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Hand Hygiene Is Important, But Why So Complex?

Hand Hygiene Is ImportantHand hygiene is important for preventing transmission of infections in industrial, healthcare, domestic and community settings. During the past few years, a lot of medical publications have included the importance of washing hands. Numerous countries have provided guidelines for healthcare workers. The majority of the guidelines are intended for healthcare facilities and workers in developed countries. The spread of infection in high-risk settings is extremely high in developing countries.

Washing hands using soap may be able to save one million lives each year. Washing hands is very important in developing countries due to non-existent or limited public health infrastructures. A different approach is necessary for these countries. Very few worldwide public health campaigns regarding hand hygiene have been successful. A new campaign has been initiated to promote washing hands in Ghana and India.

With the onset of the Coronavirus (COVID-19) the developed world is again promoting hand washing.

History of Hand Hygiene


Handwashing has been classified as personal hygiene for centuries. The connection between infectious diseases and hand washing has only been established for the past 200 years. Hand washing was performed for cultural or religious reasons as opposed to preventing infections. The mortality rate of Jews during the Black Death was lower. The belief is that they were protected by ritual hand washings based on faith.

Until the last several decades, there were no written guidelines for washing hands. The United States posted recommendations regarding hand washing for healthcare workers. Hands were to be washed with soap for one or two minutes both before and after making contact with patients. Recent guidelines include using water-less antiseptic agents as opposed to soap and water.

Latest guidelines is to wash your hands for the amount of time it takes to sing Happy Birthday x 2 – around 20 seconds.

Hospitals and Microorganisms

Microorganisms thrive in hospital environments including Gram-negative bacilli, enterococci and Staphylococcus aureus. Despite the variation of skin flora between individuals, resident and transient flora remain uniform. The data for activities occurring in healthcare settings resulting in hand contamination leading to pathogen transmission to patients is limited.

The skin and fluids of patients can contain nosocomial pathogens. The nurse’s hands can become contaminated with nosocomial flora while touching the shoulder or hand of a patient or taking blood pressure. The contamination level is dependent on the nature and duration of the activity.

Preparations for Hand Hygiene

There is not enough data to make recommendations regarding the best hygiene products for hands. Every product has disadvantages and benefits. The goal of hygiene products is decontaminating hands prior to patient contact. No skin damage should result from the preparations. Soap contains potassium or sodium hydroxide and esterified fatty acids. Plain soap offers little antimicrobial activity due to mechanical or detergent cleaning activity.

Studies have shown pathogens were not removed from hands with plain soap. While in use, liquid and bar soaps can be contaminated with bacteria. Soap can also cause skin dryness and irritation. Antiseptics with an alcohol base contain n-propanol, isopropanol and ethanol. The most effective alcohol concentration is between 60 and 95 percent. The antimicrobial spectrum of alcohol includes Gram-negative bacteria, Gram-positive bacteria, fungi, mycobacteria and certain enveloped viruses.

Alcohol is not effective for certain non-enveloped viruses, oocysts and bacterial spores. One of the recent recommendations is rubbing hands using an alcohol base as opposed to using an antiseptic soap for hand washing. Alcohol has been recommended for clinical settings for years due to the fast action, wide antimicrobial spectrum and ability to spread easily without resulting in skin damage. The need for a drying facility or sink is effectively eliminated.

Hand Drying

Hand drying is an important part of hand washing. The concept of more effective microorganism transmissions in wet environments as opposed to dry is globally accepted. Hand drying needs to be effective without risking further contamination. Damp hands can result in skin excoriation leading to a greater number of bacteria on the skin. The three types of hand drying are hot air dryers, paper towels and cloth towels.

Evaporation can also be used for drying hands. When all of these methods were compared, no significant differences were noted. Cloth towels should not be used for healthcare settings because fewer microorganisms are removed. A cross-infection risk is also present. According to a recent study, the risk of environmental contamination through hand-dryers was no greater than with paper towels. When using paper towels, the environment must be clean and the dispenser must be used correctly.

A contaminated dispenser can be the source of microorganisms. Infection risk is also possible with damp towels. Paper towel quality is important because skin abrasions can result from poor quality. Absorbent and soft paper towels are recommended for washing hands.


During the past two decades, gloves have been used more frequently in healthcare settings. This resulted from blood-borne viruses including HIV and promoting universal precautions. Gloves are recommended for decreasing hand contamination, preventing healthcare workers from contracting infections and preventing the transfer of flora to patients.

