***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: The impact of improved water , sanitation , and hygiene ( WASH ) access on mitigating illness is well documented , although impact of school-based WASH on school-aged children has not been rigorously explored . We conducted a cluster-r and omized trial in Nyanza Province , Kenya to assess the impact of a school-based WASH intervention on diarrhoeal disease in primary -school pupils . Two study population s were used : schools with a nearby dry season water source and those without . Pupils attending ' water-available ' schools that received hygiene promotion and water treatment ( HP&WT ) and sanitation improvements showed no difference in period prevalence or duration of illness compared to pupils attending control schools . Those pupils in schools that received only the HP&WT showed similar results . Pupils in ' water-scarce ' schools that received a water-supply improvement , HP&WT and sanitation showed a reduction in diarrhoea incidence and days of illness . Our study revealed mixed results on the impact of improvements to school WASH improvements on pupil diarrhoea Elementary school-age children are particularly vulnerable to infections . While h and washing is the best method of preventing infections , many elementary schools are housed in buildings that have barriers to effective h and hygiene . The purpose of this study was to determine the effectiveness of an alcohol gel as an adjunct to h and washing in reducing absenteeism secondary to infectious illness .  Two-hundred and fifty-three elementary school children were r and omized by classroom into an experimental or control group . With a crossover design , all children participated in both groups , with a one-week washout period between phases . A 45-minute “ Germ Unit ” was taught to all children as they started the experimental phase and a st and ard unit on h and hygiene was taught as they started the control phase . Sixty-nine children were absent due to illness while in the control group . Thirty-nine children became ill while in the experimental group . Alcohol gel as an adjunct to h and washing was shown to be effective in reducing absenteeism due to infectious illness by 43 % Background Day care center attendance has been recognized as a risk factor for acquiring gastrointestinal and respiratory infections , which can be prevented with adequate h and hygiene ( HH ) . Based on previous studies on environmental and sociocognitive determinants of caregivers ’ compliance with HH guidelines in day care centers ( DCCs ) , an intervention has been developed aim ing to improve caregivers ’ and children ’s HH compliance and decrease infections among children attending DCCs . The aim of this paper is to describe the design of a cluster r and omized controlled trial to evaluate the effectiveness of this intervention . Methods / design The intervention will be evaluated in a two-arm cluster r and omized controlled trial among 71 DCCs in the Netherl and s. In total , 36 DCCs will receive the intervention consisting of four components : 1 ) HH products ( dispensers and refills for paper towels , soap , alcohol-based h and sanitizer , and h and cream ) ; 2 ) training to educate about the Dutch national HH guidelines ; 3 ) two team training sessions aim ed at goal setting and formulating specific HH improvement activities ; and 4 ) reminders and cues to action ( posters/stickers ) . Intervention DCCs will be compared to 35 control DCCs continuing usual practice . The primary outcome measure will be observed HH compliance of caregivers and children , measured at baseline and one , three , and six months after start of the intervention . The secondary outcome measure will be the incidence of gastrointestinal and respiratory infections in  600 children attending DCCs , monitored over six months by parents using a calendar to mark the days their child has diarrhea and /or a cold . Multilevel logistic regression will be performed to assess the effect of the intervention on HH compliance . Multilevel poisson regression will be performed to assess the incidence of gastrointestinal and respiratory infections in children attending DCCs . Discussion This is one of the first DCC intervention studies to assess HH compliance of both caregivers and children , as well as the incidence of gastrointestinal and respiratory infections in children , as outcome measures . When an effect of the intervention on improving HH compliance and /or reducing incidence of infections is shown , (inter)national dissemination of the intervention in other DCCs may be considered . Trial registration Netherl and s trial registry : The Ny and o  Integrated Child Health Education ( NICHE ) project was a collaborative effort by the U.S. Centers for Disease Control and local partners to assess the effectiveness of multiple interventions for improving child survival in western Kenya . To increase h and washing in schools ,  NICHE trained teachers  and installed h and washing stations with treated water and soap in 51 primary schools . This cluster-r and omized trial evaluated an additional educational