Handwashing Related Literature

There are grave consequences when people do not wash their hands or wash them improperly. It is known that hands are the main media for contaminants getting to people, whether the infections are airborne, oral or tactile. Infectious diseases that are commonly spread through hand to hand contact include the common cold, and several gastrointestinal disorders such as diarrhoea (WaterAid, 2006). Human hands usually harbour microorganisms both as part of a person’snormal microbial flora as well as transient microbes acquired from the environment (Lindberg et al, 2004).According to Kartha (200! ), many people consider handwashing a waste of time. However, they are unaware that hands are hosts to many bacteria and viruses that can cause infectious diseases. Every human being comes in contact with germs and bacteria in their daily life. These harmful microorganisms are present all around – on door knobs, faucets, light switches, tables, and railings. People touch these things during the day while doing their routine work without much thought, and then touch their face, eyes, nose, and sometimes eat food too.Through these acts, the microorganisms get into the body, causing several diseases. People, who are careless at washing hands, risk catching flu, or cold, or any gastrointestinal illness (Kartha, 2001). Mayo Clinic (2009) also asserted that as people touch one another, surfaces and objects throughout the day, they accumulate germs on their hands. In turn, they can infect themselves with these germs by touching their eyes, nose or mouth. Hands serve as vectors transmitting pathogens to foodstuffs and drinks and to the mouths of susceptible hosts (Huttly, 1997).Many food borne diseases and pathogenic microorganisms are spread by contaminated hands. If pathogens from human faeces enter a person’s mouth, they will cause diarrhoea. School going children are exposed to greater risks of diarrhoeal disease by consuming contaminated water and food (Dasg upta, 2005). Students in schools or colleges are more likely to take meal and water without washing hands and may be exposed to risk of infection (Tambekar et al, 2007). If proper treatment is not given, this can prove fatal, particularly to children (WHO, 2006).In Ghana, funeral celebrations are very important social functions at which hundreds of people gather. From experience, one important activity during such gatherings is handshaking. Indeed, it is considered offensive and disrespectful for cultural values when one does not proffer his hand for shaking. It is however unfortunate that when people are served snacks and food during such occasions, handwashing facilities are not made available. People therefore eat with unwashed hands.The advent of some serious gastrointestinal illnesses (for example, cholera) had been traced to such gatherings. Handwashing defined Handwashing is defined as the act of cleansing the hands with water or other liquid, with or without the inclusion of soap or other detergent, for the purpose of removing soil or microorganisms (Biology-online, 2011; Medconditions, 2011). 2. 6. 1 Attitudes of handwashing Handwashing has been an age old practice globally. It is carried out for varied reasons, including religious, cultural, health and moral reasons.Attitudes towards handwashing are very important. They go a long way to determine the practice of handwashing and its effect on health. In a study by Hoque et al (1995), 90 women from randomly selected households in rural Bangladesh were observed washing their hands after defaecation. Thirty-eight percent of the women used mud, 2% used ash, 19% used soap, and 41% used water only without a rubbing agent. A total of 44% of women washed both hands, while 56% washed only their left hands.About 78% of the women dried or wiped their hand on their clothes and the rest let them air dry. According to SHEWA-B (2007), in Bangladesh (and in some regions of the sub-continent), observations on handwash ing practices identified that handwashing with water alone before food preparation and eating was quite common (47 – 76%), but washing hands with soap or ash was observed =2% of the time. Washing of both hands with soap or ash was more common after defaecation (17 – 18 %), after cleaning a child’s anus (22 – 24%) or after handling cow dung (12 – 20%).Findings also showed that availability of handwashing materials such as soap, ash or mud at the site of handwashing was low, with approximately 30%, and =1% of households having the specified material. Water availability was high. Hand drying was observed to take place before preparing food, after defaecation, after eating and before serving food. A high proportion of females did not dry their hands after handwashing. A staggering one out of three Americans skips handwashing after going to the bathroom.Only 30% of people who have coughed or sneezed into their hands wash their hands afterwards. Kids are even worse. In a survey of junior high and high school boys and girls, only 58% of girls and 48% of boys washed up after using the rest room (Wisegeek. com, 2011). Worldwide rates of handwashing with soap are very low. While many wash their hands with water, only a small percent use soap at critical times. In Ghana, for example, the rates for handwashing with soap after defaecation is 3% and after cleaning up a child is also 3% each (PPPHW, 2010). 