***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: In response to a recorded increasing incidence of diarrhoea in Tumpat District , Malaysia , a case-control study was performed to identify modifiable risk factors for the transmission of diarrhoea , in children aged 4 - 59 months . Ninety-eight pairs of children , matched on age and sex , were recruited prospect ively from health centres . Exposure status was determined during a home visit . Interviewers were ' blinded ' as to the disease status of each child . Odds ratios were measured through matched pair analysis and conditional logistic regression . Risk factors for diarrhoea identified were : reported -- drinking of unboiled water , storage of cooked food before consumption and bottle feeding ; and observations -- animals inside the house and absence of washing water in latrines . Water quality , source of drinking water , reported h and washing behaviour , indiscriminate defecation by children , cup use and the absence of a functional latrine were not associated with diarrhoea . Nonsignificant associations were found for : accessibility of washing water source , type of water storage container and use of fly covers for food Diarrhea has been recognized as a frequent health problem among children enrolled in day-care centers . Thus , we evaluated the effect of a h and washing program in two day-care centers ( HWC ) on the incidence of diarrhea among children when compared to children in two control centers ( CC ) . After the program was begun , the incidence of diarrhea at the HWC began to fall and after the second month of the study was consistently lower than that at the CC . The incidence of diarrhea in the HWC was approximately half that of the CC for the entire 35-week study period . Adenoviruses , rotavirus , Giardia lamblia , and enteropathogenic Escherichia coli were found in the stools of a small number of ill children , but not pathogen was identified in the stools of most children with diarrhea . These results suggest that a h and washing program will probably prevent at least some of the diarrhea in day-care centers A number of different outcome measures have been proposed for use in prospect i ve studies of morbidity associated with childhood diarrhea . These include the number of episodes experienced by each child over a defined period ( a measure of incidence ) and the number of days of diarrhea divided by the total number of days of observation for each child ( a measure denoted " longitudinal prevalence " ) . The authors examined data from Ghana to determine which of these measures is more strongly associated with weight gain  over a 4-month period and subsequent mortality . Both diarrhea incidence and longitudinal prevalence were associated with weight gain in children aged 6 - 23 months , but a statistically stronger association was observed with longitudinal prevalence ( likelihood ratio statistic 28.95 on 1 degree of freedom against 19.70 for incidence ) . Neither measure was associated with weight gain in younger or older children . Longitudinal prevalence , but not incidence , was strongly associated with subsequent mortality ( p = 0.002 for longitudinal prevalence ; p = 0.557 for incidence ) . Although many epidemiologic studies of diarrhea focus on incidence , these data suggest that longitudinal prevalence is more strongly predictive of long-term health outcome . The authors conclude that longitudinal prevalence merits greater attention as a measure of outcome in diarrhea studies UNLABELLED BACKGROUND AND HYPOTHESES : A substantial percentage of school absenteeism among children is related to transmissible infection . Rates of transmission can be reduced by h and washing with soap and water , but such washing occurs infrequently . This study tested whether an alcohol-free instant h and sanitizer ( CleanH and s ) could reduce illness absenteeism in school-age children . METHODS A 10-week , open-label , crossover study was performed on 420 elementary school-age children ( ages 5 - 12 ) . Students were given a brief orientation immediately prior to the start of the study on the relationship of germs , illness , and h and washing . Each student in the treatment group then received the test product in individual bottles , with instructions to apply one to two sprays to the h and s after coming into the classroom , before eating , and after using the restroom , in addition to their normal h and washing with soap and water . The control group was instructed to continue h and washing as normal with non-medicated soap . After 4 weeks of treatment and a 2-week wash-out period , the control and experimental groups were reversed . Data gathered on absenteeism were classified as gastrointestinal or respiratory related and normalized for nonillness-related absenteeism and school holidays . RESULTS Compared to the h and washing-only control group , students using CleanH and s were found to have 41.9 % fewer illness-related absence days , representing a 28.9 % and a 49.7 % drop in gastrointestinal- and respiratory-related illnesses , respectively . Likewise , absence incidence decreased by 31.7 % , consisting of a 44.2 % and 50.2 % decrease in incidence of gastrointestinal- and respiratory-related illnesses , respectively . No adverse events were reported during the study . CONCLUSIONS Daily use of the instant h and sanitizer was associated with significantly lower rates of illness-related absenteeism BACKGROUND AND OBJECTIVES H and washing prevents communicable illness . We evaluated the effect of a m and atory , scheduled h and -washing program in elementary school children on absenteeism due to acute communicable illness . METHODS The study was conducted at Trombley Elementary School in Grosse Pointe Park , Mich. The intervention group , approximately half of the school children ( n = 143 , including all grade s 1 - 5 ) , washed their h and s a minimum of four scheduled times a day . The control group ( n = 162 ) continued h and -washing practice s as usual . RESULTS Of the 37 school days examined , children in the h and -washing group were absent fewer days than the control group due to all acute communicable illness ( relative risk = .75 ) . There were less days of absence due to gastrointestinal symptoms ( relative risk = .43 ) . The difference in absence due to respiratory symptoms was not statistically significant . CONCLUSIONS A scheduled h and -washing program will reduce acute communicable ( gastrointestinal ) illnesses in elementary school-age children Diarrheal diseases pose a major threat to the health of people living in developing countries , particularly where there is poverty and a poor environment . The effect of h and washing in reducing the incidence of diarrhea in day-care centers has been reported recently . The present study is a prospect i ve community based study conducted to evaluate the effect of h and washing on the incidence of  diarrheal disease in Calcutta slums .  