strategy ( a poster contest themed , “ H and washing with Soap ” ) to improve h and washing behavior in 23 NICHE primary schools . Pupils were engaged in the poster development . Pupil h and washing behavior was observed unobtrusively at baseline and after four months . Intervention schools displayed a significant increase in the number of h and washing stations and proportion of teacher-supervised stations over the study period . No significant between-group differences of intervention in h and washing frequency , soap availability , or visibility of h and washing stations was observed . Despite finding a limited effect beyond the NICHE intervention , the trial appeared to promote sustainability across some measures Background Diarrheal diseases and dengue fever are major global health problems . Where provision of clean water is inadequate , water storage is crucial . Fecal contamination of stored water is a common source of diarrheal illness , but stored water also provides breeding sites for dengue vector mosquitoes . Poor household water management and sanitation are therefore potential determinants of both diseases . Little is known of the role of stored water for the combined risk of diarrhea and dengue , yet a joint role would be important for developing integrated control and management efforts . Even less is known of the effect of integrating control of these diseases in school setting s. The objective of this trial was to investigate whether interventions against diarrhea and dengue will significantly reduce diarrheal disease and dengue entomological risk factors in rural primary schools . Methods / design This is a 2 × 2 factorial cluster r and omized controlled trial . Eligible schools were rural primary schools in La Mesa and Anapoima municipalities , Cundinamarca , Colombia . Eligible pupils were school children in grade s 0 to 5 . Schools were r and omized to one of four study arms : diarrhea interventions ( DIA ) ; dengue interventions ( DEN ) ; combined diarrhea and dengue interventions ( DIADEN ) ; and control ( C ) . Schools were allocated publicly in each municipality ( strata ) at the start of the trial , obviating the need for allocation concealment . The primary outcome for diarrhea is incidence rate of diarrhea in school children and for dengue it is density of adult female Aedes aegypti per school .  Approximately 800 pupils from 34 schools were enrolled in the trial with eight schools in the DIA arm , nine in the DEN , eight in the DIADEN , and nine in the control arms . The trial status as of June 2012 was : completed baseline data collection s ; enrollment , r and omization , and allocation of schools . The trial was funded by the Research Council of Norway and the Lazos de Cal and aim a Foundation . Discussion This is the first trial investigating the effect of a set of integrated interventions to control both dengue and diarrhea . This is also the first trial to study the combination of diarrhea-dengue disease control in school setting s . Trial registration Current Controlled Trials IS RCT Background New Zeal and has relatively high rates of morbidity and mortality from infectious disease compared with other OECD countries , with infectious disease being more prevalent in children compared with others in the population . Consequences of infectious disease in children may have significant economic and social impact beyond the direct effects of the disease on the health of the child ; including absence from school , transmission of infectious disease to other pupils , staff , and family members , and time off work for parents/guardians . Reduction of the transmission of infectious disease between children at schools could be an effective way of reducing the community incidence of infectious disease . Alcohol based no-rinse h and sanitisers provide an alternative h and cleaning technology , for which there is some evidence that they may be effective in achieving this . However , very few studies have investigated the effectiveness of h and sanitisers , and importantly , the potential wider economic implication s of this intervention have not been established . Aims The primary objective of this trial is to establish if the provision of h and sanitisers in primary schools in the South Isl and of New Zeal and , in addition to an education session on h and hygiene , reduces the incidence rate of absence episodes due to illness in children . In addition , the trial will establish the cost-effectiveness and conduct a cost-benefit analysis of the intervention in this setting . Methods / Design A cluster r and omised controlled trial will be undertaken to establish the effectiveness and cost-effectiveness of h and sanitisers .  