Comparing Hand Washing to
Hand Sanitizers in Reducing
Practice Elementary School Students'
Judith A. Vessey
Janice S. Hayes, PhD, RN
Jessie J. Sherwood
Purpose: To compare the efficacy of an alcohol-based hand sanitizer to standard hand washing in reducing
illness and subsequent absenteeism in school-age children.
Method: A randomized cross-over design was used with 18 classrooms of 2nd and 3rd grade students
(n = 383) from 4 elementary schools. Half of the classes from each school used an anti-microbial gel hand
sanitizer while the other half used soap and water for regular hand hygiene for 2 months, then, the students
switched cleaning methods for the following 2 months.
Results: No significant differences in absenteeism rates were demonstrated. A follow-up focus group com-
prised of teachers and school nurses indicated that hand sanitizers were preferred over soap and water.
Conclusion: Hand sanitizers are an appropriate alternative to hand washing for hand cleansing and may
offer additional benefits in the school setting.
chool nurses are responsible for minimizing bealth Review of the Literature
threats that interfere with student's learning and staff
participation (Rodriguez, 2002). Hand cleansing is an Illness, Absenteeism, and Academic Performance
effective method for preventing the spread of infection Everyone is susceptible to the transmission of disease, but
and reducing illness-related absenteeism (Morton & Schultz, children are one group that is at greater risk (Hezel, Bartlett,
2004). Although the benefits of hand cleansing are clearly rec- Hileman, Dillon, & Cessna, 2000). Upper respiratory infec-
ognized, initiating and sustaining appropriate hand-washing tions, influenza, intestinal illnesses, conjunctivitis, and other
practices among elementary school children is difficult due to communicable diseases occur frequently among students.
the students' developmental level and constraints in school Crowded settings, shared objects, and inadequate self-care
settings. Anti-microbial gel hand sanitizers appear to be a skills all contribute to the transfer of pathogenic microorgan-
viable alternative to soap and water and offer other distinct isms, particularly in elementary schools where current peda-
advantages in the school setting. The purpose of this study gogical techniques require close and cooperative interaction
was to compare the efficacy of a hand sanitizer to standard among children. Microorganisms are readily transmitted either
hand washing in reducing illness and subsequent absenteeism directly or by inanimate objects serving as vectors, and cont-
in school-age children. aminated hands are implicated in this process. When the
organisms are pathogenic, the secondary spread of commu-
nity-acquired infections among students is inevitable (White,
Judith A. Vessey, PhD, FAAN, Is Leiia Hoiden Carroli Professor in Shinder, Shinder, & Dyer, 2001).
iNursing, Boston College, William F. Conneii School of Nursing, Community-acquired infections are a major reason for
Chestnut Hill, MA. absenteeism among elementary school students (Dyer,
Jessie J. Sherwood, BSN, RN, is Chronic Illness Care Manager, Shinder, & Shinder, 2000; Hammond, Ali, Fendler, Dolan, &
Maine Medical Center Physician - Hospital Organization, Portland, Donovan, 2000; McGuckin, & Ali, 2002). Absenteeism from
ME. communicable illnesses is estimated to range from 70 to 164
Dorothy Warner, MS, BSN, RN, is Elementary School Nurse, million lost school days annually (Adams, Hendershot, &
Butte School District #1, Butte, MT. Marano, 1999), with absenteeism usually higher during winter
months due to influenza and other infectious illnesses.
Diane Clark, RN, is Elementary School Nurse, Butte School Because attendance is predictive of academic success,
District # 1, Butte, MT. repeated absences disrupt students' learning processes and
Acknowledgement: This research study was supported by an academic performance. Frequent, shorter absences—^the pat-
unrestricted grant from GoJo Industries awarded to the National tern associated with repeated communicable diseases—is
Association of School Nurses. The assistance of Linda Boland, more detrimental than a singular, longer absence (Hezel,
RN, also is noted. Bartlett, Hileman, Dillon, & Cessna, 2000; Kimel 1996;
Ohiund & Ericsson, 1994). Student learning also is disrupted
The Practice Applications of Research section pre- by unplanned teacher absenteeism, which in turn, interferes
sents reports of research that are clinically fccused and with curriculum coordination and delivery.
