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Hand washing

Food safety
Terms
Foodborne illness
HACCP
Critical control point
Critical factors
FAT TOM
pH
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E. coli
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Blastocystis
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Trichinosis

Hand washing for hand hygiene is the act of cleansing the hands with water or another liquid, with the use of soap, for the purpose of removing soil, dirt and/or microorganisms.

Medical hand hygiene pertains to the hygiene practices related to the administration of medicine and medical care that prevents or minimizes disease and the spreading of disease. The main medical purpose of washing hands is to cleanse the hands of pathogens (including bacteria or viruses) and chemicals which can cause personal harm or disease. This is especially important for people who handle food or work in the medical field. The Centers for Disease Control and Prevention (CDC) has stated: "It is well-documented that one of the most important measure for preventing the spread of pathogens is effective hand washing." In addition to hand washing with soap and water, the use of alcohol rubs is a much more efficient and safer way to kill germs than the use of soap and water or antibacterial soap and water.

In symbolic hand washing using water only to wash hands is a part of ritual handwashing as a feature of many religions, including Bahá'í Faith, Hinduism and tevilah and netilat yadayim in Judaism. Similar to these are the practices of Lavabo in Christianity, Wudu in Islam and Misogi in Shintō.

Contents

Effectiveness

This hygienic behavior has been shown to cut the number of child deaths from diarrhea (the second leading cause of child deaths) by almost half and from pneumonia (the leading cause of child deaths) by one-quarter.[1] There are five critical times in washing hands with soap and/or using of a hand antiseptic related to fecal-oral transmission: after using a bathroom (private or public), after changing a diaper, before feeding a child, before eating and before preparing food or handling raw meat, fish, or poultry, or any other situation leading to potential contamination and see below.[2] To reduce the spread of germs, it is also better to wash the hands and/or use a hand antiseptic before and after tending to a sick person. If your hands are not visibly dirty or soiled, washing one's hands with a good hand antiseptic is the most effective overall way to prevent the spread of infectious disease. If your hands are dirty or soiled, washing your hands with soap and water followed by a good hand antiseptic is the most effective overall way to prevent the spread of infectious disease.

Substances used

Soap and detergents

The application of water alone is inefficient for cleaning skin because water is often unable to remove fats, oils, and proteins, which are components of organic soil. To remove pathogens, two gallons of water per minute is needed in washing hands using flowing water.[3]

Therefore, removal of microorganisms from skin requires the addition of soaps or detergents to water. Currently most products sold as "soaps" are actually detergents, so that is the substance most used to wash hands.

Water temperature

Hot water that is comfortable for washing hands is not hot enough to kill bacteria. However, warm, soapy water is more effective than cold, soapy water at removing the natural oils on your hands which hold soils and bacteria.[4]

Solid soap

Solid soap, because of its reusable nature, may hold bacteria acquired from previous uses, so it's important to wash the soap itself before and after use.[5][6]

Hand washing with contaminated soap could colonize the hands with Gram-negative bacteria, which results in an increase in bacterial counts on the skin.[7]

Hand washing with soap
Schoolchildren washing their hands before eating lunch.

Antibacterial soap

Antibacterial soaps have been heavily promoted to a health-conscious public. To date, there is no evidence that using recommended antiseptics or disinfectants selects for antibiotic-resistant organisms in nature.[8] However, antibacterial soaps contain common antibacterial agents such as Triclosan, which has an extensive list of resistant strains of organisms. So, even if antibacterial soaps aren't selected for antibiotic resistant strains, they might not be as effective as they are marketed to be.

A comprehensive analysis from the University of Oregon School of Public Health indicated that plain soaps are as effective as consumer-grade anti-bacterial soaps containing triclosan in preventing illness and removing bacteria from the hands.[9]

Hand antiseptic

A hand sanitizer or hand antiseptic is a non-water-based hand hygiene agent.[10] In the late 1990s and early part of the 21st century, Alcohol rub non-water-based hand hygiene agents (also known as alcohol-based hand rubs, antiseptic hand rubs, or hand sanitizers) began to gain popularity. Most are based on isopropyl alcohol or ethanol formulated together with a thickening agent such as Carbomer into a gel, or a humectant such as glycerin into a liquid, or foam for ease of use and to decrease the drying effect of the alcohol.