Several studies have shown gloves can prevent contamination by microorganisms. Gloves are used to help prevent contamination because hand hygiene does not always successfully eliminate pathogenic organisms from contaminated hands. Unless the contamination is visible, knowing how many organisms are present is difficult if not impossible. Gloves can decrease the transmission of pathogens and help control outbreaks in clinical settings.

Gloves do not provide 100 percent protection regarding contamination due to patient flora. Gloves are only effective when used properly. Gloves should not be reused, washed or used for more than one patient. There have been reports of herpes simplex and hepatitis B to healthcare workers wearing gloves. This may result from small defects or contamination when the gloves are removed.

Gloves must provide both sensitivity, comfort and strength. Gloves are available in synthetic materials including nitrile and vinyl or natural latex. Due to latex sensitivity among healthcare workers, more than one material should be available. Some studies show latex gloves are more reliable than vinyl. Protection can be increased by double gloving.

Taps and Sinks

Stagnant water sitting in sinks will support microorganism growth. This means the source of the bacteria can be the sink. This bacteria can be transferred during hand hygiene. Due to the risk of contamination linked to sinks, automated sinks and sensor taps are frequently used in public toilets and healthcare settings. Both can potentially improve hand hygiene effectiveness.

Emollients and Hand Creams

Healthcare workers often experience issues with dry, sore hands due to the frequency of decontaminating and washing hands. Emollients, lotions and creams increase hydration and protect the skin. A study revealed oil-based lotion and barrier cream protected the skin of healthcare workers when used for preparation. Skin improvement was linked to additional hand washing. There is no evidence showing barrier creams have a significant impact on preventing skin issues.

Wearing Rings

The skin beneath rings has been shown to contain more microorganisms than other areas. There were more microorganisms when the number of rings was increased. One study showed rings presented a significant risk for S. aureus and Gram-negative bacilli on the hands. Evidence also determined the organisms beneath rings can remain for several months. No evidence has stated hand washing is less effective when rings are worn. The majority of reports noted no difference in hand hygiene due to rings.

Cuffs and Sleeves

The recommendation is rolling up sleeves prior to performing hand hygiene procedures. Short sleeves are recommended by the majority of uniform policies. Short sleeves are not enforced for healthcare workers not required to wear uniforms. Moist surfaces including wet sleeves may attract microorganisms transferable through direct contact. According to medical literature, there is no evidence supporting macroscopic cuff contamination.

Bracelets and Wrist-Watches

The infection control guidelines for hospitals recommend all bracelets and watches are removed prior to performing hand hygiene. A study revealed there are more microorganisms beneath wrist-watches than in other areas. Despite the unlikeliness of resulting in an infection, the microorganisms are recognised as nosocomial pathogens. There is no other evidence supporting removing wrist-watches prior to performing hand hygiene.

Fingernails and Nail Polish

There are numerous areas containing bacteria in the subungual region inaccessible through hand hygiene. Most guidelines for infection control recommend short fingernails. Not only are shorter fingernails easier to clean, but there are more microorganisms present with long fingernails. Long nails can also break the barrier by tearing gloves. There have been reports of infections in clinical settings having the potential of transmitting infections.

Artificial nails have a greater risk of yeast and Gram-negative bacilli than natural nails. A study was conducted comparing alcohol gel and soap for hand hygiene. The results showed more bacteria remained on the hands of healthcare workers with artificial nails as opposed to natural nails. Most policies for hand hygiene do not recommend wearing nail polish in any clinical setting. Despite this, there is no evidence linking hospital infections to nail polish.

A study was conducted regarding the operating room nurse’s fingernails. The results showed more bacteria when the nurse wore the nail polish longer than five days or chipped polish as opposed to fresh polish. There was no difference in the bacterial counts between natural and polished nails.

Hand Hygiene Outside Clinical Settings

The majority of medical literature pertaining to hand hygiene is meant for healthcare settings. Hand hygiene has been recognised as a solution for numerous infectious diseases for years. One of the most common illnesses and the cause of death for children all over the world is a diarrhoeal illness. The main cause is coming in contact with human excretions. Washing hands after contact is a substantial intervention for preventing infectious agents from being transmitted.