2. 6. Economic considerations Efforts to modify human behaviour are complex. People can only expect to be successful if there is an understanding of what motivates, facilitates, and hinders adequate handwashing behaviour (Curtis et al, 1997; O’Boyle et al, 2001). Curtis et al (2001) noted that modern methods of promoting handwashing can be effective and cost-effective on a large scale. Studies suggest that soap is widely available, even in poor households in developing countries, although it is mostly used for bathing and washing c lothes (Borghi et al, 2002).In rural India and Bangladesh, soap is often considered a beautifying agent or for the physical feeling of cleanliness which it gives, rather than being associated with the removal of microorganisms or health benefits (Hoque and Briend, 1991; Hoque et al, 1995). In low income communities, soil, mud or ash may be used as a zero cost alternative to soap for handwashing (Zeitlyn and Islam, 1991). Hoque et al (1995) again reported that altogether, 81% of non-soap users stated that they might use soap, but were unable to afford it. Critical times for handwashingA defensive strategy is important when trying to avoid infecting oneself with an illness lying in wait (Wisegeek. com, 2011). According to Mayo Clinic (2009), frequent handwashing is one of the best ways to avoid getting sick and spreading illness. Although it is impossible to keep hands germ-free, washing hands frequently can help limit the transfer of bacteria, viruses and other microbes. It is possib le that people do not wash their hands as often as they should. Handwashing prevents both diarrhoea and respiratory infections effectively whendone properly and at critical times.The critical times must be observed and conscious efforts made to clean hands at such times. A number of sources (Mayo Clinic, 2009; ASH, 2011, All Family Resources, 1999 and CDC, 2010) agree on a number of critical times when hands must be washed. The critical times include: ? Before preparing food; ? Before eating; ? Before treating wounds or giving medicine; ? Before touching a sick or injured person; ? Before inserting or removing contact lenses; ? After preparing food, especially raw meat or poultry; ? After using the toilet/bathroom; ? After changing a diaper; After touching an animal, or animal toys, leashes or waste; ? After blowing your nose, coughing or sneezing into your hands; ? After touching a sick or injured person; ?After handling garbage or something that could be contaminated, such as a cl eaning cloth or soiled shoes; ? Whenever hands look dirty. Some include also washing hands after handling money (ASH, 2011), before going home, immediately one gets home, on arrival at the workplace (All Family Resources, 1999), after combing hair (USDA, 2011) and after smoking (Earth’s kids, 2011). . 6. 4 Process of handwashing Though people know the importance of handwashing, not many know how to do it properly. Handwashing does not mean just running water over your palms. It has to be done very carefully and in detail (Kartha, 2001). Mayo Clinic (2009) suggests the following steps: ? Wet hands with (running) water; ?Apply cleansing agent; ? Lather well; ? Rub hands vigorously for at least 10 to 20 seconds, remembering to scrub all surfaces, including the backs of hands, wrists, between fingers and under fingernails; ? Rinse well; Dry hands with a clean or disposable towel or dryer. The above steps have been advocated by several sources as well. These include ASH (2011); Al l Family Resources (1999); CDC (2010); Kartha (2001); Wisegeek. com (2011) and Gavin (2011). 2. 6. 5 Correct length of time Equally important is the length of time that hands are to be washed. The key is to lather up hands and rub vigorously for at least 15 to 20 seconds. Some suggest singing ‘Happy Birthday’ or the ABCs to keep a child washing hands for the correct amount of time (Wisegeek. com, 2011).Earth’s Kids (2011) suggested that children sing a fun song while washing hands to mark the time of 15 – 20 seconds, so that they know how long they wash. Gavin ((2011) said to use soap and lather up for 20 seconds. Mayo Clinic (2009) noted that wet, soapy hands should be rubbed together outside the stream of running water for at least 20 seconds. CDC (2010) suggested scrubbing hands for 20 seconds, and while singing ‘Happy Birthday’ twice to get to 20 seconds. PPPHW (2008) also suggested singing any local fun song that would make up to 20 secon ds while hands are being rubbed together after applying cleansing agent.According to ASH (2011), hands must be rubbed together for at least 10 seconds while singing ‘Happy Birthday’ once for a perfect length of time. Rub hands vigorously until a soapy lather appears and continue for at least 15 seconds (All Family Resources, 1999). Mohave County Information Technology (2001) also recommends rubbing hands briskly for at least 20 seconds. From the foregone discussions it can be seen that rubbing hands together vigorously for anytime between 10 to 20 seconds or more should be adequate for pathogen reduction on the hands. Quantity of water needed for rinsing handsAccessible and plentiful water has been shown to encourage better hygiene, particularly handwashing (Curtis and Cairncross, 2000). Also, interventions to improve water quality at the source along with treatment of household water and safe storage systems have been shown to reduce diarrhoea incidence by as much as 4 7% (WHO, 2008). Hoque et al (1995), in a study, observed that as many as 74% of the 90 women rinsed their hands with 0. 