Hand sanitizers containing a minimum of 60 to 95% alcohol are efficient germ killers. Alcohol rub sanitizers kill bacteria, multi-drug resistant bacteria (MRSA and VRE), tuberculosis, and viruses (including HIV, herpes, RSV, rhinovirus, vaccinia, influenza, and hepatitis) and fungus. Alcohol rub sanitizers containing 70% alcohol kill 3.5 log10 (99.9%) of the bacteria on hands 30 seconds after application and 4 to 5 log10 (99.99 to 99.999%) of the bacteria on hands 1 minute after application. Alcohol rub sanitizers can prevent the transfer of health-care associated pathogens (Gram-negative bacteria) better than soap and water.

The increasing use of these agents is based on their ease of use and rapid killing activity against micro-organisms.

However frequent use of alcohol-based formulations for hand sanitizers can cause dry skin unless emollients and/or skin moisturizers are added to the formula. The drying effect of alcohol can be reduced or eliminated by adding glycerin and/or other emollients to the formula. In clinical trials, alcohol based hand sanitizers containing emollients caused substantially less skin irritation and dryness than soaps or antimicrobial detergents. Allergic contact dermatitis, contact urticaria syndrome or hypersensitivity to alcohol or additives present in alcohol hand rubs rarely occurs.[7][11] The lower tendency to induce irritant contact dermatitis also become an attraction as compared to soap and water hand washing.

Despite their effectiveness, the non-water agents do not clean hands of organic material, they simply disinfect them. However, disinfection does prevent transmission of infectious microorganisms. The commercial products of those include the brands of Aqium, Germ Warfare, Cuticura et cetera, GermOut and Rochon-Edouard et al. has provided a good review of those products.[12]

The efficacy of alcohol-free hand sanitizers is heavily dependent on their ingredients and formulation. In the past, alcohol-free hand sanitizers tended to significantly under-perform alcohol or alcohol rubs as germ killers in clinical studies using standard protocols such as EN1500. More recently, advanced formulations have been developed, some of which have been shown to out-perform alcohol. An example of this is HandClens, with a patented SAB (Surfactant, Allantoin and Benzalkonium Chloride) formulation. A further aspect of efficacy that is sometimes overlooked is the effect of repeated use. The efficacy of alcohol as a hand disinfectant has been shown to decrease after repeated use, probably due to progressive adverse skin reactions, whereas the efficacy of an alcohol-free hand sanitizer based on Benzalkonium Chloride as its active ingredient has been shown to increase with repeated use.[13] However, in a more recent study, the effectiveness of alcohol did not decrease after repeated use. This study also demonstrated that, unlike Benzalkonium Chloride, alcohol does not have persistent or cumulative antimicrobial activity after application.[14] However, Purell has been previously shown to fail to meet the FDA 21 CFR 333.470 performance standards for health-care personnel antiseptic hand washes not just as a consequence of the decrease in effectiveness with repeated use, but also due to a lack of persistence in antimicrobial activity after application and the decrease in effectiveness with heavy soil loads. [15] In the same study, HandClens was shown to meet and exceed the FDA performance standards.

Techniques

Soap and water

Conventionally, the use of soap and warm running water and the washing of all surfaces thoroughly, including under fingernails is seen as necessary. One should rub wet, soapy hands together outside the stream of running water for at least 20 seconds, before rinsing thoroughly and then drying with a clean or disposable towel.[16] It has been shown that the use of a towel is a necessary part of effective contaminant removal, since the washing action separates the contaminants from the skin but does not completely flush them from the skin - removing the excess water (with the towel) also removes the suspended contaminants. After drying, a dry paper towel should be used to turn off the water (and open the exit door if one is in a restroom or other separate room). Moisturizing lotion is often recommended to keep the hands from drying out, should one's hands require washing more than a few times per day.[17]

Hand antiseptics

Enough hand antiseptic or alcohol rub must be used to thoroughly wet or cover both hands. The front and back of both hands and between and the ends of all fingers are rubbed for approximately 30 seconds until the liquid, foam or gel is dry. The use of a hand antiseptic or alcohol rub is much quicker and more effective than hand washing with soap and water. Hand antiseptics and alcohol rubs with moisturizers will also not dry out the skin on hands as much as soap and water.