Studies across the globe have revealed washing hands with soap occurs in less than 20 percent of all cases. Workers in the home environment within the United Kingdom only washed their hands 42 percent of the time when changing a dirty nappy. Only 56 percent of all women and 34 percent of men in the United Kingdom washed their hands after using public toilets.

Increasing hand washing all over the world is difficult considering just 60 percent of the world population has access to adequate sanitation.

Hygiene Practices and Compliance

There has been a poor response regarding compliance with the recommendations for hand hygiene. To improve compliance, human behaviour must be changed. This involves numerous disciplines including social and behavioural sciences. There are many different factors involved in hand hygiene. No single theory is capable of predicting behaviour regarding hand hygiene. To improve compliance, individual motivation must be understood. This varies among different cultures.

Certain religions embrace washing hands with water. This is a spiritual cleansing ritual lacking cleansing agents including soap. There is no religious mention of the importance of soap for infectious diseases. A dichotomy exists in healthcare settings between hand hygiene behaviour and hand hygiene knowledge. Healthcare workers are familiar with the recommendations for hand hygiene, Unfortunately, education and knowledge do not always motivate behaviour, resulting in low compliance.

There are also differences in the observed and self-reported rates of hand hygiene compliance. Evidence has shown healthcare workers may not realise their compliance is poor because they intend to remain compliant. Non-adherence results from other factors. Hand hygiene behaviour is also influenced by the opinions of third parties. The main reasons given for hand hygiene after changing a dirty nappy in the United Kingdom was keeping the child well and aesthetics.

In both Burkino Faso and Botswana, one of the most important reasons for hand washing is the conformity to social ideals. Superiors and management in healthcare settings must make a strong commitment in order for changes in hand hygiene behaviour to occur. Patient pressure is also being used to improve compliance. A Speak Up campaign was sponsored specifically to observe whether or not healthcare workers were washing their hands. The workers received reminders to use hand hygiene whenever necessary.

The effect of the programme regarding hand hygiene to decrease the rate of nosocomial infections in participating healthcare facilities has not yet been determined. Conforming to social ideals and peer pressure are both critical for motivating hand hygiene procedures. Neither mandate or force will result in a hand hygiene culture. A new system must be accepted, but the changes necessary will be a major challenge. Compliance can only be achieved when users accept the importance of hand hygiene.

Adequate facilities for hand hygiene must be provided including easy access to the equipment and preparations required for hand hygiene. The most obvious is alcohol hand rubs placed at the bedsides of patients and the number of sinks available. Facilities making improvements have seen conflicting results for recommendations regarding hand compliance. A study showed more available hand sinks did not effectively increase how many times hands were washed when this was the only improvement made.

One of the main components necessary for compliance with hand hygiene policies was the behaviour of other healthcare workers including superiors. For years, the message in regard to hand hygiene has been promoting the procedure. The issue has become even more complicated because now using an alcohol-based rub is recommended. The motivation for hand hygiene compliance is often based on cultural aspects. A good example is the hospital trust.

The trust included a lot of Muslim staff and patients. Refusals have been encountered by the team for infection control from both the families of patients and the staff. Alcoholic rubs were refused due to religious concerns. What is interesting is the comparison to a tertiary referral hospital located within the EAU. Despite in excess of 95 percent of the staff and patients being Muslim, alcohol rubs were only refused due to religious concerns once during the past three years.

There is no way to be certain if this issue will become serious during the future. What is important is the illustration of different factors regarding the behaviour of washing hands in healthcare settings. A broad approach has become necessary to improve compliance for professionals not working in a healthcare environment. Hand hygiene is extremely important for decreasing infection. There is recognition that proper hand hygiene within the healthcare industry will not be enough to prevent infectious diseases from spreading.

Other hygiene aspects must be met including eliminating under staffing and overcrowding. Adequate facilities and clean surfaces are necessary for effective practices for hand hygiene. This is extremely important for both the community and the healthcare environment.



The Future of Hand Hygiene

The actual practices for appropriate hand hygiene are simple. The issue is human behaviour. Making the necessary changes to this behaviour is both difficult and complex. This is the reason so many campaigns have been unsuccessful. Promoting hand hygiene must not be for just healthcare settings.

A culture must be created to promote hand hygiene as the basis for compliance in every level of society. Making global recommendations for hand hygiene is impossible because every culture is different. What works for one, may not work for another. Every recommendation must incorporate both cultural and geographic factors.




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