over the specific handwashing instructions. For the control group, weekly telephone calls were made to patients only to ask the number of handwashing episodes per day and whether they had had diarrhoea in the preceding week, as recorded in the daily diarrhoea diary by the patient. Prior to informed consent, patients in both the intensive handwashing group and the control group were informed that this was a study on intensive handwashing and diarrhoeal illness.
A demonstration by the study nurse was given to patients in both the intensive handwashing group and the control group on handwashing, which included wetting their hands, lathering them completely with soap and rubbing them together for at least 15 s. Hands were dried with paper towels. After the demonstration by the study nurse, patients in both the handwashing group and the control group were asked to demonstrate their handwashing technique to the study nurse. All 148 patients in the two groups demonstrated an adequate handwashing technique. Patients were instructed to wash their hands after defecation, after cleaning infants who had defecated, before preparing food, before eating, and before and after sex. Measurements. All 148 patients were given a daily handwashing diary to record the number of handwashing episodes per day and a diarrhoea diary to record stool frequency and characteristics (formed vs unformed). The study nurse made a weekly telephone call to all patients for 1 year and asked the patient the number of handwashing episodes per day (determined by taking the sum of the handwashing episodes by week and dividing by seven) and whether he or she had had diarrhoea in the preceding week, as recorded in the daily diarrhoea diary by the patient. Diarrhoea was defined as ¢3 unformed stools within a 24 h period (Luby et al., 2004). Patients who developed diarrhoeal illness were asked to come to the clinic to submit a stool sample, which was processed immediately for conventional pathogens. Faecal microbiological studies. The presence of bacterial, viral and parasitic pathogens was determined in submitted stools using published methods. These pathogens included Shigella spp., Salmonella spp., enteroaggregative Escherichia coli, Campylobacter jejuni and Yersinia enterocolitica (Huang et al., 2004). The presence of human cytomegalovirus (HCMV) was determined by detecting HCMV DNA in a 10 % faecal suspension in PBS from stool samples of patients with diarrhoeal illness, as described previously (Shimizu et al., 2006). A QIAamp DNA stool mini kit was used to purify HCMV DNA (Qiagen). The primer pair amplified a 578 bp DNA fragment from exon 4 of the major immediate-early gene of HCMV (Shimizu et al., 2006). The presence of rotavirus and adenovirus was examined using commercial ELISA kits (Premier Rotaclone and Adenoclone; Meridian Diagnostics). Noroviruses were identified by RT-PCR from viral RNA extracted from 10 % faecal suspensions in PBS using a QIAamp viral RNA extraction kit (Qiagen) using two sets of primers for the capsid region of the target viral genome (G1-SKF/F1-SKR and G2-SKF/G2-SKR), as described previously (Kojima et al., 2002). The presence of Giardia lamblia, Cryptosporidium, Entamoeba histolytica and Microsporidium was determined by staining, microscopy and/or direct fluorescent antibody assays (Techlab). Antimicrobial susceptibility tests were carried out for bacterial pathogens using the disc diffusion method (National Committee for Clinical Laboratory Standards, 1999). Statistics. The primary study outcome, as defined before the study
was initiated, was the incidence of diarrhoea among patients with 660
AIDS randomly assigned to a handwashing or control group during a 1 year observation. Our hypothesis was that the incidence of diarrhoea would be lower among patients in the intensive handwashing group compared with those in the control group. Statistical analysis was carried out using SAS version 9.0. Descriptive statistics were used to summarize the baseline demographical and laboratory data. Data were expressed as means±SD. Comparisons between the different variables of the study groups (demographic, handwashing episodes, CD4 count and viral load levels) were performed using Student’s t-test, Fisher’s exact test and a x2 test, where appropriate. A value of P ¡0.05 was considered to be statistically significant.
RESULTS Table 1 summarizes the baseline characteristics of patients with AIDS in the intensive handwashing and control groups. No differences in baseline characteristics were identified between patients in the two groups. The number of baseline handwashing episodes per day was determined prior to the patient’s random allocation to the intervention or control group. No differences in the baseline frequency of handwashing were identified among patients in the handwashing group compared with those in the control group (3.3 vs 3.4 times per day in the handwashing and control groups, respectively). Ninety per cent of patients randomized to the intensive handwashing group and 94 % of patients in the control group were taking prophylactic agents against opportunistic infections. Most of the patients were taking trimethoprim/sulfamethoxazole (78 %) and many of the patients were taking azithromycin (67 %), as indicated by their CD4 cell count (77 and 89 cells mm23 in the handwashing and control groups, respectively). Fig. 1 shows the incidence of diarrhoea among the AIDS patients by group during the 1 year observation. The incidence of diarrhoea was lower among patients in the intensive handwashing intervention group compared with those assigned to the control group (1.24±0.9 and 2.92±0.6 new episodes of diarrhoea, respectively; P ,0.001). Table 2 summarizes the microbiological diagnosis of diarrhoeal illness among the AIDS patients in the two groups. No pathogen was identified in the majority of stool samples submitted from the handwashing and control groups patients who had diarrhoea (88 vs 70 %, respectively). The most common pathogens identified from the stools of both groups were parasites such as Giardia, Cryptosporidium and Entamoeba histolytica. The most common bacteria identified in both groups were Shigella flexneri and Campylobacter spp. The most common virus identified in the two groups was HCMV.
