Diarrhea is one of the most perennial health problem causing both morbidity and mortality worldwide in children especially among developing nations. The vast majority of deaths worldwide from diarrhea (2-3 million deaths per year) are from young children in developing countries. The United States have 220,000 children younger than 5 years old that are hospitalized each year with diarrhea comprising approximately 9% of all hospitalization in this age group. Diarrhea incidence in children younger than3 years of age has been estimated to be 1.3 to 2.3 episodes per child per year. The incidence rate in children attending day care centers are higher. More than US$ 2 billion are spent yearly as direct cost of hospitalization and outpatient care [1].
Despite advances in treatment and diagnostics, recurrence of cases and epidemics surface from time to time from different parts of the world. The problem seem to be not just of diagnostics and treatment but more so with the basic preventive aspect of diarrhea among children.
The promotive and preventive role of handwashing in diarrheal cases can not be overemphasized. Its cost effectiveness, relative ease of application and implementation are evidence- based and makes a lot of economic and healthful sense considering the cost related to hospitalization and out patient care of diarrheal cases.
II. Objectives:
Establish causal relation between handwashing and occur-
rence of diarrhea among children.
Highlight the key role of handwashing for health promotion
and prevention of diarrhea among children
Provide recommendations relating to the legal, ethical and
health policy implication of handwashing for the prevention of diarrhea among  children.
III. Methodology
Literature search was done from scholarly published materials
to meet the objectives of this seminar discussion. The subject of
the research is limited to children aged 0-12 years old.
IV. Discussion
  Evidences of clinical benefit of handwashing/hand hygiene dates back from Semmelweis (1818-1865). While working in the General Hospital of Vienna, he demonstrated that puerperal fever was a contagious disesase caused by infectious organism which was spread from patient to patient via the hands of health care workers (HCW) [9]. A hundred years later another key observation by Rammelkamp and his co-worker who demonstrated that direct contact was the main mode of transmission of Staphylococcus aureus among neonates in the nursery [3].
The same controlled study done by Rammelkamp and co-
workers demonstrated that handwashing between patient contacts reduced levels of S. aureus acquisition to the low levels resulting from airborne transmission. The EPIC Systematic Review in 2001 showed that liquid (even non-medicated) soap and water will effectively decontaminate hands but 70% alcohol or an alcohol based antiseptic hand rub provides the most effective decontamination for a wide variety of organisms (S. aureus, Pseudomonas aeroginosa, Klebsiella, Clostridium difficile and rotavirus).
A review of published literature from 1879 through 1986 consisting of 423 articles and spanning 107 years demonstrated that except for specificity, all the elements of causality, including temporality, strength, plausibility, consistency of association and dose response were present. As concluded, the emphasis on handwashing as a primary infection control measure has not been misplaced and should continue [6].
Studies specifically linking handwashing to prevent diarrhea in children was conducted in different countries in various care settings. A study comparing 2 day care centers with handwashing program (HWC) and 2 control centers (CC) showed that incidence of diarrhea in HWC began to fall (after the program was begun) and after the second month of the study was consistently lower than the CC. The incidence of diarrhea in HWC was approximately half that of the CC for the entire 35-week study period [1].

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In a randomized controlled trial in a high risk community in Pakistan where diarrhea is a leading cause of child death, an improvement in handwashing in the household reduced the incidence of diarrhea among children at high risk of death from the same cause. Children living in households that received handwashing promotion and plain soap had a 53% lower incidence of diarrhea compared to children in the control population. Infants in households that received handwashing promotion and plain soap had 39% fewer days with diarrhea vs infants living in control neighborhoods. Severely malnourished children younger than 5 years in the intervention group had 42% fewer days with diarrhea vs severely malnourished children in control group. Similar reductions in diarrhea were observed among children living in households receiving antibacterial soap[5].
A systematic review with random effects meta-analysis by Curtis and Cairncross showed data sources which are studies linking handwashing with diarrheal diseases. Of which were seven intervention studies, six case control, two cross sectional and two cohort studies. Results showed that washing hands with soap can reduce the risk of diarrheal disease by 42-47% and interventions to promote handwashing might save a million lives[2].
A clinical advisory from the CDC[7] and Mayo Clinic[8] stated that handwashing is the easiest, simplest to do and most effective way to stay healthy and to prevent spread of infection and illness in all settings. For the specific purpose of this discussion, among children in various care settings, in home, day care, school and neighborhoods. Clean hands can stop germs from spreading from one child to another and even entire communities.
The potential ways of dealing with this situation includes education, development, implementation and enforcement of regulations and use of infection control and for this particular case, handwashing.
V. Summary, Conclusions, Recommendations
The preponderance of evidence from studies spanning hundreds of years effectively establish the practice of handwashing as evidence-based not only for prevention of diarrhea among children but even as primary infection control in the transmission of nosocomial infections.
Handwashing, being the simplest, most health promotive and effective primary infection control for the prevention of diarrhea among children can not be overemphasized in the light of economic cost, sick days and lives lost attributable to diarrhea.
It is therefore recommended that advocacy for handwashing in terms of educating involved individuals, caregivers, families and children themselves should be given top priority. This should come in a form of tri-media campaign in schools, workplaces, communities, homes, etc. Handwashing programs should be implemented and even enforcement of strict regulations or legislations might as well be in place if needed be.