Handwashing (or hand hygiene) is the single most important method of preventing the spread of infection—in the hospital, at home, and in the community. Experts agree that regular and proper handwashing using soap and water is the simplest and most effective way to promote personal hygiene and reduce infections at school and in most workplaces. In the hospital, however, studies have shown that using alcohol-based hand sanitizers are effective in reducing the numbers of transient pathogens (infectious microorganisms) residing on the hands, and, as they are quicker to use, they are used more often by busy hospital personnel.
Handwashing minimizes the spread of pathogens between people, or between other living things and people. Fomites, or inanimate objects and surfaces, such as contaminated computer keyboards, desk tops, stair rails, and cutlery often provide surfaces that harbor microorganisms that are easily transferred to membranes of the mouth, nose, and eyes via the hands.
As early as the mid-nineteenth century, doctors and nurses began to assert that handwashing could reduce illness. Florence Nightingale (1820–1910), an English pioneer of the nursing profession, wrote about her perceived relationship between unsanitary conditions and disease based on her nursing experiences during the Crimean War in 1855. At about the same time, the Viennese physician Ignaz Philipp Semmelweis (1818– 1865) noted the connection between mortalities (deaths) in hospital patients and contact with physicians who often moved from patient to patient without washing their hands. After Semmelweis introduced handwashing with a solution containing chloride, the incidence of mortality due to puerperal fever (infection after childbirth) diminished from 18% to less than 3%.
Today, handwashing protocols are a cornerstone of the infection control program in any healthcare facility. Standard precautions, the most basic concept of infection control (which assumes that all body fluids are potential sources of infection), state that handwashing should occur both before and after routine contact with body fluids, even though latex gloves are worn. For surgery or other involved procedures, handwashing is accomplished with a non-irritating antimicrobial preparation that has fast, long-lasting, broad-spectrum activity against pathogens.
WORDS TO KNOW
BROAD-SPECTRUM: The term “broad spectrum” refers to a series of objects or ideas with great variety between them. In medicine, the term is often applied to drugs, which act on a large number of different disease causing agents.
ELBOW BUMP: The elbow bump is a personal greeting that can be used as an alternative to the handshake: the two people greeting each other bump elbows. It is recommended by the World Health Organization for use by researchers handling highly infectious organisms, such as Ebola virus.
FOMITES: Objects that can spread disease organisms are fomites. Papers, clothing, dishes, and other objects can all act as fomites.
PATHOGEN: A disease causing agent, such as a bacteria, virus, fungus, etc.
In 2005, the American Society for Microbiology (ASM) and The Soap and Detergent Association (SDA) released the results of a study showing that people do not wash their hands as often as they report doing so. The study first conducted a telephone survey about hand hygiene habits, and then observed people in public restrooms at six public attractions in four major cities: Atlanta (Turner Field), Chicago (Museum of Science and Industry, Shedd Aquarium), New York City (Grand Central Station, Penn Station), and San Francisco (Ferry Terminal Farmers Market). Results showed that 91% of American adults say they always wash their hands after using public restrooms, but only 83% actually did so. Women washed their hands more than men after using public restrooms (90% versus 75%).
In the telephone survey, women were reportedly also slightly better than men at washing their hands after coughing or sneezing, although at only 39% and 24% respectively, hand hygiene after a cough or sneeze was reportedly low. The viruses that cause colds and influenza are spread more often by contaminated hands that come in contact with mucous membranes in the eyes, mouth, and nose than are spread through the air during sneezing, according to the Secretary of the ASM.
To maximize effectiveness, careful attention must be paid to proper handwashing technique. The act of handwashing is best accomplished by vigorous rubbing together of the hands and fingers. This is because the removal of microorganisms is accomplished not only by the presence of the soap or antiseptic, but also by the friction of the opposing skin surfaces rubbing together. Warm water, soap, and friction loosen dirt and grime. The soap does not need to specifically labeled as “anti-bacterial,” but liquid soap lasts longer without hosting bacterial growth than bar soap. Far more important than the type of soap is the effort put into washing. Friction is key and it is important to work the soap into lather on both sides of the hands, wrists, between the fingers, and on the fingertips. Careful attention should also be given to areas around nail beds that may harbor bacteria in broken cuticles. It is important to wash for about 15 seconds (contact time is often critical in effectively killing germs) before rinsing well without touching the faucet or sides of the washbasin, and drying with an air dryer or disposable towel (preferred) or clean cloth towel. Equally important is to avoid recontamination by turning the water faucet off with the paper towel or cloth. Children can be taught to count, repeat a simple rhyme, or to softly sing a “washing song” to make sure they invest the needed time in washing.
Although it is difficult to estimate the financial impact of proper hygienic practices, conservative estimates by the U.S. Centers for Disease Control place the savings due to successful handwashing in clinical settings at over one billion dollars per year. As more than 20 million school days are lost due to the common cold alone, the savings of proper handwashing in schools and in the workplace could exceed this figure by a significant factor.
The American Society for Microbiology began focusing on increasing public awareness about the importance of handwashing in regular campaigns since 1996. The ASM also belongs to the Clean Hands Coalition, along with the Centers for Disease Control and Prevention (CDC) and other partners, which sponsors yearly handwashing awareness programs throughout the United States, usually in September near the start of the school year.
Especially during influenza season, both the CDC and World Health Organization (WHO) recommend the “elbow bump” greeting as a replacement for the handshake. Cold and influenza viruses that remain on the hands after a sneeze (and before handwashing) are often passed on through a handshake, then the recipient infects himself when touching his eyes or mouth with the contaminated hand. As it is difficult to contaminate the elbow with a sneeze, bumping elbows transfers fewer pathogens. WHO and CDC scientists responding to outbreaks of infectious disease where infrastructure is lacking commonly use the elbow bump greeting. In the event of an influenza pandemic, the U.S. government recommends the elbow bump greeting as a measure of social distancing in addition to regular handwashing to prevent the spread of infection.
Handwashing is a primary means of stopping the spread of germs and preventing routine infectious diseases such as influenza and common colds. Shaking hands, a common greeting in several nations, can transmit germs from person to person. While handwashing is recommended as part of a routine of basic hygiene, it is not always possible. The article below discusses the use of hand sanitizer gels on the political campaign trail. Political candidates in the United States often meet and exchange greetings with thousands of people every day. Some politicians use gel hand sanitizers to ward off infection. Others assert that the practice is not particularly beneficial—at least to their image.
The article's author, Mark Leibovich, is a writer and political correspondent for the New York Times.
Goldmann, Donald. “System Failure versus Personal Accountability—The Case for Clean Hands” NEJM (July 13, 2006): 355: 121–123.
American Society for Microbiology. “Don't Get Caught Dirty Handed.” <http://www.washup.org/> (accessed June 10, 2007).
American Society for Microbiology. “Gross…You Didn't Wash Your Hands?” <http://www.microbeworld.org/know/wash.aspx> (accessed June 10, 2007).
National Food Service Management Institute. “Wash Your Hands.” <http://www.nfsmi.org/Information/handsindex.html>. (accessed June 10, 2007).
Brenda Wilmoth Lerner