Volume 95, Issue 6
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Household members of cholera patients are at a 100 times higher risk of cholera than the general population. Despite this risk, there are only a handful of studies that have investigated the handwashing practices among hospitalized diarrhea patients and their accompanying household members. To investigate handwashing practices in a hospital setting among this high-risk population, 444 hours of structured observation was conducted in a hospital in Dhaka, Bangladesh, among 148 cholera patients and their household members. Handwashing with soap practices were observed at the following key events: after toileting, after cleaning the anus of a child, after removing child feces, during food preparation, before eating, and before feeding. Spot-checks were also conducted to observe the presence of soap at bathroom areas. Overall, 4% (4/103) of key events involved handwashing with soap among cholera patients and household members during the structured observation period. This was 3% (1/37) among cholera patients and 5% (3/66) for household members. For toileting events, observed handwashing with soap was 7% (3/46) overall, 7% (1/14) for cholera patients, and 6% (2/32) for household members. For food-related events, overall observed handwashing with soap was 2% (2/93 overall), and 0% (0/34) and 3% (2/59) for cholera patients and household members, respectively. Soap was observed at only 7% (4/55) of handwashing stations used by patients and household members during spot-checks. Observed handwashing with soap at key times among patients and accompanying household members was very low. These findings highlight the urgent need for interventions to target this high-risk population.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. Sack DA, Sack RB, Nair GB, Siddique AK, , 2004. Cholera. Lancet 363: 223233.[Crossref] [Google Scholar]
  2. World Health Organization (WHO), 2015. Cholera, Fact Sheet N°107. Geneva, Switzerland: WHO. [Google Scholar]
  3. Bhuiyan MU, Luby SP, Zaman RU, Rahman MW, Sharker MY, Hossain MJ, Rasul CH, Ekram AS, Rahman M, Sturm-Ramirez K, , 2014. Incidence of and risk factors for hospital-acquired diarrhea in three tertiary care public hospitals in Bangladesh. Am J Trop Med Hyg 91: 165172.[Crossref] [Google Scholar]
  4. Chikere C, Omoni V, Chikere B, , 2008. Distribution of potential nosocomial pathogens in a hospital environment. Afr J Biotechnol 7. [Google Scholar]
  5. Rimi NA, Sultana R, Luby SP, Islam MS, Uddin M, Hossain MJ, Zaman RU, Nahar N, Gurley ES, , 2014. Infrastructure and contamination of the physical environment in three Bangladeshi hospitals: putting infection control into context. PLoS One 9: e89085.[Crossref] [Google Scholar]
  6. Harris JB, LaRocque RC, Chowdhury F, Khan AI, Logvinenko T, Faruque ASG, Ryan ET, Qadri F, Calderwood SB, , 2008. Susceptibility to Vibrio cholerae infection in a cohort of household contacts of patients with cholera in Bangladesh. PLoS Negl Trop Dis 2: e221.[Crossref] [Google Scholar]
  7. Acosta CJ, Galindo CM, Kimario J, Senkoro K, Urassa H, Casals C, Corachán M, Eseko N, Tanner M, Mshinda H, , 2001. Cholera outbreak in southern Tanzania: risk factors and patterns of transmission. Emerg Infect Dis 7 (Suppl): 583.[Crossref] [Google Scholar]
