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Efficacy of Waterless Hand Hygiene Compared with Handwashing with Soap: A Field Study in Dar es Salaam, Tanzania

Effective handwashing with soap requires reliable access to water supplies. However, more than three billion persons do not have household-level access to piped water. This research addresses the challenge of improving hand hygiene within water-constrained environments. The antimicrobial efficacy of alcohol-based hand sanitizer, a waterless hand hygiene product, was evaluated and compared with handwashing with soap and water in field conditions in Dar es Salaam, Tanzania. Hand sanitizer use by mothers resulted in 0.66 and 0.64 log reductions per hand of Escherichia coli and fecal streptococci, respectively. In comparison, handwashing with soap resulted in 0.50 and 0.25 log reductions per hand of E. coli and fecal streptococci, respectively. Hand sanitizer was significantly better than handwashing with respect to reduction in levels of fecal streptococci (P = 0.01). The feasibility and health impacts of promoting hand sanitizer as an alternative hand hygiene option for water-constrained environments should be assessed.

Received April 28, 2009. Accepted for publication October 27, 2009.

We thank Mwajuma Mbaga, Fred George Njegeja, Helena Horak, Joshua Chynoweth, Kirsten Rogers, Annalise Blum, Rachelle Strickfaden, Jessie Liu, Sara Marks, Iain Clark, our Tanzanian laboratory assistants, the enumerator field team, and the study participants for their assistance with the study; The Health and Environmental Rescue Organization and the Tanzanian office of Population Services International for help in implementing the project; and three anonymous reviewers for their feedback in improving the manuscript.

Financial support: This study was supported by the American Public Health Association International Health Section Award Program (sponsored by the Colgate-Palmolive Company, 2008). GOJO Industries supplied the hand sanitizer product tested in this investigation.

Authors' addresses: Amy J. Pickering, Alexandria B. Boehm, and Jennifer Davis, The Jerry Yang and Akiko Yamazaki Environment and Energy Building, Stanford University, Stanford, CA, E-mails: amyjanel{at}stanford.edu, aboehm{at}stanford.edu, and jennadavis{at}stanford.edu. Mathew Mwanjali, Population Services International, Dar es Salaam, Tanzania, E-mail: mmwanjali{at}psi.or.tz.

*Address correspondence to Jennifer Davis, The Jerry Yang and Akiko Yamazaki Environment and Energy Building, Stanford University, 473 Via Ortega, Room 255, MC 4020, Stanford, CA 94305. E-mail: jennadavis{at}stanford.edu