DISCUSSION Patients who were randomly assigned to the intensive handwashing intervention group reported a lower number of episodes of diarrhoea compared with patients in the Journal of Medical Microbiology 56
Handwashing reduces diarrhoea in AIDS patients
Table 1. Baseline characteristics of the patients Characteristics
Age (years; mean±SD) Male (%) Race (%) White Black Hispanic Other Handwashing (episodes per day; mean±SD) CD4 count (cells mm23; mean±SD) HIV-1 load (log10 copies ml21; mean±SD) Receiving OI prophylaxisD (%)
Group
P value*
Handwashing (n575)
Control (n573)
43.7±11 57 (77)
41.9±11 54 (75)
17 (23) 46 (61) 5 (7) 7 (9) 3.3±0.98 77±44.6 4.79±0.9 68 (90)
14 (19) 47 (65) 6 (8) 6 (8) 3.4±1.1 88±45.4 4.86±0.8 69 (94)
NS NS NS
NS NS NS NS
*NS, Not significant. DOI, Opportunistic infection.
control group during a 1 year observation. Prior to randomization, patients in both the handwashing and control groups washed their hands approximately three times a day. During and at the end of the study, all patients were asked how many times they washed their hands. Patients in the control and handwashing groups increased the mean number of times they washed their hands to four and seven times per day, respectively. The weekly telephone call to patients in the handwashing group concerning handwashing compliance, the importance of handwashing and repeating the specific handwashing instructions was the likely reason for the increased frequency of handwashing. A weekly telephone call was also made to patients in the control group asking them their number of handwashing episodes per day and whether any diarrhoeal episodes had developed. The weekly telephone calls and daily diarrhoea diary given to patients in both groups served as a method of minimizing recall bias in both the reporting of diarrhoeal illness and the frequency of handwashing. Due
Fig. 1. Incidence of diarrhoea among patients with AIDS in the handwashing and control groups during a 1 year observation. *P ,0.001. http://jmm.sgmjournals.org
to the randomized nature of the study design, any recall bias that may have been present in the control group would likely be present in the intensive handwashing group. The weekly call to the patients in the control group may have caused the patients to increase their frequency of handwashing (from three times a day to four times per day), although the increase in handwashing was not statistically significant from their baseline frequency of three times per day. Thus regular and frequent careful assessment and education on the importance of handwashing, hygiene and sanitation by telephone from health care providers may be a strategy for preventing diarrhoeal illness among patients with AIDS. Overall, the most commonly identified pathogen from both the control and handwashing groups was a parasite, G. lamblia [6 % (n512) in the control group vs 2 % (n52) in the handwashing group]. The most commonly identified bacterial pathogen was S. flexneri [4 % (n58) in the control group vs 1 % (n51) in the handwashing group] and the most commonly identified viral pathogen was HCMV [3 % (n55) in the control group vs 2 % (n52) in the handwashing group]. No other Shigella species was identified besides S. flexneri. Most of the patients (94 vs 90 % in the control and handwashing groups, respectively) in this study were on prophylaxis against opportunistic infections. Trimethoprim/sulfamethoxazole (78 %), dapsone (11 %) and azithromycin (67 %) were the most frequently used prophylactic antibiotics. Not surprisingly, parasitic infections (i.e. G. lamblia, Cryptosporidium spp. and Entamoeba histolytica), which are not susceptible to these antibiotics, were frequently identified in the stools of patients with diarrhoea in both the control and intensive handwashing groups. Interestingly, bacterial pathogens such as S. flexneri, Campylobacter spp., enteroaggregative Escherichia coli and Clostridium difficile were identified in the stools of patients with diarrhoea in both the control and the 661
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Table 2. Microbiological diagnosis of diarrhoeal illness among patients in the handwashing and control groups Diagnosis
Total no. of diarrhoeal episodes Bacteria Shigella flexneriD Campylobacter spp. Enteroaggregative Escherichia coliD Clostridium difficileD Salmonella spp. Viruses HCMVD AdenovirusD NorovirusD Rotavirus Parasites Giardia lambliaD Cryptosporidium spp. Entamoeba histolytica Microsporidium None identified
Group
P value*
Handwashing
Control
(n586 stool samples from 75 patients)
(n5197 stool samples from 73 patients)
86
197
,0.05
1 1 1 1 0
(1) (1) (1) (1) (0)
8 6 4 4 4
(4) (3) (2) (2) (2)
NS
2 1 0 0
(2) (1) (0) (0)
5 1 1 0
(3) (1) (1) (0)
NS
2 2 2 0 74
(2) (2) (2) (0) (88)
12 8 8 2 137
(6) (4) (4) (1) (70)
NS
NS NS
NS NS NS
,0.05 NS NS NS
,0.05
*NS, Not significant. DCo-infection of: 1 S. flexneri and adenovirus; 1 enteroaggregative E. coli and norovirus; 1 G. lamblia and HCMV; 1 G. lamblia and adenovirus; 1 Clostridium difficile and cytomegalovirus.