discuss the nursing application of the findings. If you are
Interested in author guidelines and/or assistance, con- Student absenteeism affects more than student academic
tact Janice S. IHayes, PhD, RN; Section Editor; Pediafric performance. Because public school funding formulas are
Nursing; East Holly Avenue Box 56; Pitman, NJ based on attendance numbers, increased absenteeism direct-
08071-0056; (856) 256-2300 or FAX (856) 256-2345. ly translates to fewer federal and state dollars for school pro-
;/July-Augusf 2007/Vol. 33/No. 4
grams. When sick students need to be cared for at home, par- When multiplied by four times over the course of the school
ents are absent from the workplace which in turn, negatively day, 2 hours—or a third of the school day—is taken from ped-
affects the economy (Master, Hess, & Dickson, 1997). Student agogical activities (White et al., 2001). In some schools, the
and staff absenteeism also results in increased school admin- time required for a class to wash their hands is the entire lunch
istrative costs (e.g., student tracking, hiring substitutes) and break.
greater health-care expenditures. Environmental obstacles include the placement and num-
ber of sinks. They are often too few in number, too high, or
Efficacy of Hand Cleansing located outside the classroom where supervision is limited.
Skin fiora contains resident and transient flora. Resident Faucets are rarely operated by foot pedals or sensors, result-
fiora refers to colonizing microorganisms not readily removed ing in hand recontamination when turning off the water. The
through the mechanical friction associated with hand washing. inability to control the water temperature, frequently only cold
Transient flora, noncolonizing and present on hands due to water is available, is objectionable. Soap and paper towels are
contamination, is more likely to cause illness and are of frequently in short supply, sometimes misguidedly removed
greater concern. Hand-cleansing techniques are aimed at sig- by custodians to eliminate mess.
nificantly reducing the amount of transient flora on hands. Hand sanitizers. The use of anti-microbial gel hand sanitiz-
Although data fi^om schools are not available, studies con- ers appears to provide an effective, convenient, and simple
ducted on hospital personnel as to the impact of hand wash- alternative to hand washing. A comparison of traditional hand
ing on illness are compelling. These studies have shown that washing with soap and water versus gel hand sanitizers has
the bacteria found on the hands of hospital personnel caused shown that using a hand sanitizer is effective at disinfecting
21% of the nosocomial infections, but hand-washing can sig- hands of health care personnel as well as reducing the irrita-
nificantly (p<.05) decrease the nosocomial infection rates tion associated with the regular use of the soap and water
among hospital patients (Conly, Hill, Ross, Lertzman, & Louie, (Boyce, 2000; Boyce & Kelleher, 2000; Kimel, 1996). The
1989;Larson,1981). most effective regimens use antimicrobial gel sanitizers in
Hand-cleansing education leading to improved hand combination with either anti-microbial or plain soap and water
hygiene helps reduce the spread of infections (Kimel, 1996; for hand cleansing (Paulson, Fendler, & Dolan, 1999; Boyce &
Niffenegger, 1997; Wilson, 1985). Unfortunately, formal Pittet, 2002).
instruction on hand cleansing is not universal in schools and To date, multiple studies have studied the effects of hand
even when taught, not all students practice hand cleansing sanitizers on school children. In a randomized clinical trial of
regularly (Day, St. Arnaud, & Monsma, 1993; Kimel, 1996). 6,000 elementary schools comparing groups using hand san-
School nurses, accountable for minimizing health threats that itizers paired with control groups (p < .05) receiving no inter-
interfere with learning, must promote regular hand cleansing vention, the data showed an overall reduction in infection-
by students and staff (Kimel, 1996). related absenteeism of 19.8% (Hammond, Ali, Fendler, Dolan,
Varieties of hand-cleansing programs have been imple- & Donovan, 2000). Dyer (2000) and colleagues' 10-week
mented in schools and have met with mixed success. The crossover study involving 420 elementary school children
Scrubby Bear Program, initiated in 1986, was found to be using an alcohol-free hand sanitizer support these findings.