Sixty-eight primary schools will be recruited from three regions in the South Isl and of New Zeal and . The schools will be r and omised , within region , to receive h and sanitisers and an education session on h and hygiene , or an education session on h and hygiene alone . Fifty pupils from each school in years 1 to 6 ( generally aged from 5 to 11 years ) will be r and omly selected for detailed follow-up about their illness absences , providing a total of 3400 pupils . In addition , absence information will be collected on all children from the school rolls . Investigators not involved in the running of the trial , outcome assessors , and the statistician will be blinded to the group allocation until the analysis is completed . Trial registration Background : Laboratory-based evidence is lacking regarding the efficacy of nonpharmaceutical interventions ( NPIs ) such as alcohol-based h and sanitizer and respiratory hygiene to reduce the spread of influenza . Methods : The Pittsburgh Influenza Prevention Project was a cluster-r and omized trial conducted in 10 elementary schools in Pittsburgh , PA , during the 2007 to 2008 influenza season . Children in 5 intervention schools received training in h and and respiratory hygiene , and were provided and encouraged to use h and sanitizer regularly .  Children in 5 schools acted as controls . Children with influenza-like illness were tested for influenza A and B by reverse-transcriptase polymerase chain reaction . Results : A total of 3360 children participated in this study . Using reverse-transcriptase polymerase chain reaction , 54 cases of influenza A and 50 cases of influenza B were detected . We found no significant effect of the intervention on the primary study outcome of all laboratory-confirmed influenza cases ( incidence rate ratio [ IRR ] : 0.81 ; 95 % confidence interval [ CI ] : 0.54 , 1.23 ) . However , we did find statistically significant differences in protocol -specified ancillary outcomes . Children in intervention schools had significantly fewer laboratory-confirmed influenza A infections than children in control schools , with an adjusted IRR of 0.48 ( 95 % CI : 0.26 , 0.87 ) . Total absent episodes were also significantly lower among the intervention group than among the control group ; adjusted IRR 0.74 ( 95 % CI : 0.56 , 0.97 ) . Conclusions : NPIs ( respiratory hygiene education and the regular use of h and sanitizer ) did not reduce total laboratory-confirmed influenza . However , the interventions did reduce school total absence episodes by 26 % and laboratory-confirmed influenza A infections by 52 % . Our results suggest that NPIs can be an important adjunct to influenza vaccination programs to reduce the number of influenza A infections among children Intensive h and washing promotion can reduce  diarrheal and respiratory disease incidence . To determine whether less intensive , more scalable interventions can improve health , we evaluated a school-based h and washing program . We r and omized 87 Chinese schools to usual practice s : st and ard intervention ( h and washing program ) or exp and ed intervention ( h and washing program , soap for school sinks , and peer hygiene monitors )  . We compared student absence rates , adjusting for cluster design . In control schools , children experienced a median 2.0 episodes ( median 2.6 days ) of absence per 100 student-weeks . In st and ard intervention schools , there were a median 1.2 episodes ( P = 0.08 ) and 1.9 days ( P = 0.14 ) of absence per 100 student-weeks . Children in exp and ed intervention schools experienced a median 1.2 episodes ( P = 0.03 ) and 1.2 days ( P = 0.03 ) of absence per 100 student-weeks . Provision of a large-scale h and washing promotion program and soap was associated with significantly reduced absenteeism . Similar programs could improve the health of children worldwide Background Process evaluations are useful for underst and ing how interventions are implemented in trial setting s. This is important for interpreting main trial results and indicating how the intervention might function beyond the trial . The purpose of this study was to examine the reach , dose , fidelity , acceptability , and sustainability of the implementation of an educational h and washing intervention in primary schools , and to explore views regarding acceptability and sustainability of the intervention . Methods Process evaluation within a cluster r and omised controlled trial , including focus groups with pupils aged 6 to 11 , semi-structured interviews with teachers and external staff who coordinated the intervention delivery , and school reports and direct observations of the intervention delivery . Results The educational package was delivered in 61.4 % of schools ( 85.2 % of intervention schools , 37.8 % of control schools following completion of the trial ) . Teachers and pupils reacted positively to the intervention , although concerns were raised about the age-appropriateness of the re sources . Teachers adapted the re sources to suit their school setting 
    Output:
    
Individual study results suggest interventions may reduce children 's absence , RT infection incidence and symptoms , and laboratory confirmed influenza-like illness .
Evidence of impact on GI infection or symptoms was equivocal .
Despite updating existing systematic review s and identifying new studies , evidence of the effect of h and hygiene interventions on infection incidence in educational setting s is mostly equivocal but they may decrease RT infection among children .