  8. Hughes JM, Boyce JM, Levine RJ, Khan M, Aziz K, Huq M, Curlin GT, , 1982. Epidemiology of eltor cholera in rural Bangladesh: importance of surface water in transmission. Bull World Health Organ 60: 395. [Google Scholar]
  9. Hutin Y, Luby S, Paquet C, , 2003. A large cholera outbreak in Kano City, Nigeria: the importance of hand washing with soap and the danger of street-vended water. J Water Health 1: 4552. [Google Scholar]
  10. Weil AA, Khan AI, Chowdhury F, LaRocque RC, Faruque A, Ryan ET, Calderwood SB, Qadri F, Harris JB, , 2009. Clinical outcomes in household contacts of patients with cholera in Bangladesh. Clin Infect Dis 49: 14731479.[Crossref] [Google Scholar]
  11. Ali M, Nelson AR, Lopez AL, Sack DA, , 2015. Updated global burden of cholera in endemic countries. PLoS Negl Trop Dis 9: e0003832.[Crossref] [Google Scholar]
  12. Rashed SM, Mannan SB, Johura FT, Islam MT, Sadique A, Watanabe H, Sack RB, Huq A, Colwell RR, Cravioto A, Alam M, , 2012. Genetic characteristics of drug-resistant Vibrio cholerae O1 causing endemic cholera in Dhaka, 2006–2011. J Med Microbiol 61: 17361745.[Crossref] [Google Scholar]
  13. Alam M, Hasan NA, Sadique A, Bhuiyan N, Ahmed KU, Nusrin S, Nair GB, Siddique A, Sack RB, Sack DA, , 2006. Seasonal cholera caused by Vibrio cholerae serogroups O1 and O139 in the coastal aquatic environment of Bangladesh. Appl Environ Microbiol 72: 40964104.[Crossref] [Google Scholar]
  14. Faruque SM, Chowdhury N, Kamruzzaman M, Dziejman M, Rahman MH, Sack DA, Nair GB, Mekalanos JJ, , 2004. Genetic diversity and virulence potential of environmental Vibrio cholerae population in a cholera-endemic area. Proc Natl Acad Sci USA 101: 21232128.[Crossref] [Google Scholar]
  15. Alam M, Islam A, Bhuiyan NA, Rahim N, Hossain A, Khan GY, Ahmed D, Watanabe H, Izumiya H, Faruque AS, Akanda AS, Islam S, Sack RB, Huq A, Colwell RR, Cravioto A, , 2011. Clonal transmission, dual peak, and off-season cholera in Bangladesh. Infect Ecol Epidemiol 1. [Google Scholar]
  16. Spira W, Khan MU, Saeed Y, Sattar M, , 1980. Microbiological surveillance of intra-neighbourhood El Tor cholera transmission in rural Bangaldesh. Bull World Health Organ 58: 731. [Google Scholar]
  17. Mosley WH, Ahmad S, Benenson AS, Ahmed A, , 1968. The relationship of vibriocidal antibody titre to susceptibility to cholera in family contacts of cholera patients. Bull World Health Organ 38: 777785. [Google Scholar]
  18. Glass RI, Svennerholm AM, Khan MR, Huda S, Huq MI, Holmgren J, , 1985. Seroepidemiological studies of El Tor cholera in Bangladesh: association of serum antibody levels with protection. J Infect Dis 151: 236242.[Crossref] [Google Scholar]
  19. George CM, Jung DS, Saif-Ur-Rahman K, Monira S, Sack DA, Rashid M-u, Mahmud T, Mustafiz M, Rahman Z, Bhuyian SI, Winch PJ, Leontsini E, Perin J, Begum F, Zohura F, Biswas S, Parvin T, Sack RB, Alam M, , 2016. Sustained uptake of a hospital-based handwashing with soap and water treatment intervention (Cholera-Hospital-Based Intervention for 7 days [CHoBI7]): a randomized controlled trial. Am J Trop Med Hyg 94: 428436.[Crossref] [Google Scholar]
  20. George CM, Monira S, Sack DA, Rashid MU, Saif-Ur-Rahman KM, Mahmud T, Rahman Z, Mustafiz M, Bhuyian SI, Winch PJ, Leontsini E, Perin J, Begum F, Zohura F, Biswas S, Parvin T, Zhang X, Jung D, Sack RB, Alam M, , 2016. Randomized controlled trial of hospital-based hygiene and water treatment intervention (CHoBI7) to reduce cholera. Emerg Infect Dis 22: 233241.[Crossref] [Google Scholar]