effective with teaching 4-year-olds in day-care centers to wash Illness-related absences were decreased by 41.9% when stu-
their hands and has been used in many day-care centers and dents were supervised throughout the school day and used
elementary schools since its origination (Glasby & Snow, hand sanitizer in addition to regular hand washing. White
1986; Eliason & True, 2004). Since then, other hand-cleans- (2001) and colleagues conducted a double-blind, placebo-
ing curricula have been disseminated. Studies of the effective- controlled study to evaluate the effectiveness of adding a hand
ness of all these curricula report positive short-term findings sanitizer to routine hand washing. FYior to conducting this
(Master, Longe, & Dickson, 1997; Pete, 1986). But in cases study, students received a half-hour educational program on
where long-term behavior change was tracked, evidence indi- the transmission or germs, their relationship to illness, the
cates that that students did not routinely wash their hands importance of hand washing, and how to use a hand sanitizer.
without periodic verbal reinforcement accompanied by other All students were supervised in the use of the hand sanitizer or
reminders (Monsma, Day, & St. Arnaud 1992). Consistent placebo six times per day and were allowed to wash their
adult supervision and incorporating hand cleansing into daily hands at will without supervision. The results indicated a
routines are needed to help children maintain consistent hand- 31.1% difference in student absences related to illness for the
cleansing habits. hand sanitizer group (N = 381) compared to the control group
(N = 388). Finally, Morton and Schultz (2004) demonstrated a
Hemd Cleansing Techniques 43% reduction in illness-related absenteeism over a 3-month
period in their crossover-design study of elementary students
Soap and water. Mechanical friction, soap, and water
(N = 253) when hand sanitizers were used as an adjunct to
removes most transiently acquired organisms and is a highly
effective techniques for hand cleansing. To be effective,
experts recommend using warm running water and soap; Meadows and Le Saux (2004) conducted a critical review
applying 30 seconds of friction between hands; drying hands of these studies using criteria published in the Cochrane
witji a paper towel; and turning off the faucet with a paper Reviewers' Handbook, the leading authority in evaluating the
towel to avoid hand-to-surface contact (Centers for Disease quality of research evidence for practice. Collectively, the find-
Control, 2003). Warm water, while making hand washing eas- ings from these studies were deemed to be of low quality and
ier and more pleasurable, is not essential to removing most should be interpreted with caution. Additional, well-controlled
microorganisms from hands. randomized clinical trials were recommended.
Developmental and physical barriers impede the imple-
mentation of this seemingly simple skill (Pete, 1986). Barriers to Hand Cleansing
Children's limited psychomotor coordination and the inability Neither soap and water or hand sanitizer will be effective in
to easily estimate a 30-second time period often result in insuf- reducing micro-organisms if they are not used. Placement of
ficient scrubbing. For the entire class of 30 students to wash wash stations and sanitizers, frequency and duration of hand
their hands appropriately, it requires approximately one-half washing, ease of product use, and verbal prompts have all
hour when there is only one sink available in the classroom. been positively correlated with improved adherence and
PEDIATRIC NURSING/July-August 2007/VoL 33/No. 4
reduced infection risk (Early et al.,1998; Morton & Schultz, tional formal education was provided.
2004). Education, accessible and convenient hand hygiene Data collection then took place in two phases: January and
methods, and verbal prompts will result in a sustainable February (phase 1) and March and April (phase 2). These
increased hand washing and sanitizer use and in the reduction time periods were selected because they minimized the effects
of illness and absenteeism among elementary school children of holidays and vacations on illness communicability. During
(Early et al., 1998; Rodriguez, 2002). Although teachers rec- the data collection phase and following standard educational
ognize the importance of hand cleansing, little is known practices, teachers, nurses, and other school personnel
regarding their preferences regarding soap and water or hand reminded all students to clean their hands as they normally
sanitizers. Yet, they are in the position of providing ongoing would. This included regular reminders, such as before going
messages regarding the importance of hand cleansing and for to lunch and after using the bathroom, and episodic reminders,
modeling correct hand-cleansing behaviors to their students. such as after activities that resulted in soiled hands. A strict
Direct comparisons of hand sanitizers to soap and water used reminder protocol was not used; rather the intent was for
and their effect on absenteeism are not in evidence. teachers to give the reminders they normally would through-
out the school day.
