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School children the key to curb spread of viral infections?

This article was published on 30th March on the website of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B).

Based in Dhaka, Bangladesh, the ICDDR,B are committed to solving public health problems facing low- and middle-income countries through innovative scientific research – including laboratory-based, clinical, epidemiological and health systems research. By developing, testing and assessing the implementation of interventions specifically designed for resource-poor settings, they aim to improve the health and well-being of people living in the world’s poorest nations.

For more than 50 years, they have been carrying out high-quality research and promoting the uptake of evidence-based interventions. Their initial focus was on diarrhoeal disease, but they now study multiple infectious diseases, other threats to public health, and methods of healthcare delivery. Their work has had a profound impact on health policy and practice both locally and globally.

At the end of December 2019, several cases of acute respiratory symptoms were first reported in Wuhan city of Hubei, a province in China. Scientists in China quickly identified a new strain of the coronavirus as the main cause. This disease – now referred to as COVID-19 – rapidly spread since its initial outbreak, affecting not only other parts of China but cases were soon detected in several other countries. Outbreaks this disease have since been detected in Asia, Europe, Australia, Africa and the Americas.

Hand and respiratory hygiene are crucial factors in preventing the spread of droplet-transmission diseases such as COVID-19 and other viral infections including seasonal influenza. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when an infected person coughs or sneezes. The World Health Organization and the US Center for Disease Control and Prevention (CDC) recommends several easy-to-follow steps to prevent the spread of this virus through droplet transmisson:

  • using disposable tissue to cough and sneeze, and disposing the used tissue into a closed bin and washing hands
  • if covered with hands, washing hands with soap and water or alcohol-based hand rub
  • using upper sleeve or bend of your elbow, and not hands

Prevention factors in Bangladesh are challenging due to the population density, lack of awareness and practice, and low nutritional status among the general population. However, tissues, alcohol-based hand rub, soap and water are often expensive and currently inaccessible which demands the need for low-cost and acceptable interventions.

Local understandings about who gets sick, why, when, how illness spreads and how it can be prevented are varied, and therefore could contribute to the transmission of respiratory infections. School children offer a unique opportunity to communicate public health messages to the family and larger community, which might be a useful strategy for wider prevention efforts, especially during epidemics.

Farhana Sultana, assistant scientist at ICDDR,B and colleagues piloted a zero-cost respiratory hygiene intervention among school children in Mymensingh and Dhaka which has seen a remarkable increase from 0% to 39%1 of coughing and sneezing into upper sleeves. There was also a 45% reduction of coughing and sneezing into the open air.

The teachers at the various schools led the intervention by teaching correct respiratory hygiene behaviour and the basics of respiratory disease transmission. The intervention also included targeted messaging to tap into social norms and approval. These initiatives were proven to be successful at increasing the uptake of respiratory hygiene behaviour. The strategies were also highly acceptable according to students who found that coughing/sneezing into upper elbows was a simple measure which protected them and their classmates from germs.

Thus, proper respiratory hygiene can be performed without access to tissues or water and soap for handwashing and it is effective at reducing the spread of infectious respiratory diseases like COVID-19.


Sultana F, Nizame FA, Southern DL, Unicomb L, Winch PJ, Luby SP. Pilot of an elementary school cough etiquette intervention: acceptability, feasibility, and potential for sustainability. The American journal of tropical medicine and hygiene. 2017;97(6):1876-85.