Good Intentions but bad outcomes: Communal-bowl hand-rinsing before meals transmits pathogens and diseases: a systematic review

BackgroundCommunal Bowl-Hand Rinsing (CB-HR), refers to more than one person washing their hands in one shared container of water, without soap and without changing the water between individuals, before meals. CB-HR has persisted in Africa despite decades of handwashing education during communicable disease epidemics, including Covid-19. We systematically reviewed the literature to provide a better understanding of the spread and motivations for the practice, its association with disease or pathogen transmission, and targeted interventions. MethodsSeveral electronic databases and grey literature were searched. We extracted data and appraised their methodological rigour using the Mixed Methods Appraisal Tool (MMAT). A narrative synthesis and Forest Plot were used to summarise the data. FindingsFifteen studies (all from 10 Sub-Saharan Africa (SSA) countries) were identified from 10,711 records. Study settings were schools (n=4), funerals (n=1), and households (n=10). Four case-control studies reported increased odds of cholera (Adjusted-OR=6.50;95%CI,2.30, 18.11), dysentery (at households Adjusted-OR=10.52(95%CI,2.81, 39.0), and at public gatherings Adjusted-OR=2.92(95%CI,1.24,7.21)), diarrhoea (Adjusted-OR=2.89;95%CI,1.33, 6.39), Hepatitis E virus risk (Adjusted-OR=1.90; 95%CI,1.07, 3.38), and one found a lower height-for-age z-score in babies whose families perform CB-HR. A cross-sectional study reported odds of cysticercosis (Adjusted-OR=3.8;95%CI,2.5, 5.9). Two cross-sectional studies conducted laboratory water and/or hand-swab microbiology investigations, demonstrating pathogen transmission from CB-HR. No intervention studies were found. ConclusionResearch on CB-HR was sparse. CH-BR is widely practised in SSA and spreads diseases. However, there is a need for the development and evaluation of culturally sensitive interventions to address this practice in Africa. The review was not funded but the authors were funded by various grants. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSGastrointestinal diseases are an important cause of disease and death, especially in young children. The risk of Gastrointestinal diseases can be reduced by hand hygiene. Extremely limited primary research has been conducted into the health effects of Communal Hand Rinsing (CB-HR) in a shared bowl of water before meals. CB-HR simply refers to the practice before eating where more than one person wash/rinse their hands in one shared container of water, without soap and without changing the water between individuals. No systematic reviews have been conducted on this topic. What this study addsThis systematic review collates all available research on the prevalence, motivators, and disease transmission of pathogens following CB-HR, thus providing important new insights about this practice. CB-HR is a common practice and found to be a risk factor for the spread of communicable diseases such as diarrhoea, cholera, and dysentery. How this study might affect research, practice or policyFurther research is urgently needed to develop culturally sensitive interventions to reduce the risk of disease associated with CB-HR.