The growing use of child day-care centers (CDCCs) has produced a significant rise in morbidity due to infectious diseases which carry such consequences as discomfort, disability, and parental anxiety.1,2 Haskins conservatively estimated the cost of day-care illnesses among children to be $1.8 billion.3 To this must be added the cost of parents' and care givers' excess illness attributable to CDCCs.
No published study describes a successful intervention to reduce the risk of upper respiratory disease in CDCCs. Although many research groups have advocated hand washing and diapering hygiene as a means of reducing the spread of enteric disease in CDCCs,4-11 there are only two controlled studies in the literature. In their pioneering work, Black et al showed the incidence of diarrhea in CDCCs following a rigorously monitored hand-washing program to be nearly twice that in intervention centers.12 Bartlett et al monitored the impact of hand washing in randomly assigned CDCCs and found no intervention effect. However, rates of diarrhea were significantly lower among children in the actively monitored centers regardless of intervention status.13
These studies share several limitations: the sources of incidence data were not blinded to center intervention status, the analyses did not statistically control for potential confounders, and non-independence of multiple diarrhea episodes in the same child were not accounted for. The purposes of our study were to develop a feasible, multicomponent hygienic intervention and to carefully measure its impact while controlling for sources of bias.
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Child Day-Care Centres as Supervisory Authorities? The Control of the Measles Vaccination in Germany Burdens the Trust Relationship Between Centres, Parents and Children