Methods The classrooms were divided into two cohorts. Cohort 1 (n
The study consisted of two parts. Part 1 included a con- = 191) consisted of 9 classes, four 2nd grade classes from
trolled clinical trial designed to compare the efficacy of soap schools A and B andfive3rd grade classes from schools C and
and water to hand sanitizers in reducing illness-related absen- D. Cohort II (n = 192) consisted of 9 classes, four 2nd grade
teeism. Part II used a qualitative focus group technique to classes from schools C and D and five 3rd grade from four
ascertain school personnel's preferences and insights into schools A and B. Classes in cohort I/phase 1 were assigned to
product selection. treatment 1 (hand washing) and classes in cohort ll/phase 1
were assigned to treatment 2 (hand sanitizing). The appropri-
Parti ate product—soap or hand sanitizer—was made available in
Design. A randomized cross-over design was chosen to their classrooms and restrooms during this period. The cohorts
control for the seasonality of illness and treatment order. switched treatments for phase 2 after 2 months. At the con-
Site. The Butte, Montana school district was chosen for this clusion of data collection, all students were given a certificate
study as there was district administrative support, qualified of appreciation.
school nurses available to help design and execute the study, Absentee data were forwarded each week to the
and support personnel who collected the data. Moreover, 4 of researchers at Boston College where it was entered, cleaned,
the 7 elementary schools in the district were similar in size and and analyzed. No identifying information for individual stu-
demographics needed for the research design. dents was provided. Demographic information and enrollment
Sample. The sample consisted of the 2nd and 3rd grade and absentee data were only reported in the aggregate.
student population of the participating schools. The total con-
sisted of 383 elementary students drawn from 18 classes, 8 Findings
classes of 2nd grade students and 10 classes of 3rd grade stu- All 18 classes and 360 students completed the study. Of the
dents. The classroom size ranged from 15 to 27 students. 3 students who withdrew, 2 did so because the soap was too
Grades 2 and 3 were chosen as younger students have a high- irritating and 1 because both soap and hand sanitizer were too
er rate of communicable disease than older students. irritating. Absentee data are presented in Table 1. Data fi-om
Kindergarten students and 1st grade students were not includ- cohort A, phase 1 and cohort B, phase 2 were combined to
ed because they attend only half-day sessions or were less form the Soap and Water Group. Data from cohort A, phase 2
familiar with school routines. All students in the designated and cohort B, phase 1 were combined to form the Hand
grades were eligible to participate. Those who did not give Sanitizer Group. Absentee data from these two treatment
consent had allergies to soap, sanitizers, or one of their groups are presented in Table 1. Both groups had 18
components. This sample size assumed a medium effect size absences. The students' f-test was then applied. No significant
(.50) = .05, and power = .80. differences were noted between the groups, indicating that the
Measure: Absentee rates. School secretaries collected number of student absences was not appreciably affected by
absentee information and specifically asked whether the the hand-cleansing technique used.
absence was due to acute, communicable illnesses for stu-
dents in study classrooms. When additional information was Part II
needed, the school nurse and/or teacher validated the reason
for a student's absence. Absenteeism for reasons other than Design, Site, and Sample
communicable illness such as injuries, lice infestation, vaca- At the conclusion of Part I of the study, a focus group of
tions, or exacerbation of chronic conditions were determined teachers, school nurses, and office personnel (n = 13) was
by parental report and were not included in the data analysis. conducted to ascertain their observations and preferences.
Procedure. The study was initially approved by the Boston
College Institutional Review Board and the Butte, Montana Procedure
School District. Procedures for the waiver of active parental The primary objective of the focus group was to elucidate
informed consent were followed. A letter describing the study participants' experiences with soap and water and hand sani-
was sent home to the parents of students in the participating tizers. The analytic approach was manifest content analysis,
classes. Parents who did not wish for their child to participate with emphasis on information that was evident and apparent
in the study completed the enclosed form notifying the inves- in the participants' remarks. Open-ended questions with
tigators of their intent. Children were told about the study in probes were used to facilitate discussion. Questions such as—
age-appropriate language and their assent was obtained. "What do you like/dislike about soap and water? hand sanitiz-
The month prior to data collection, a school nurse with con- er?"—^were asked. Data were audio-taped, transcribed, and
tent expertise but no affiliation with the school district data col- coded. Recurring themes were identified.