Drying

Effective drying of the hands is an essential part if the hand hygiene process. But there is some debate over the most effective form of drying in washrooms. A growing volume of research suggests paper towels are much more hygienic than the electric hand dryers found in many washrooms.

In 2008, a study was conducted by the University of Westminster, London, to compare the levels of hygiene offered by paper towels, warm air hand dryers and the more modern jet-air hand dryers [18]. The key findings were:

  • after washing and drying hands with the warm air dryer, the total number of bacteria was found to increase on average on the finger pads by 194% and on the palms by 254%
  • drying with the jet air dryer resulted in an increase on average of the total number of bacteria on the finger pads by 42% and on the palms by 15%
  • after washing and drying hands with a paper towel, the total number of bacteria was reduced on average on the finger pads by up to 76% and on the palms by up to 77%.

The scientists also carried out tests to establish whether there was the potential for cross contamination of other washroom users and the washroom environment as a result of each type of drying method. They found that:

  • the jet air dryer, which blows air out of the unit at claimed speeds of 400 mph, was capable of blowing micro-organisms from the hands and the unit and potentially contaminating other washroom users and the washroom environment up to 2 metres away
  • use of a warm air hand dryer spread micro-organisms up to 0.25 metres from the dryer
  • paper towels showed no significant spread of micro-organisms.

In 2005, in a study conducted by TUV Produkt und Umwelt, different hand drying methods were evaluated [19] . The following changes in the bacterial count after drying the hands were observed:

Drying method Effect on Bacterial Count
Paper towels and roll Decrease of 24%
Hot-air drier Increase of 117%

Medical use

Microbial growth on a cultivation plate without procedures (A), after washing hands with soap (B) and after disinfection with alcohol (C).

Medical hand washing is for a minimum of 15 seconds using generous amounts of soap and water or gel to lather and rub each part of the hands.[20] Hands should be rubbed together with digits interlocking. If there is debris under fingernails, a bristle brush may be used to remove it. Since germs may remain in the water on the hands it is important to rinse well and wipe dry with a clean towel. After drying, the paper towel should be used to turn off the water (and open any exit door if necessary). This avoids re-contaminating the hands from those surfaces.

The purpose of hand washing in the health care setting is to remove pathogenic microorganisms ("germs") and avoid transmitting them. The New England Journal of Medicine reports that lack of hand washing remains at unacceptable levels in most medical environments, with large numbers of doctors and nurses routinely forgetting to wash their hands before touching patients.[21] One study showed that proper hand washing and other simple procedures can decrease the rate of catheter-related bloodstream infections by 66 percent.[22]

World Health Organization has published a sheet demonstrating standard handwashing and handrubbing in health care sectors.[23] The draft guidance of hand hygiene by the organization can also be found at its website for public comment.[24] A relevant review was conducted by Whitby et al.[12] Commercial devices can measure and validate the hand hygiene, if demonstration of regulatory compliance is required.[25]

The addition of antiseptic chemicals to soap ("medicated" or "antimicrobial" soaps) confers killing action to a hand washing agent. Such killing action may be desired prior to performing surgery or in settings in which antibiotic-resistant organisms are highly prevalent.[26]

To 'scrub' one's hands for a surgical operation, a tap that can be turned on and off without touching with the hands, some chlorhexidine or iodine wash, sterile towels for drying the hands after washing, and a sterile brush for scrubbing and another sterile instrument for cleaning under the fingernails are required. All jewelry should be removed. This procedure requires washing the hands and forearms up to the elbow, usually 2-6 minutes. Long scrub times (10 minutes) are not necessary. When rinsing, one must prevent water to run back from the elbow to the hand. After hand washing is completed, the hands are dried with a sterile cloth and a surgical gown is donned.

