An arsenal of hand sanitizers, hygiene education and good old-fashioned soap failed to prevent asthma attacks among school children in one Alabama county.

For children with asthma, the common cold is the top trigger of symptom attacks. So in theory, cleaner hands at school could mean fewer colds being passed around - and fewer asthma attacks.

But in a new clinical trial, researchers found that kids at schools with a “hand hygiene” plan, including alcohol-based hand sanitizers, suffered asthma attacks just often as their peers at other schools.

The findings are not, however, the final word, according to Lynn B. Gerald, a professor of health promotion sciences at the University of Arizona in Tucson who led the study.

That’s because the trial hit an obstacle when the H1N1 “swine” flu epidemic broke out right at the study’s outset: All of the schools in the trial became a lot more vigilant about clean hands, Gerald said.

Schools that weren’t part of the hand-hygiene program started putting hand sanitizer on the list of school supplies given to parents.

“Hand sanitizer became ubiquitous in schools,” Gerald said.

So, she told Reuters Health, it’s hard to draw conclusions about whether hand sanitizers, added to old-fashioned hand washing, might prevent some asthma attacks.

The sanitizers and soap used in the trial were provided to schools for free by Akron, Ohio-based GOJO, which makes the Purell brand hand sanitizers.

GOJO “believes there is great benefit in establishing the effectiveness of hand hygiene interventions under real-world conditions and supports scientific studies that take that approach,” the company told Reuters Health.

“We agree with the conclusion that the results of this study were highly confounded by increased overall hand hygiene practices, even in the usual-care schools, as a result of the H1N1 pandemic,” they said in an emailed statement.

The findings appear in the Journal of Allergy and Clinical Immunology.

VALUE OF INVESTMENT UNCLEAR

Frequent hand washing is one of the keys to protecting yourself from colds and the flu, or from passing the viruses to other people. But soap and water are not always at the ready, and even in school bathrooms soap dispensers may be broken or empty - especially at low-income schools like the ones in this trial, Gerald noted.

Many schools already have hand sanitizer available. At some schools, that’s all they use, Gerald said. But no one knows how effective the products are versus soap and water alone.

For the current study, Gerald’s team randomly assigned 31 Alabama elementary schools to either follow a special hand hygiene plan or stick with their standard ways for one school year. The schools then switched groups for the following school year.

When schools were on the hand hygiene plan, they were given hand soap for the bathrooms, and alcohol-based hand sanitizer for the bathrooms and classrooms. Students were also taught about good hand hygiene.

Gerald’s team then focused on 527 students who had asthma. They found that over the two years, kids had no fewer asthma attacks when their school provided soap, sanitizers and education.

Still, the swine flu outbreak muddied the waters, according to Gerald. Asthma attacks spiked across the schools in the fall of 2009, when the swine flu was at its peak. In October, 41 percent of asthmatic kids in both groups of schools had a symptom attack, versus about 25 percent in October 2010.

And since hand sanitizers became so widely used after the swine flu arrived, the study essentially lost its “control” group.

But while these findings don’t mean hand sanitizers are useless against asthma, there’s also little evidence that their use in schools benefits kids.

Some other in-school clinical trials have failed to show that hand sanitizers cut down on kids’ colds and flu, Gerald and her colleagues point out.

“Hand washing is probably best, and it’s cheapest,” Gerald said.

“It’s unclear right now,” she added, “whether hand sanitizers are a worthwhile investment for schools.”

Gerald thinks studies should continue to look at the question, though. One reason is the fact that some schools are already using hand sanitizers, sometimes as a replacement for soap and water.

“I think we need to know how they can be used most effectively,” Gerald said.

Many parents may be sending their kids off to school with a little bottle of hand sanitizer. That may or may not be helpful.

Gerald suggested teaching your kids about good hygiene in general, whether they have asthma or not. That includes hand washing, “covering up” when you cough, and keeping your fingers away from your mouth and eyes, she said.

GOJO said it “hopes the researchers will continue to study the effect of hand hygiene to reduce asthma rates with future scientific studies conducted in real world settings.”

None of the researchers reports any connection to the company, but one of Gerald’s colleagues on the work has ties to drug companies that make asthma medication.

SOURCE: Journal of Allergy and Clinical Immunology, online October 15, 2012.

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Can a school-based hand hygiene program reduce asthma exacerbations among elementary school children?

Results
Five hundred twenty-seven students with asthma were enrolled among 31 schools. The hand hygiene intervention did not reduce the number of asthma exacerbations compared with the schools’ usual hand hygiene practices (P = .132). There was a strong temporal trend because both sequences experienced fewer exacerbations during year 2 compared with year 1 (P

< .001).

Conclusions
Although the intervention was not found to be effective, the results were confounded by the H1N1 influenza pandemic that resulted in substantially increased hand hygiene behaviors and resources in usual-care schools. Therefore these results should be viewed cautiously.

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Lynn B. Gerald, Joe K. Gerald, Bin Zhang, Leslie A. McClure, William C. Bailey, Kathy F. Harrington
The Journal of Allergy and Clinical Immunology - 15 October 2012 (10.1016/j.jaci.2012.08.031)