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Hand washing

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Bacterial pathogens
Viral pathogens
Parasitic pathogens

Hand washing is the act of cleansing the hands with water or another liquid, with or without the use of soap or other detergents, for the sanitary purpose of removing soil and/or microorganisms.

The main 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 the most important measure for preventing the spread of pathogens is effective handwashing."

Handwashing with water

The application of water alone is ineffective for cleaning skin because water is unable to remove fats, oils, and proteins, which are components of organic soil. Therefore, removal of microorganisms from skin requires the addition of soaps or detergents to water.

To remove pathogens, in the absence of soap, two gallon of water per minute is needed in washing hands using flowing water only.[1]

Handwashing in 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.

Handwashing with hot water

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.[2]

Hand washing with soap

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

Hand washing with soap is the common method of attempting to remove bacteria from the hands.

This hygienic behavior 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.[3]. There are five critical times in washing hands with soap related to fecal-oral transmission: after defecation, after cleaning a child, 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.[4] To reduce the spread of germs, it is also better to wash the hands after tending to a sick person.

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.[5] 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.[6]

However 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].

Handwashing using 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]

Handwashing in medical setting

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

The proper washing of hands in a medical setting generally consists of the use of generous amounts of soap and water to lather and rub each part of one's hands systematically for 15 to 20 seconds[10]. Hands should be rubbed together with digits interlocking. If there is debris under fingernails, a bristle brush may be used to remove it. Finally, it is necessary 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), to avoid re-contaminating the hands from those surfaces.

The purpose of hand washing in the health care setting is to remove pathogenic microorganisms ("germs") to avoid transmitting them to a patient. 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.[11] One study has shown that proper hand washing and other simple procedures can decrease the rate of catheter-related bloodstream infections by 66 percent.[12]

World Health Organization has published a sheet which demonstrates the standard procedures of handwashing and handrubbing in health care sectors [13]. The draft guidance of hand hygiene by the organization can also be found at its website for public comment [14]. A relevant review is conducted by Whitby et al. [15]. Commercial devices are available which measure and validate the hand hygiene, if demonstration of regulatory compliance is required.[16]

The addition of antiseptic chemicals to soap ("medicated" or "antimicrobial" soaps) does confer 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.[17]

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 elbows, and one must in this situation ensure that all parts of the hands and forearms are well scrubbed several times. 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.

Handwashing with hand sanitizer

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

Hand sanitizer is a non-water-based hand hygiene agent [18]. In the late 1990s and early part of the 21st century, 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, and a humectant such as glycerin into a gel, 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 microorganisms.

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][19]. 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 [20], Germ Warfare [21], Cuticura [22] etc and Rochon-Edouard et al. has provided a good review of those products [15].

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. 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. [23]

Alcohol rubs (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.[24][25]

Alcohol rubs and combination hand sanitizers are effective at killing germs on the hands, but not effective at removing dirt[26]. 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.[19]

However alcohol rub sanitizers are not appropriate for use when the hands are visibly dirty, soiled or contaminated with blood. 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 are ineffective against non-lipid-enveloped viruses (e.g., Noroviruses) and the spores of bacteria (e.g., Clostridium difficile) and protozoa (e.g., Giardia lamblia). When such microorganisms are likely to be encountered, soap and water hand washing is preferable[7].

Both hand washing with hand sanitizer 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 other types of bacteria such as those from the gastro-intestinal tract, or hazards such as e-coli and salmonella because alcohol doesn't destroy spores, but washing hands washes the spores down the sink[27].

In the U.S. hand sanitizers being banned from some schools because of flammability concern. The fire department allows Tallahassee Memorial Hospital to have a certain about of hand sanitizer per smoke compartment, and supply it up to that limit [28].