lectors taught the students in each designated class correct
hand-washing/sanitizing procedures using a standardized cur-
riculum including the video, "Wash those Hands." No addi-
itiuly-August 2007/Vol. 33/No. 4
Findings Table 1. Two-Tailed f-Test Mean Differences of the
Many of the participants' observations indicated that they Number of Days Absent Between the Soap and Water
preferred the use of the hand sanitizer over soap and water as and Hand Sanitizer Groups
it better matched the pragmatics of the school day. The
amount of time required was a key consideration, as noted in
Soap and Water 25.44 10.27 .664 34
...they [the students] would try to skip it [hand washing
(N = 18)
with soap and water] or wouldn 't do it properly ...it took up to
probably an extra 10 minutes to get out to lunch. 26.77
Hand Sanitizer 7.00
I liked the hand sanitizer because it took so long to get the
(N = 18)
kids out to lunch [when hand washing with soap and water]
and my kids would use it [hand sanitizer] because it was
Improved adherence and better hand cleansing by students
during the study period were also noted in teachers' com- which case no hand-cleansing technique would be used) that
ments: there was insufficient statistical power to detect a significant
We have the sanitizer by the door and it was funny, the difference between the groups. Ideally, data would have been
kids walk by it and subconsciously would just take a collected and analyzed by student rather than by classroom,
squirt.. .Lots of time I don't think they were paying attention to but logistical issues preclude this from occurring in a natural-
what they were doing. istic setting such as a school. Secondly, obtaining accurate
It [hand sanitizer] was easy, it smelled good. It didn't make data for absenteeism due to communicable illness was diffi-
their food taste funny...in the lunchroom. cult, even when parents were aware of the reason for provid-
.. .you can't let the water run.. .they touch [the faucet] with ing accurate information. School personnel noted that fre-
their dirty hands...touch it again with their clean hands... quently a parent would report a child's absence as due to ill-
The ability to observe student behavior and maintain class- ness but upon questioning the child, a different reason was
room decorum were other perceived benefits of hand sanitiz- given. Lastly, this study did not manipulate the environment to
ers: maximize differences between the control and experimental
We teach them a lot about coughing and sneezing into their groups, common in other research studies. For example, other
hands and then to go wash their hands but many times they studies that reported significantly less absenteeism with the
are in the classrooms and they can't leave. But if you haue the use of hand sanitizers were used, additional cues were given to
gel, they can go over and use it. the experimental groups, including throughout the school day
When you haue them go to in the bathroom with soap and to use the sanitizer and/or adults supervised sanitizer use
water you can't tell if they are really using it... (Dyer, Shinder, & Shinder, 2000; White, Shinder, Shinder, and
Equally important was the potential for mess; teachers Dyer; 2001).
viewed hand washing with soap and water as extremely prob- The results of this study differ from previous published stud-
lematic: ies that all reported significant decreases in absenteeism with
The floors wereJust covered with water and you know kids the use of sanitizers. Because of the heterogeneity and low
were having accidents. quality of reporting in previous studies (Meadows & Le Saux,
Paper towels were all over the place... 2004), it is difficult to draw conclusions as to why these differ-
The soap makes a great missile. ences occurred. Additionally, publication bias in favor of stud-
Misuse of hand sanitizers was less of an issue but still pos- ies that demonstrate significant, positive findings for the inter-
sible, limited only by students' creativity as noted by this vention may play a role. This study addresses some of the
observation: problems found in earlier studies and provides additional infor-
The cleaning person put a cup underneath of it [the sani- mation on the role of hand sanitizers in school to the growing
tizer dispenser] and you know that got one kid deciding that body of literature. It is not without its limitations, however. Only
he could Just keep pushing it and see how much it took to fill one district was used and better measures for determining
it up. community-acquired infections than absenteeism rates are
Although the pros clearly outweighed the cons in teachers' clearly needed. The results of this study, therefore, need to be
and staff member's views of hand sanitizers over soap and interpreted cautiously.
water, one drawback of hand sanitizers that was noted was that Although soap and water needs to be available for frankly
when the sanitizer dripped on to the floor, it removed the wax soiled hands, teachers and staff clearly favored using hand
fi-om the tile. Teachers observed that maintaining adequate sanitizers over soap and water as their was less mess, less skin
supplies of soap, paper towels, and sanitizer was an issue. In irritation, and less time away from classroom activities.