  21. Molla A, Ahmed S, Greenough W, 3rd, 1985. Rice-based oral rehydration solution decreases the stool volume in acute diarrhoea. Bull World Health Organ 63: 751. [Google Scholar]
  22. Islam MS, Luby SP, Sultana R, Rimi NA, Zaman RU, Uddin M, Nahar N, Rahman M, Hossain MJ, Gurley ES, , 2014. Family caregivers in public tertiary care hospitals in Bangladesh: risks and opportunities for infection control. Am J Infect Control 42: 305310.[Crossref] [Google Scholar]
  23. Hadley MB, Blum LS, Mujaddid S, Parveen S, Nuremowla S, Haque ME, Ullah M, , 2007. Why Bangladeshi nurses avoid ‘nursing’: social and structural factors on hospital wards in Bangladesh. Soc Sci Med 64: 11661177.[Crossref] [Google Scholar]
  24. Fewtrell L, Kaufmann RB, Kay D, Enanoria W, Haller L, Colford JM, Jr, 2005. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Lancet Infect Dis 5: 4252.[Crossref] [Google Scholar]
  25. Curtis V, Cairncross S, , 2003. Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infect Dis 3: 275281.[Crossref] [Google Scholar]
  26. Luby SP, Halder AK, Huda T, Unicomb L, Johnston RB, , 2011. The effect of handwashing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: an observational study. PLoS Med 8: e1001052.[Crossref] [Google Scholar]
  27. Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, Altaf A, Hoekstra RM, , 2005. Effect of handwashing on child health: a randomised controlled trial. Lancet 366: 225233.[Crossref] [Google Scholar]
  28. Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JP, Wolf J, Pruss-Ustun A, Bonjour S, Hunter PR, Fewtrell L, Curtis V, , 2014. Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Trop Med Int Health 19: 906916.[Crossref] [Google Scholar]
  29. Pruss-Ustun A, Bartram J, Clasen T, Colford JM, Jr Cumming O, Curtis V, Bonjour S, Dangour AD, De France J, Fewtrell L, Freeman MC, Gordon B, Hunter PR, Johnston RB, Mathers C, Mausezahl D, Medlicott K, Neira M, Stocks M, Wolf J, Cairncross S, , 2014. Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries. Trop Med Int Health 19: 894905.[Crossref] [Google Scholar]
  30. George CM, Rashid MU, Sack DA, Sack RB, Saif-Ur-Rahman K, Azman AS, Monira S, Bhuyian SI, Zillur Rahman K, Mahmud T, , 2013. Evaluation of enrichment method for the detection of Vibrio cholerae O1 using a rapid dipstick test in Bangladesh. Trop Med Int Health 19: 301307.[Crossref] [Google Scholar]
  31. World Health Organization (WHO), 2015. The Treatment of Diarrhoea: A Manual for Physicians and Other Senior Health Workers. Geneva, Switzerland: WHO. [Google Scholar]
  32. Unicomb L, Islam DK, Noor KA, , 2014. Bangladesh National Hygiene Baseline Survey: Preliminary Report. Available at: BangladeshNationalHygieneBaselineSurveyPreliminaryReport.pdf. [Google Scholar]
  33. Halder A, Tronchet C, Akhter S, Bhuiya A, Johnston R, Luby S, , 2010. Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh. BMC Public Health 10: 545.[Crossref] [Google Scholar]
  34. Luby SP, Kadir MA, Yushuf Sharker , Yeasmin F, Unicomb L, Sirajul Islam M, , 2010. A community-randomised controlled trial promoting waterless hand sanitizer and handwashing with soap, Dhaka, Bangladesh. Trop Med Int Health 15: 15081516.[Crossref] [Google Scholar]

Data & Media loading...

  • Received : 12 May 2016
  • Accepted : 09 Aug 2016
  • Published online : 07 Dec 2016

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error