Hand antiseptics

Liquid hand antiseptics are much more effective germ killers than gel and foam hand sanitizers. To use in a medical or surgical setting a sterile stainless bowl is filled with antiseptic and both hands are dipped and rinsed in the liquid up to the elbows. The hands and lower arms are removed from the liquid, rubbed and allowed to dry. After, drying in approximately 30 to 60 seconds the healthcare provider is gloved and gowned.

An example of how minuscule particles can be caught between dermal ridges in the hand, yet remain unseen by the naked eye.


Alcohol rubs and hand antiseptics (biocides) kill microorganisms. Current scientific evidence has not demonstrated a link between the use of topical antimicrobial formulations and antiseptic or antibiotic resistance. Antiseptics (biocides) have multiple (thousands) of nonspecific killing sites on and in the microbial cell which cannot easily mutate. Antibiotics and antibacterial soaps (triclosan) have one very specific killing site on and in the microbial cell which can easily mutate. Antibiotic resistance has no effect on the effectiveness of antiseptics.[27][28]

Alcohol rubs and combination hand sanitizers are effective at killing germs on the hands.[29] Many clinical studies have shown that alcohol rubs containing two germ killers (ie. Alcohol and Chlorhexidine gluconate or Benzalkonium chloride) are significantly better germ killers than alcohol rubs containing alcohol alone.[11]

However alcohol rub sanitizers are not appropriate for use when the hands are visibly dirty, soiled. Visible soiling of any sort on the hands must be washed with soap and water because alcohol-based hand rubs are ineffective in the presence of organic material. In addition, alcohols may not be as effective against non-lipid-enveloped viruses (e.g., Noroviruses) as enveloped viruses. Hand antiseptics are not effective against the endospores of bacteria (e.g., Clostridium difficile and Anthrax) and the spores of protozoa (e.g., Giardia lamblia). When such microorganisms are likely to be encountered, soap and water hand washing followed by use of a good hand antiseptic is preferable.[7]

Both hand washing with hand sanitizer (hand antiseptic) and with soap are effective in cleaning staph aureus, and the bacteria that are causing these staph infections, but alcohol-based hand sanitizers are not effective in killing spore forming organisms because alcohol doesn't destroy bacterial spores, but washing hands washes the spores down the sink.[30]

In the U.S. alcohol rubs have been banned from some schools because of flammability concern. The fire department allows Tallahassee Memorial Hospital to have a certain amount of hand sanitizer per smoke compartment, and supply it up to that limit.[31]

Hand washing with wipes

Hand washing using hand sanitizing wipes is also recommended by CDC as a convenient alternative during traveling in the absence of soap and water[32] in nonacute health care settings.[33]

Religion

Tsukubai, provided at a Japanese temple for symbolic hand washing and mouth rinsing

In symbolic hand washing using water only to wash hands is a part of ritual handwashing as a feature of many religions, including Bahá'í Faith, Hinduism and tevilah and netilat yadayim in Judaism. Similar to these are the practices of Lavabo in Christianity, Wudu in Islam and Misogi in Shintō.

Other handwashing behavior

The phrase "washing one's hands of" something, means declaring one's unwillingness to take responsibility for the thing or share complicity in it. In the New Testament book of Matthew, verse 27:24 gives an account of Pontius Pilate washing his hands of the decision to crucify Jesus: "When Pilate saw that he could prevail nothing, but that rather a tumult was made, he took water, and washed his hands before the multitude, saying, 'I am innocent of the blood of this just person: see ye to it'."

In Shakespeare's Macbeth, Lady Macbeth begins to compulsively wash her hands in an attempt to cleanse an imagined stain, representing her guilty conscience regarding crimes she had committed and induced her husband to commit.

It has also been found that people, after having recalled or contemplated unethical acts, tend to wash hands more often than others, and tend to value hand washing equipment more. Furthermore, those who are allowed to wash their hands after such a contemplation are less likely to engage in other "cleansing" compensatory actions, such as volunteering.[34][35]

Excessive hand washing is commonly seen as a symptom of obsessive-compulsive disorder (OCD).

