Proper handwashing is crucial to reduce the risk of transmitting all sorts of diseases.
DURING the H1N1 outbreak in 2009, it was noticeable that the health message of clean hands was taken seriously by healthcare facilities and the public. Many members of the public used the dispensers of hand sanitisers put up by the owners or tenants of healthcare facilities, offices, shopping complexes and other buildings.
It was then cool to keep one’s hands clean.
Many doctors and healthcare professionals had then hoped that the response to the then little known H1N1 virus would be translated into a habit.
With time, it was established that H1N1 was like any other flu for most individuals and like no other flu for some individuals. There was then a noticeable decline in the practice of keeping one’s hands clean. This is reflected in the reports of food poisoning and the high percentage of bacterial contamination of food sold since then.
Keeping one’s hands clean is a beneficial behaviour as many infections are spread by touch. This article is about the why, when and how of always keeping one’s hands clean.
A clean environment
There are various modes of transmission of organisms from one person to another.
Micro-organisms are present on everyone’s skin and body as well as surfaces in our surroundings. Direct physical contact between one person and another can lead to transmission of infections like respiratory viruses, hepatitis A and B, HIV and bacterial infections. The modes include shaking hands, touching, sexual intercourse, blood and other body fluids from a patient to a doctor or healthcare professional through skin lesions.
Micro-organisms like respiratory viruses and salmonella can be transmitted indirectly from one person to another through an intermediate, usually inanimate object. The modes include touching contaminated surfaces and sharing objects.
Droplet transmission involves the spread of micro-organisms like influenza through large particle droplets through the air when one person and another are in close proximity. The modes include talking, coughing and sneezing.
Airborne transmission involves the breathing in of micro-organisms like tuberculosis and legionella evaporated from droplets or within dust particles through the air within the same area or over a longer distance.
Micro-organisms can also be transmitted through common vehicles like water, food, medicines as well as shared syringes and needles among injecting drug users. These common vehicles can lead to the transmission of micro-organisms to many people.
The hands are the most common vehicle for the transmission of healthcare associated infections (HCAI), which has been defined by the Centre for Disease Control of the United States as “any infection associated with a medical or surgical intervention”.
HCAI is a major patient safety issue worldwide. It has been found to affect about 5 to 10% of patients in the developed world and double to 20 times more in developing countries. The incidence is higher in critical care units.
HCAI can lead to an increase in the severity of an illness, an increase in antimicrobial resistance, prolongation of the stay in a healthcare facility, long term disability, increased deaths and additional financial and personal costs for those affected and their families. The more ill a person is, the more likely he or she will be at risk of HCAI and its consequences.
Although HCAI involves patients and their caregivers and/or healthcare professionals, transmission of infections also occur between people with infections and their family and friends.
The sequence of events in the transmission of micro-organisms from an infected person to others is as follows:
- Every person’s skin sheds off tissue containing micro-organisms all the time and they contaminate the hands directly or indirectly.
- The micro-organisms also contaminate the surfaces in our surroundings.
- The micro-organisms survive and multiply on the hands and the surfaces. The degree of contamination is influenced by the duration of exposure and the survival time of the micro-organisms, which is variable.
- The hands remain contaminated unless there is action taken to ensure effective hand hygiene.
- The micro-organisms are transmitted from one person to another through the contaminated hands.
As such, hand hygiene should be the concern of everyone whether they are sick or not. It is of particular importance in the sick, their caregivers and healthcare professionals.
Everyone needs to have clean hands to protect themselves and their environment from harmful micro-organisms. There is also a need for a person providing care to the sick, whether as a caregiver or healthcare professional, to have clean hands so that the patient is protected against harmful micro-organisms on the hands of the caregiver or the patient.
Planning for effectiveness
It is pertinent that the World Health Organization (WHO) launched its Global Patient Safety Challenge, “Clean Care is Safer Care” in October 2005, with the objective of reducing HCAI globally.
WHO’s decision was evidence based.
Hand hygiene has been found to reduce the risk of cross-transmission in schools, day care centres and in the community. (Luby SP et al Lancet, 2005, 366:225-233; Meadows E & Le Saux N BMC Public Health, 2004, 4:50). Hand hygiene promotion has reduced respiratory tract infections, diarrhoea and impetigo among children in the developing world.
The effectiveness of improved hand hygiene in reducing HCAI rates is well documented (Allegranzi B & Pittet D Journal of Hospital Infection, 2009 Aug 29). The reduction in HCAI rates in various reports has been as high as 70%.