addition to answering the stated objectives, one auxiliary find- Research conducted in school and health care settings repeat-
ing was noted. Teachers reported that through their participa- edly supports that personal attitudes and behaviors of author-
tion in the study, they were more were more critical in their ity figures directly influence hand-cleansing behaviors (Early
decision making when referring students to the school nurse's et al., 1998; Monsma et al., 1992; Muto, Sistrom, & Farr, 2000;
office for suspected illness. Although no specific teacher train- Niffenegger, 1997). Although the intent of this study was not
ing in illness detection was included in the study protocol, to shape attitudes or behavior modification, it is conceivable
teachers were aware that the investigators were tracking that addressing staff preference could result in greater motiva-
absenteeism. The teachers became more attentive as to which tion to reinforce frequent hand cleansing. Subsequent long-
students had upper respiratory infections or other illnesses, as term behavioral change in students would require further
compared to those who were absent for other reasons. investigation.
In determining whether schools should adopt hand sanitiz-
Discussion ers, one important factor for consideration is the structure of
No significant differences in absenteeism were noted the school. Older schools often do not have sinks in the class-
between the groups. Although this is likely an accurate finding, rooms, so students must leave class every time their hands
it is possible that since there was no true control group (in need washing, a significant issue when numerous students
have upper respiratory infections. A second problem is the Centers for Disease Control (2003). Guideline for hand hygiene in
inability to appropriately adjust the water temperature. This health-care settings. Morbidity and Mortality Weekly Report,
may occur because sinks have two faucets or the school may 53, 431-433.
Conly, J.M., Hill, S., Ross, J., Lertzman, J., & Louie, T.J. (1989).
have turned off the hot water due to safety and cost concerns.
Handwashing practices in an intensive care unit: The effects of
The lack of auto-sensors or foot pedals on sinks also results in an educational program and its relationship to infection rates.
recontamination of hands when the water is turned off. Staff American Journal of Infection Control, 17, 330-339.
were aware that hand sanitizers eliminated these problems. Day, R., St. Arnaud, S. & Mosma, M. (1993). Effectiveness of a hand
A variety of hand-sanitizer dispensers are available. Care washing program. Clinical Nursing Research, 2, 24-40.
should be taken in selecting a product and dispenser to best Dyer, D., Shinder, F., & Shinder, A. (2000). Alcohol-free instant hand
meet the needs of the school environment. Ease of installation, sanitizer reduces elementary school illness absenteeism.
tamper resistant, low malfunctioning rates, and easy determi- Family Medicine, 32, 633-638.
nation of refills are needed as all influence the likelihood of Early, E., Battle, K., Cantwell, E., English, J., Lavin, J.E., & Larson, E.
(1998). Effect of several interventions on the frequency of hand
adherence (Kohan, Ligi, Dumigan, & Boyce, 2002). Dispenser
washing among elementary public school children. American
placement also is critical. When hand-sanitizer dispensers Journai of Infection Control, 26, 263-269.
were placed in a highly visible and readily accessible location, Eliason, K. &True, A. (2004). Combining health promotion classroom
teachers reported that students frequently "took a squirt" as lessons with health fair activities. Journal of School Nursing,
they walked by. Teachers preferred that the dispensers be 20, 50-53.
placed in the classroom, and if there was a restroom in the Glasby, C. & Snow, B. L (1986). Scrubby Bear can make an impact
classroom, outside the restroom door. That way they were bet- on your community. American Journal of Infection Control, 14,
ter able to monitor and encourage students' usage. In the cafe- 57-63.
teria area, a sufficient number of dispensers should be mount- Hammond, B., Aii, Y, Fendler, E., Dolan, M., & Donovan, S. (2000).
ed in open areas to encourage use and prevent congestion. Effect of hand sanitizer use on elementary school absenteeism.
American Journal of Infection Control, 28, 340-346.
Hezel, L, Bartlett, C, Hileman, J.W., Dillon, L, & Cessna, T (2000).
Summary Effective hand washing in elementary school. School Nurse
Although additional large, well-designed clinical trials with News, 77(3), 26-28.
longitudinal follow-up to measure sustained behavioral change Kimel, LS. (1996). Hand washing education can decrease illness
still need to be conducted, hand sanitizers are a viable alterna- absenteeism. Journal of School Nursing, 12,14-16,18.
tive to routine hand cleansing using soap and water. As Kohan, C, Ligi, C, Dumigan, D.G., & Boyce, J.M. (2002). The impor-
schools are being called upon to increase surveillance for tance of evaluating product dispensers when selecting alcohol-
infectious diseases and mount prevention campaigns, hand based handrubs. American Journal of Infection Control, 30,
sanitizers can play an important role in this effort.