Pros and cons of hand washing practices

Pros

  • helps minimize the spread of influenza[36]
  • diarrhoea prevention [37]
  • avoiding respiratory infections [38]
  • a preventive measure for infant deathes at their home-birth-deliveries [39]

Cons

  • prone to skin damage [40]

Related

  • Antibacterial soap
  • E. coli O157:H7
  • Antibiotic resistance
  • Ignaz Semmelweis
  • Soap dispenser
  • Methicillin-resistant Staphylococcus aureus
  • Nosocomial infection
  • Rubbing alcohol
  • Patient safety
  • Occupational biosafety
  • Stainless steel soap

Notes & References

  1. ^ World Health Organization. Global Handwashing Day 2008: Planner's Guide.
  2. ^ Campaign aims to promote hand-washing and save young lives in Malawi
  3. ^ (English) Standard Operating Procedure
  4. ^ U.S Food and Drug Administration Center for Food Safety and Applied Nutrition "Handwashing"
  5. ^ http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=241514
  6. ^ http://www.supplychain.nhs.uk/portal/pls/portal/!PORTAL.wwpob_page.show?_docname=3854532.PDF
  7. ^ a b c "Hand Hygiene for Healthcare Workers". LearnWell Resources, Inc, a California nonprofit public benefit 501(c)(3) corporation. http://www.learnwell.org//handhygiene.htm. Retrieved 2007-04-27. 
  8. ^ Weber DJ, Rutala WA (2006). "Use of germicides in the home and the healthcare setting: is there a relationship between germicide use and antibiotic resistance?". Infect Control Hosp Epidemiol 27 (10): 1107–19. doi:10.1086/507964. PMID 17006819. 
  9. ^ "Plain soap as effective as antibacterial but without the risk". http://www.physorg.com/news106418144.html. Retrieved 2007-08-17. 
  10. ^ Clean hands from the CDC
  11. ^ a b Hibbard JS (2005). "Analyses comparing the antimicrobial activity and safety of current antiseptic agents: a review". J Infus Nurs 28 (3): 194–207. doi:10.1097/00129804-200505000-00008. PMID 15912075. 
  12. ^ a b Rochon-Edouard, Stéphanie et al. (2004). "Comparative in vitro and in vivo study of nine alcohol-based handrubs". American Journal of Infection Control 32 (4): 200–204. doi:10.1016/j.ajic.2003.08.003. 
  13. ^ AORN; Dyer, etal; Aug 1998; VOL 68, No2;http://www.aornjournal.org/article/abstracts?terms1=&terms2=&terms3=
  14. ^ Garcia R, Hibbard JS. Antimicrobial activity of a recently approved chlorhexidine isopropyl alcohol antiseptic vs. 70% isopropyl alcohol: a randomized, blinded trial. An oral presentation at the 28th Annual Educational Conference and International Meeting of the Association for Professionals in Infection Control and Epidemiology, June 12, 2001.
  15. ^ AORN; Dyer, etal; Aug 1998; VOL 68, No2;http://www.aornjournal.org/article/abstracts?terms1=&terms2=&terms3=
  16. ^ Hand washing from Mayo Clinic
  17. ^ Hand washing from Tufts University
  18. ^ A comparative study of three different hand drying methods: paper towel, warm air dryer, jet air dryer’ by Keith Redway and Shameem Fawdar of the School of Biosciences, University of Westminster London
  19. ^ TÜV Produkt und Umwelt GmbH Report No. 425-452006 A report concerning a study conducted with regard to the different methods used for drying hands; September 2005
  20. ^ APIC Guidelines for handwashing and hand antisepsis in health care settings. American Journal of Infection Control. 1995;23:251-269
  21. ^ Goldmann D (2006). "System failure versus personal accountability--the case for clean hands". N. Engl. J. Med. 355 (2): 121–3. doi:10.1056/NEJMp068118. PMID 16837675. 
