Background: Handwashing (HW) compliance, although an effective means of limiting childhood illness, remains low among personnel in early childhood centers (ECCs). Our study determined HW compliance and efficacy of ECC personnel. Methods: Surveillance cameras were used to determine HW opportunities, compliance, occurrences, and effectiveness based on child-care oriented criteria. Results: We observed 349 HW triggering events, with 14 events per hour; a median of 2 personnel (caregivers, paraprofessional aides, or parents) were present at any given time period. Compliance was 30% (caregivers), 11% (paraprofessional aides), and 4% (parents), with an overall compliance of 22%. Between-room and between-age groups of children being cared for and compliance of caregivers and paraprofessional aides were not found to be significantly different (P .05). For all personnel between the 10 different rooms, the median compliance was 20.2% (95% confidence interval, 8%-35%). Only 7% of personnel taking care of 2- to 3-year-old children washed their hands, the lowest compliance per age group. Of all steps in HW, paper towel usage had the highest compliance, with a 97% adherence, whereas turning off the faucet with a paper towel was the lowest at 17%. Conclusions: Methods and strategies need to be developed to increase compliance. Current technology provides an effective means of gathering data for determining HW compliance in ECCs. (author abstract)