7 litre of water or less. They however recommend that rinsing with 2 litres of clean water was protective, although such volumes may be difficult tosustain in the absence of on-plot access to water.Since pathogens removed during handrubbing have to be rinsed away, there must be a reasonable flow of water (Standard Operating Procedures, 1997). Mayo Clinic (2009) suggested the use of running water for rinsing hands. Water scarcity has an impact on hygiene practices such as handwashing. It could lead to person-to-person transmission due to inadequate personal and domestic hygiene. Water scarcity can therefore result in faecal-oral, skin and eye infections (Cairncross, 2011). Temperature of waterContrary to popular belief, scientific studies by Michaels et al (2002), and Laestadius and Dimberg (2005), have shown that using warm water has no effect on reducing the micro bial load on hands. Hot water that is comfortable for washing hands is not hot enough to kill bacteria. Microorganisms proliferate much faster at body temperature (37 degrees C). However, warm, soapy water is more effective than cold, soapy water at removing the natural oils which hold soils and bacteria (US Food and Drugs Administration, 2006). All Family Resources (1999) indicated that warm water should always be used for handwashing.ASH (2011), Kartha (2001), Wisegeek. com (2011) and Gavin (2011) also suggested the use of warm water for handwashing. CDC (2010) said that clean running water that was warm or cold could be used. The temperature of water has not been shown to be important in handwashing (Standard Operating Procedures, 1997). Efficacy of cleansing agents in microbial reduction Esrey et al (1991) have suggested that reducing the rate of pathogen ingestion causes the incidence of severe infections to begin to fall before that of mild ones. The reduction in the severity of infection is the ultimate purpose of handwashing.Therefore microbial reduction on hands would reduce the ingestion of pathogens since the hands have been proved to be the main transport route for gastrointestinal diseases, respiratory tract infections, skin infections (eg. impetigo) as well as eye infections (eg. conjunctivitis). This makes the agent employed in handwashing a necessary factor. Water only Pure water has a pH of seven, which makes it neutral. It is also known as a universal solvent. A number of studies (Cairncross, 1993; Ghosh et al, 1995; Khan, 1982; Oo et al, 2000) suggested that handwashing with water only provides little or no benefit.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 (Standard Operating Procedure, 1997). Kalanke (Mali) (2011) noted that handwashing with water alone does not remove many germs. Hoque and Briend (1991), on the contra ry, showed that whilst less effective than when using a rubbing agent such as soap, mud or ash, some reductions in contamination were found when washing with water alone.Data on the effectiveness of handwashing with soap-based formulations, compared with water alone, in the removal of bacteria and viruses (Ansari et al, 1989; Mbithi et al, 1993) suggest that, in most (but not all) cases, liquid soap-based formulations were more effective than water only. However, the authors concluded that the differences were not statistically significant. Ash Hoque and Briend (1991) indicated that the use of alternative rubbing agents (mud or ash) provided the same benefits as soap.Again, Hoque et al (1995) also found that the use of ash and soap all achieved the same level of cleanliness. Ash, however, is considered less pleasant on the hands compared with soap or soil (Hoque and Briend, 1991). Despite the positive lifesaving potential of handwashing with soap (ash), proper handwashing is not bei ng practiced regularly by children in schools and homes (WASH United, 2010). Citrus lime fruit Scientifically known as Citrus aurantifolia, there are two natural groups of the citrus lime fruit – acid (sour) limes, and acidless (sweet) limes.The ‘West Indian’ lime, also called Mexican and Key lime is round, small-fruited, moderately seedy and highly polyembryonic; it has a thin, smooth rind, greenish flesh and a citric acid content ranging from 7% to 8%. It is usually grown as a seedling, as no satisfactory rootstock is known, but in Ghana it is grown on Rough lemon stock (Samson, 1986). Soap A number of studies indicate that washing hands with soap is the critical component of the handwashing behaviour (Cairncross, 1993; Ghosh et al, 1997; Khan, 1982; Oo et al, 2000). Kartha (2001) noted that the most essential thing required to wash hands is soap.Again, studies have shown that hands can carry faeces to surfaces, to foods, and to future hosts, and handwashing wi th soap is effective in removing pathogens (Han et a. , 1986; Kaltenthaler et al, 1991; Ansari et al, 1991). Improvements in access to safe water and adequate sanitation, along with the promotion of good hygiene practices (particularly handwashing with soap), can help prevent diarrhoea (Black et al, 2003). PPPHW (2011) affirmed that