  22. ^ Pronovost P, Needham D, Berenholtz S, et al. (2006). "An intervention to decrease catheter-related bloodstream infections in the ICU". N. Engl. J. Med. 355 (26): 2725–32. doi:10.1056/NEJMoa061115. PMID 17192537. 
  23. ^ World Health Organization. "How to Handrub & How to Handwash". http://www.who.int/gpsc/tools/GPSC-HandRub-Wash.pdf. Retrieved 21 July 2008. 
  24. ^ World Health Organization. "WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft)". http://www.who.int/patientsafety/information_centre/Last_April_versionHH_Guidelines%5B3%5D.pdf. Retrieved 21 July 2008. 
  25. ^ Online Science Mall. "Ultraviolet LED Flashlight Blacklight - Good with Glo Germ Simulated Germs 21LED". http://www.onlinesciencemall.com/Shop/Control/Product/fp/vpid/2679076/vpcsid/0/SFV/30852. Retrieved 21 July 2008. 
  26. ^ WHO Guidelines on Hand Hygiene in Health Care
  27. ^ Jones RD (1999). "Bacterial resistance and topical antimicrobial wash products". Am J Infect Control 27 (4): 351–63. doi:10.1016/S0196-6553(99)70056-8. PMID 10433675. 
  28. ^ Barry AL, Fuchs PC, Brown SD (1999). "Lack of effect of antibiotic resistance on susceptibility of microorganisms to chlorhexidine gluconate or povidone iodine". Eur. J. Clin. Microbiol. Infect. Dis. 18 (12): 920–1. doi:10.1007/s100960050434. PMID 10691210. 
  29. ^ "Alcohol Hand Rub and Hand Hygiene". Clinical Excellence Commission, Health, New South Wales, Australia. http://www.cec.health.nsw.gov.au/pdf/AlcoholHandRub061013.pdf. Retrieved 2007-04-27. 
  30. ^ (English) WXTL TV: Hand Sanitizer vs. Washing
  31. ^ (English) WXTL TV: Hand Sanitizer vs. Washing
  32. ^ (English) About.com Cold and Flu:Is Hand Sanitizer Better Than Hand Washing?
  33. ^ (English) PubMed.gov: Alcohol-impregnated wipes as an alternative in hand hygiene
  34. ^ Benedict Carey. Lady Macbeth Not Alone in Her Quest for Spotlessness. The New York Times, 12 September 2006
  35. ^ Zhong CB, Liljenquist K (2006). "Washing away your sins: threatened morality and physical cleansing". Science 313 (5792): 1451–2. doi:10.1126/science.1130726. PMID 16960010. ; Simone Schnall, Jennifer Benton, and Sophie Harvey: Clean Conscience : Cleanliness Reduces the Severity of Moral Judgments. Psychological Science, 16, 780–784.
  36. ^ Cowling, Benjamin J. et al. (2009). "Facemasks and Hand Hygiene to Prevent Influenza Transmission in Households". Annals of Internal Medicine 151 (7). http://www.annals.org/cgi/content/full/0000605-200910060-00142v1. Retrieved 11 August. 
  37. ^ Luby, Stephen P. et al. (2006). "Combining drinking water treatment and hand washing for diarrhoea prevention, a cluster randomised controlled trial". Tropical Medicine & International Health 11 (4): 479. doi:10.1111/j.1365-3156.2006.01592.x. 
  38. ^ Scott, Beth et al.. "Protecting Children from Diarrhoea and Acute Respiratory Infections: The Role of Hand Washing Promotion in Water and Sanitation Programmes". http://www.searo.who.int/LinkFiles/Regional_Health_Forum_1.pdf#page=49. Retrieved 21 May 2009. 
  39. ^ Ramashwar, S.. "Hand Washing May Reduce Risk of Infant Death in Home Births in Nepal". https://www.agi-usa.org/pubs/journals/3415108.html. Retrieved 21 May 2009. 
  40. ^ e Borges, Lizandra Ferreira de Almeida et al. (2007). "Hand washing: Changes in the skin flora". American Journal of Infection Control 35 (6): 417 - 420. doi:10.1016/j.ajic.2006.07.012. 

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