Larson, E. (1981). Persistent carriage of gram-negative bacteria on
hands. American Journai of Infection Control, 9, 112-119.
Master, D., Longe, S.H., & Dickson, H. (1997). Scheduled hand wash-
References ing in an elementary school population. Family Medicine, 29,
Adams, P.F., Hendershot, G., & Marano, M.A. (1999). Current esti- 336-339.
mates from the National Health Interview Survey, 1996. McGuckin, M., & AM, Y (2002). The effect of a comprehensive hand-
National Center for Health Statistics. Vital and Health Statistics, washing program on absenteeism in elementary schools.
70, 200. American Journal of Infection Control, 30, 217-20.
Boyce, J.M. (2000). Using alcohol for hand antisepsis: Dispelling old Meadows, E. & Le Saux, N. (2004). A systematic review of the effec-
myths. Infection Control and Hospital Epidemiology, 21, 438- tiveness of antimicrobial rinse-free hand sanitizers for preven-
441. tion of illness-related absenteeism in elementary school chil-
Boyce, J.M. & Kelleher, S.N. (2000). Skin irritation and dryness asso- dren. BMC Public Health, Retrieved from http:/A«ww.biomed-
ciated with two hand-hygiene regimens: Soap- and- water central.com/content/pdf/1471-2458-4-50.pdf.
hand washing versus hand antisepsis with an alcoholic hand Monsma, M. Day, R., & St. Arnaud, S. (1992). Hand washing makes
gel. Infection Control and Hospital Epidemiology, 21, 442-448. a difference. Journal of School Health, 62,109-111.
Boyce, J.M., & Pittet D. (2002, October 25) Guideline for hand Morton, J.L. & Schuitz, A.A. (2004). Healthy hands: Use of alcohol gel
hygiene in health-care settings: Recommendations of the as an adjunct to handwashing in elementary school children.
Healthcare Infection Control Practices Advisory Committee and Journal of School Nursing, 20,161-167.
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity Muto, C.A., Sistrom, B.G., & Farr, B.M. (2000). Hand hygiene rates
and Mortality Weekly Review, 51, 32-34. unaffected by installation of dispensers of a rapidly acting hand
antiseptic. American Journal of Infection Control, 28, 273-276.
Niffeneger, J.P (1997). Proper hand washing promotes wellness in
childcare. Journal of Pediatric Health Care, 11, 26-31.
Advertisers' Index Ohiund, LS., & Ericsson, K.B. (1994). Elementary school achieve-
ment and absence due to illness. The Journal of Genetic
Beta Dermaceuticals, Inc 321, 341 Psychology; Child Behavior, Animal Behavior, and Comparative
Braintree Laboratories, Inc. .' 297-298 Psychology, 755,409-421.
Paulson, D.S., Fendler, E.J., & Dolan, M.J. (1999). A close look at alco-
Children's Hospital of Philadelphia 375
hol gel as an anti-microbial sanitizing agent. American Journal
Children's Medical Center, Dallas 355 of Infection Control, 27, 332-338.
Fletcher Allen Health Care 332 Pete, J. (1986). Hand washing practices among various school age
Genentech, Inc 333-334 students. Health Education, 77(6), 37-39.
Rodriguez, S. (2002, October). The importance of school-based
Gebauer Company 312 handwashing programs. Journal of School Nursing, 78(Suppl.),
Johnson & Johnson, Inc 294 19-22.
Merck & Company, Inc 300-302 White, C.G., Shinder, FS., Shinder, A.L, & Dyer, D.L (2001).
Reduction of illness absenteeism in elementary schools using
Merz Pharmaceuticals 359 an alcohol-free instant hand sanitizer. The Journal of School
NCH Healthcare System 344 Nursing, 17, 258-265.
Nestle Infant Nutrition 360 Wilson, N.C. (1985). Scrubby Bear Program. Scrubby Bear
Sanofi Pasteur 292-293, 376
PEDIATRIC NURSING/July-August 2007/Vol. 33/No. 4