promoted on a wide enough scale, handwashing with soap can be thought of as a ‘do- it-yourself’ vaccine. Choice of soapDebate has been ongoing about the best type of soap to be used in handwashing. A study by Aiello (2007) indicated that plain soaps are as effective as consumer-grade antibacterial soaps in preventing illness and removing bacteria from the hands. Mayo Clinic (2009) admonished people to keep in mind that antibacterial soap is no more effective at killing germs than is regular soap. Using antibacterial soap may even lead to the development of bacteria that are resistant to the products’ antimicrobial agents – maki ng it harder to kill these germs in the future.Commenting on favoured features for soap, women in Ghana cited a range of attributes – smell, cost, texture and durability, and its capacity to be used for multiple purposes. For the women, the most important attribute was the smell of the soap, andthe most popular scents were mild lime and lemon. Concerning cost, cheaper soaps were preferred, although women were sometimes willing to pay more if the soap was larger or they thought it would last longer. Commenting on texture / durability, associated with cost, women preferred harder bar soaps or liquid varieties as they thought they lasted longer.So strong was the preference for hard soaps that many stored soap in cool or sunny or airy places to harden them before use. Some women thought liquid soap more economical since only a peanut size was adequate for each hand wash. Many women preferred laundry bar soap because it could be used as a multipurpose soap such as for laundering, bathing and washing dishes at the same time (PPPHW, 2010). The act of handrubbing It has been suggested by Hoque et al, (1995) that the key component of the handwashing process is the mechanical rubbing of the hands.They noted that the trend towards better results from handwashing with both hands, increased frequency of rubbing and an increased volume of rinsing water all support the prime importance of scrubbing / frictional motion and consequent washing out of loose bacteria with water. Although results of studies carried out suggest that the use of a rubbing agent is important, the authors suggested that the nature of the rubbing agent is a less important factor. Soap, they indicated, was more effective than soil and ash because soap users tend to rub their hands more and use more water to rinse away the soapy feeling on them.CDC (2011) advised people to rub hands together vigorously to make a lather and to continue scrubbing for 20 seconds because it takes that long for the soap and scrubbing action to dislodge and remove stubborn germs. Beneficial effects of handwashing Handwashing has been regarded as a key infection-control practice since Semmelweis suggested its introduction in health care settings (Semmelweis, 1847 in Koo, 2008). The handwashing behaviour has been shown to cut the number of child deaths from diarrhoea (the second leading cause of child deaths) by almost half and from pneumonia (the leading cause of child deaths) by one-quarter (WHO, 2008).The strong causal relationship between hand hygiene and gastro-intestinal disease risk has also been demonstrated by meta-analysis of community based interventions. Curtis and Cairncross (2003) estimated a reduction of 42 – 47% in diarrhoeal diseases associated with handwashing. Fewtrell et al (2005) showed a 44% reduction in diarrhoeal illness associated with handwashing. In a study, Aiello et al (2008) estimated that handwashing with soap combined with education could produce a 39% reduction in gastrointestinal illness. All the three meta-analyses were carried out using data from studies conducted in both developed and developing countries.In a review of hand hygiene studies involving respiratory tract infections, Rabie and Curtis (2006) reported that hand hygiene (handwashing, education and waterless hand sanitizers) can reduce the risk of respiratory infections by 16%. Aiello et al. (2008) also estimated that the reduction in respiratory illness associated with the pooled effects of hand hygiene (handwashing with soap, use of alcohol handrubs) was 21%. A study conducted by Luby et al (2005) reported the impact of handwashing with soap on pneumonia in children under five, in squatter settlements in Karachi, Pakistan.The results indicated a 50% reduction in pneumonia in the intervention compared with the control group. Luby et al noted that a link between handwashingand the prevention of pneumonia in developing countries is plausible on the basis that, in developing co untries it is known that viruses cause pneumonia. Another study found that children under 15 years living in households that received handwashing promotion and soap had half the diarrhoeal rates of children living in control neighbourhoods (Luby et al, 2004).Because handwashing can prevent the transmission of a variety of pathogens, it may be more effective than any single vaccine. Handwashing can also prevent skin infections (eg. impetigo), eye infections (eg. conjunctivitis), intestinal worms, Severe Acute Respiratory Syndrome (SARS), and Avian Flu. It benefits the health of people living with HIV/AIDS. Handwashing is effective in preventing the spread of disease even in overcrowded, highly contaminated slum environments (PPPHW, 2008).