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[29] in nonacute health care settings.[30]

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.[31][32]

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

Myths surrounding hand washing

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The numbers of "good germs" and "bad germs" on the hands are variable from one person to the next but remain relatively constant for each individual. Anyone can become contaminated with bad germs (pathogens) which do not always cause disease, and contrary to common belief good germs (under the certain conditions) can cause disease.[33][34]

See also

References

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  2. ^ U.S Food and Drug Administration Center for Food Safety and Applied Nutrition "Handwashing"
  3. ^ World Health Organization. Global Handwashing Day 2008: Planner's Guide.
  4. ^ Campaign aims to promote hand-washing and save young lives in Malawi
  5. ^ Hand washing from Mayo Clinic
  6. ^ Hand washing from Tufts University
  7. ^ a b c "Hand Hygiene for Healthcare Workers". LearnWell Resources, Inc, a California nonprofit public benefit 501(c)(3) corporation. 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". Retrieved 2007-08-17.
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  13. ^ World Health Organization. "How to Handrub & How to Handwash" (PDF). Retrieved 21 July. {{cite web}}: Check date values in: |accessdate= (help); Cite has empty unknown parameter: |coauthors= (help); Unknown parameter |accessyear= ignored (|access-date= suggested) (help)
  14. ^ World Health Organization. "WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft)" (PDF). Retrieved 21 July. {{cite web}}: Check date values in: |accessdate= (help); Cite has empty unknown parameter: |coauthors= (help); Unknown parameter |accessyear= ignored (|access-date= suggested) (help)
  15. ^ a b Whitby, M .; et al. "Behavioural considerations for hand hygiene practices: the basic building blocks". Journal of Hospital Infection. 65 (1). Elsevier: 1–8. Retrieved 22 July. {{cite journal}}: Check date values in: |accessdate= (help); Cite has empty unknown parameter: |coauthors= (help); Explicit use of et al. in: |first= (help); Unknown parameter |accessyear= ignored (|access-date= suggested) (help) Cite error: The named reference "cvvs" was defined multiple times with different content (see the help page).
  16. ^ Online Science Mall. "Ultraviolet LED Flashlight Blacklight - Good with Glo Germ Simulated Germs 21LED". Retrieved 21 July. {{cite web}}: Check date values in: |accessdate= (help); Cite has empty unknown parameter: |coauthors= (help); Unknown parameter |accessyear= ignored (|access-date= suggested) (help)
  17. ^ WHO Guidelines on Hand Hygiene in Health Care
  18. ^ Clean hands from the CDC
  19. ^ 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.
  20. ^ Ego Pharmaceuticals Pty Ltd. "Aqium Gel". Retrieved 22 July. {{cite web}}: Check date values in: |accessdate= (help); Cite has empty unknown parameter: |coauthors= (help); Unknown parameter |accessyear= ignored (|access-date= suggested) (help)
  21. ^ Paragon PE Ltd. "Germ Warfare". Retrieved 22 July. {{cite web}}: Check date values in: |accessdate= (help); Cite has empty unknown parameter: |coauthors= (help); Unknown parameter |accessyear= ignored (|access-date= suggested) (help)
  22. ^ Cuticura. "Cuticura Anti Bacterial Hand Hygiene Gel". Retrieved 22 July. {{cite web}}: Check date values in: |accessdate= (help); Cite has empty unknown parameter: |coauthors= (help); Unknown parameter |accessyear= ignored (|access-date= suggested) (help)
  23. ^ AORN; Dyer, etal; Aug 1998; VOL 68, No2;http://www.aornjournal.org/article/abstracts?terms1=&terms2=&terms3=
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  28. ^ Transclusion error: {{En}} is only for use in File namespace. Use {{langx|en}} or {{in lang|en}} instead. WXTL TV: Hand Sanitizer vs. Washing
  29. ^ Transclusion error: {{En}} is only for use in File namespace. Use {{langx|en}} or {{in lang|en}} instead. About.com Cold and Flu:Is Hand Sanitizer Better Than Hand Washing?
  30. ^ Transclusion error: {{En}} is only for use in File namespace. Use {{langx|en}} or {{in lang|en}} instead. PubMed.gov: Alcohol-impregnated wipes as an alternative in hand hygiene
  31. ^ Benedict Carey. Lady Macbeth Not Alone in Her Quest for Spotlessness. The New York Times, 12 September 2006
  32. ^ 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.
  33. ^ Schaberg DR, Culver DH, Gaynes RP (1991). "Major trends in the microbial etiology of nosocomial infection". Am. J. Med. 91 (3B): 72S–75S. doi:10.1016/0002-9343(91)90346-Y. PMID 1928195.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  34. ^ Richet H, Hubert B, Nitemberg G; et al. (1990). "Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients". J. Clin. Microbiol. 28 (11): 2520–5. PMID 2254429. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
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