intensive handwashing groups, despite most patients taking prophylactic agents against opportunistic infections. However, many of these pathogens were identified among patients taking dapsone, without azithromycin, to which these bacterial pathogens are not susceptible. Also, among the few patients taking trimethoprim/sulfamethoxazole who developed bacterial diarrhoea, it is likely that these patients were not 100 % adherent to their prophylaxis, as the pathogens were found to be susceptible to trimethoprim/sulfamethoxazole by antimicrobial susceptibility testing. Very few viral pathogens were identified in this study, which is in contrast to other studies reporting that cytomegalovirus, adenovirus and norovirus are frequent causes of diarrhoeal illness among patients with AIDS (Thomas et al., 1999).
1998). Stockmann et al. (1998) obtained duodenal biopsies of HIV-infected patients with diarrhoea and without other identified causes of diarrhoea and found no evidence for active ion secretion return or malabsorption. They identified impaired epithelial-barrier function and evidence of tight junction openings between epithelial cells through postulated HIV-stimulated cytokine release (tumour necrosis factor or gamma interferon). Another possible cause of diarrhoeal illness without other identified cause is as a side effect of HAART. However, this study was designed to minimize this possibility as none of the 148 patients reported having diarrhoeal illness within 3 months of starting the study and all subjects had been receiving stable HAART for at least 6 weeks prior to entering the study.
The pathogen was not identified in the majority of patients in the intensive handwashing group (88 %) and the control group (70 %) who developed diarrhoea. This occurred despite a thorough gastrointestinal examination. This finding is consistent with other studies where pathogens are not commonly identified among HIV-infected patients with diarrhoea (Bellosillo & Gorbach, 1998; Kartalija & Sande, 1999). HIV-infected patients with diarrhoea and no identified pathogen may have HIV enteropathy where HIV itself may be the cause of diarrhoea (Stockmann et al.,
In summary, during a 1 year observation, this randomized controlled study found that intensive handwashing among patients with AIDS reduced the number of new episodes of diarrhoeal illness. An increase in the frequency of handwashing can occur as a result of regular and frequent telephone contact from health care workers. The authors believe that health care providers should at least educate and emphasize the importance of handwashing among patients with AIDS at each office visit. Increased handwashing is also important because it is possible that other
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Journal of Medical Microbiology 56
Handwashing reduces diarrhoea in AIDS patients
infections and illnesses, in addition to diarrhoeal disease, could be prevented, such as those caused by respiratory pathogens. Handwashing is an economical method of primary prevention. Additional studies are needed to evaluate the durability of this behavioural change in handwashing and the prevention of diarrhoeal illness and other illnesses in the USA and in developing regions of the world.
ACKNOWLEDGEMENTS
Kartalija, M. & Sande, M. A. (1999). Diarrhea and AIDS in the era of
highly active antiretroviral therapy. Clin Infect Dis 28, 701–707. Kojima, S., Kageyama, T., Fukushi, S., Hoshino, F. B., Shinohara, M., Uchida, K., Natori, K., Takeda, N. & Katayama, K. (2002). Genogroup-
specific PCR primers for detection of Norwalk-like viruses. J Virol Methods 100, 107–114. Luby, S. P., Agboatwalla, M., Painter, J., Altaf, A., Billhimer, W. L. & Hoekstra, R. M. (2004). Effect of intensive handwashing promotion
on childhood diarrhea in high-risk communities in Pakistan. JAMA 291, 2547–2554. National Committee for Clinical Laboratory Standards (1999).
We would to thank the study nurses for their hard work and dedication to improving the health of patients with AIDS. We would also like to thank Drs Huang and Chen for their critical review of this manuscript.
Performance Standards for Antimicrobial Susceptibility Testing. Ninth International Supplement, vol. 19. M100–S9. Villanova, PA: National Committee for Clinical Laboratory Standards.
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