H and washing was implemented in 1 slum and the other nearby slum , without h and washing program , served as control . The incidence of watery diarrhea during the 13 month period , between the study and control groups was not significantly different . However , the incidence of dysentery in individuals above 5 years of age in the control group was significantly higher as compared to those in the study group ( p 0.05 ) . The results of this study indicate that h and washing with soap may reduce the incidence of dysenteric cases in the community by interruption of transmission of the pathogens from 1 person to the other The most common types of situations that lend themselves to community- based assessment are described along with aspects of these trials that call for modification of the r and omized controlled design and the problems that doing this entails . Other possible design s that may lend themselves to these circumstances are suggested . Some interventions can only be effectively done on an area or population basis . Theoretically r and omized controlled trials are preferred . They are modified so that the community is investigated not the individual . However these studies are difficult to do . Sample size requirements may be large ; a small increase in the number of communities should be undertaken . A pilot study can be done to see which communities are similar at first . Evaluating changes in outcome values may be more sensitive than comparing postintervention values . Different community subgroups may be compared . Care must be taken in defining these subgroups . Also the r and om element is missing in these subgroups . Environmental changes and vector control procedures are 1 type of intervention that tries to reduce disease transmission . Another type is where intervention is done at the individual level but the goal is to reduce transmission in the whole community . Measures of intervening variables may be used to evaluate these studies . In clinical trials the population is captive . They have agreed to participate ; informed consent is obtained . Community-based interventions are often preventive measures done on a home-based population . This is only appropriate for common diseases . Agreement to participate must be gotten from the whole community . Case control or stepped wedge design s can be used as a research approach . Case control design s have many problems . They are costly both in personnel and in time . A clinic-based case control study is proposed . It is simple logistically . The stepped wedge design is applicable to evaluate new interventions which are introduced on a wide scale . Its rationale and use are described Background . Diarrheal infections are common in children who attend child care , and preventing transmission of disease in this setting depends on actions by child care staff . We set out to discover whether transmission of gastrointestinal infections in child care could be reduced by improved infection control procedures . Methods . We performed a cluster r and omized , controlled trial of an infection control intervention conducted in child care centers for 1 city in Australia . The intervention was training of child care staff about transmission of infection and h and washing and focused on both staff and child behavior . Implementation of the intervention was recorded by an observer . Illness was measured by parent report in telephone interviews every 2 weeks . Results . There were 311 child-years of surveillance for diarrheal episodes . The rate of episodes of diarrhea was 1.9 per child-year in intervention centers and 2.7 per child-year in control centers . Multivariable analysis showed that diarrheal episodes were significantly reduced in intervention center children by 50 % . However , the impact of the intervention was confined to children over 24 months of age . For those centers in which children 's compliance with h and washing was high , diarrheal episodes were reduced by 66 % . Conclusions . This trial supports education about infection control , for staff and children in child care , as a means of reducing transmission of diarrhea . Reduction in episodes of diarrhea in children in child care was limited to children over 24 months of age To identify risk factors for typhoid fever in Semarang city and its surroundings , 75 culture-proven typhoid fever patients discharged 2 weeks earlier from hospital and 75 controls were studied . Control subjects were neighbours of cases with no history of typhoid fever , not family members , r and omly selected and matched for gender and age . Both cases and controls were interviewed at home by the same trained interviewer using a st and ardized question naire . A structured observation of their living environment inside and outside the house was performed during the visit and home drinking water sample s were tested bacteriologically . Univariate analysis showed the following risk factors for typhoid fever : never or rarely washing h and s before eating ( OR = 3.28 ; 95 % CI = 1.41 - 7.65 ) ; eating outdoors at least once a week ( OR = 3.00 ; 95 % CI = 1.09 - 8.25 ) ; eating outdoors at a street food stall or mobile food vendor ( OR = 3.86 ; 95 % CI = 1.30 - 11.48 ) ; consuming ice cubes in beverage in the 2-week period before getting ill ( OR = 3.00 , 95 % CI = 1.09 - 8.25 ) and buying ice cubes from a street vendor ( OR = 5.82 ; 95 % CI = 1.69 - 20.12 ) . Water quality and living environment of cases were worse than that of controls , e.g. cases less often used clean water for taking a bath ( OR = 6.50 ; 95 % CI = 1.47 - 28.80 ) , for brushing teeth ( OR = 4.33 ; 95 % CI = 1.25 - 15.20 ) and for drinking ( OR = 3.67 ; 95 % CI = 1.02 - 13.14 ) . Cases tended to live in houses without water supply from the municipal network ( OR=11.00 ; 95 % CI = 1.42 - 85.2 ) , with open sewers ( OR = 2.80 ; 95 % CI = 1.0 - 7.77 ) and without tiles in the kitchen ( OR = 2.67 ; 95 % CI = 1.04 - 6.81 ) . Multivariate analysis showed that living in a house without water supply from the municipal network ( OR = 29.18 ; 95 % CI = 2.12 - 400.8 ) and with open sewers ( OR = 7.19 ; 95 % CI = 1.33 - 38.82 ) was associated with typhoid fever . Never or rarely washing h and s before eating ( OR = 3.97 ; 95 % CI = 1.22 - 12.93 ) and being unemployed or having a part-time job ( OR = 31.3 ; 95 % CI = 3.08 - 317.4 ) also were risk factors . In this population typhoid fever was associated with poor housing and inadequate food and personal hygiene 
    Output:
    
On current evidence , washing h and s with soap can reduce the risk of diarrhoeal diseases by 42 - 47 % and interventions to promote h and washing might save a million lives .