Most reports also demonstrate a temporal relationship between improved hand hygiene and reduced infection and cross transmission rates as well as decreased incidence of drug resistant bacteria.
There is an association between infection and poor hand hygiene practices, of which improvement has assisted in the control of epidemics in healthcare facilities.
The cost effectiveness of hand hygiene is well documented. Pittet and his colleagues reported that the direct and indirect costs of a hand hygiene programme were US$1.40 (RM4.20) per patient admitted to a 2,600 bed hospital. A less than 1% reduction in HCAIs observed was attributable to improved hand hygiene practices, which would lead cost savings. (Lancet, 2000; 356:1307-1312.)
The National Patient Safety Agency of the United Kingdom made an economic analysis of its “Clean your hands” campaign in 2004. It noted that the economic benefits were financial and patient-related. The former included reduced costs to hospitals and general practitioners because of reduced HCAI, patients and caregivers, reduced compensation and increased economic productivity because of reduced work days lost.
The latter included reduced deaths and benefits associated with non-fatal HCAIs. It concluded that “the intervention will be cost-saving even if the reduction in HCAI rates were as low as 0.1%.”
Hand hygiene is necessary before, during, and after preparing food. This is because although raw food may appear clean, it does not mean that it is safe.
It has been estimated that about 2.5 million bacteria are needed to make 250ml of water appear cloudy, while it takes about 15 to 20 bacteria to cause illness.
Cleanliness involves washing the hands before handling food and often during its preparation, washing and sanitising all utensils and surfaces used for food preparation, and protecting the food and kitchen from pests or animals.
Clean hands are needed before eating food, especially for those who eat with their hands. Harmful micro-organisms are spread when contaminated hands touch food items which are then consumed by others.
Clean hands are needed before and after caring for someone who is sick. Harmful micro-organisms are spread from the sick to their caregivers and/or healthcare professionals and vice versa, through the contaminated hands of caregivers and/or healthcare professionals.
Hand hygiene is vital before and after touching a patient; before handling an invasive device for patient care, regardless of whether or not gloves are used; after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings; if moving from a contaminated body site to another body site during care of the same patient; after contact with inanimate surfaces and objects in the immediate vicinity of the patient; after removing sterile or non-sterile gloves; and before handling medicines.
Hand hygiene is necessary after going to the toilet or after changing diapers or cleaning up a child who has used the toilet. This will prevent contamination of the hands by excretory materials.
Hand hygiene is necessary after blowing the nose, coughing, or sneezing to prevent contamination of the hands and surrounding surfaces by micro-organisms which can be harmful to others.
Hand hygiene is also necessary after touching an animal, animal waste or garbage, all of which contain micro-organisms which can be harmful to humans.
The mechanics of washing
An effective way of reducing micro-organisms growth is to wash the hands with soap and running cold or warm water for at least 40 to 60 seconds, especially when the hands are dirty or exposed to body fluids or after going to the toilet.
Liquid, bar or powdered soap can be used. When bar soap is used, the bars have to be placed such that there is drainage so that the bars will dry.
The hands should be rubbed together to make a lather and scrubbed well.
If there is no water and soap, a hand sanitiser containing at least 60% alcohol can be used. These sanitisers can reduce the number of micro-organisms in certain instances but they cannot get rid of all types of micro-organisms.
They are ineffective when the hands are obviously dirty. The hands have to be rubbed for 20 to 30 seconds.
Soap and alcohol-based hand sanitiser cannot be used together. It is important to adhere to the manufacturers’ recommendations on the use of soap and hand sanitisers, as well as the cleansing and refilling of the dispensers.
The need for hand hygiene by washing with soap or by using alcohol-based hand sanitsers is not replaced by the use of gloves, which are worn when there is likelihood of contact with blood or body fluids, mucous membranes, non-intact skin or potentially infectious materials.
There are techniques for the wearing and removal of gloves, which should be removed to perform hand hygiene when an indication occurs.
The same pair of gloves cannot be used for the care of more than one person or to touch a contaminated site of one person followed by another site of the body. Gloves should not be reused.
Hand lotions or creams that reduce the likelihood of contact dermatitis associated with hand washing or rubbing should be made available for healthcare professionals.
We all benefit
Hand hygiene has benefits for the well, the sick and their carers. Although clean hands do not totally eliminate the transmission of infection, the evidence is that it certainly reduces the incidence considerably.
Strict adherence to hand hygiene will go a long way in reducing infections and healthcare expenditures as well as improving the health status of every person.
Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.