Download Hand hygiene in the home and community

Hand hygiene in the home and community
This briefing material has been produced for those who work in the healthcare
professions, the media and others who are looking for some background
understanding of hand hygiene in the home and/or those who are responsible for
providing guidance to the public on understanding hand hygiene and its central role
in preventing the transmission of infection in the home.
In recent years a many high profile campaigns have been launched to promote the
message: “wash your hands”. A primary aim of these campaigns is the prevention of
the spread of infections such as MRSA, Clostridium difficile and norovirus in hospitals
and other healthcare settings. Promotion of handwashing is also a key part of public
health campaigns to reduce the incidence of food poisoning arising in the home,
where hand hygiene plays a crucial role. A review of hand hygiene by the IFH in 2007
concluded that a significant reduction in the infectious disease burden could be
achieved by giving greater attention to good hand hygiene in the home and
community.1 The review highlights the need for more education about the importance
of hand hygiene including guidance on how to choose and apply the best hand
hygiene methods.
This briefing document outlines why hand hygiene is so important in the home and
community and describes the potential health benefits of good hand hygiene. It also
provides a basic framework for developing hand hygiene advice for the public that
can be adapted to meet differing needs and situations. Application of this framework
can reduce the spread of all types of infections including gastrointestinal, respiratory,
skin and eye infections.
Why is hand hygiene important?
Infectious disease remains a serious problem worldwide. However, there is
increasing evidence to show that good hygiene practice in the home and community
prevents not only the spread of foodborne infections but also has an important role in
preventing the spread of many other common infections.
Foodborne illness
Foodborne diseases are a serious and global problem. The WHO estimates that
worldwide foodborne and waterborne diarrhoeal diseases taken together kill about
2.2 million people annually. In the UK, it is estimated that each year around a million
people suffer a foodborne illness, around 20,000 people receive hospital treatment
due to foodborne illness and there are around 500 deaths. The cost is £1.5 billion2
In the USA CDC estimates that each year roughly 1 in 6 Americans (or 48 million
people) get sick, 128,000 are hospitalized, and 3,000 die of foodborne diseases.3 In a
2003 report the WHO concluded that about 30% of reported foodborne outbreaks in
the WHO European region over the past decade were caused by food consumed in
private homes. 4 Most of these illnesses could have been prevented by good hygiene
practice. Good hygiene practice in the home during preparation for cooking is vital to
prevent cross contamination from raw to “prepared” foods, and is also fundamental to
prevent contamination of food from infected family members or domestic animals.
Infectious intestinal disease (IID)
It is now recognised that a substantial proportion of infectious intestinal disease in the
community is not foodborne, but is the result of person-to-person spread within
families. One US study has estimated that, of approximately 210 million cases of
infectious intestinal disease that occur annually, just 36% are foodborne. The same
study estimated that about 0.79 episodes of acute gastroenteritis occur per person
every year.5 Thus, good food hygiene practice goes only part of the way to reducing
the burden of gastrointestinal disease – preventing person-to-person spread via
hands and hand contact surfaces is also crucial.
In reality only a small proportion of the total cases (which includes outbreaks and
sporadic (individual) infections) are reported to surveillance. An estimate of the true
infection rates comes from a UK study of the incidence of IID in the UK in the
community which indicates that there are up to 17 million sporadic community cases
of IID annually.6,7 It is estimated that approximately 50% of people with IID took time
off from work or school because of their symptoms which amounts to nearly 19
million days lost – more than 11 million of these were in people of working age.
Norovirus was identified as the largest cause of IID in the UK
In developing countries, diarrhoeal disease is a major health problem. Diarrhoeal
disease is the second leading cause of death in children under five years old. It is
both preventable and treatable. Each year diarrhoea kills around 760 000 children
under five. Globally, there are nearly 1.7 billion cases of diarrhoeal disease every
year. Diarrhoea is a leading cause of malnutrition in children under five years old. A
significant proportion of diarrhoeal disease can be prevented through safe drinkingwater and adequate sanitation and hygiene.8
Intervention studies suggest that the risk of infectious intestinal disease can be
reduced by up to 50% or more by handwashing.1
Respiratory disease
The last two years have seen an unprecedented effort to develop global strategies
for preventing transmission of influenza, driven by an awareness that a pandemic
from a new strain of flu such as the H5N1 strain is now overdue. Even in the absence
of such a pandemic, adults may still expect 1.5–3.0 respiratory illnesses per year,
and children under 5 may have 3.5–5.5 respiratory illnesses per year. Hand and
surface hygiene is a significant factor in preventing the spread of colds and flu.
Intervention studies suggest that the risk of respiratory diseases can be reduced by
up to 23% or more by handwashing.9
Skin and wound infections
There is an increasing amount of evidence to suggest that the transmission of skinwound and eye infections can occur via contaminated hands. The danger posed by
methicillin-resistant Staphylococcus aureus (MRSA) infection in healthcare settings
Page 2/12
has been well publicised. Healthcare-associated strains of MRSA (HCA-MRSA) may
be transmitted into the home and community either via discharged infected patients,
or via healthcare workers who become colonised whilst caring for MRSA-infected
hospital patients. Strains of MRSA which have developed in the community quite
separately from HCA-MRSA strains (known as community-associated MRSA or CAMRSA) are now also becoming a cause for concern. CA-MRSA infections have been
found in otherwise healthy people without apparent risk factors. CA-MSRA is a
particular concern because it infects children and young adults equally and can
cause serious (in some cases fatal) infection of cuts, wounds and abrasions.
Protection of “at risk” groups in the home
The provision of adequate healthcare is an increasingly costly and politically sensitive
issue in industrialised nations. Moving patient care into the community, including inhomecare, helps to extend limited resources, but this can be fatally undermined by
inadequate infection control in the home. Demographic changes mean that the
number of people in the home needing special care because they are at particular
risk of infection has significantly increased and will continue to do so. The majority of
these people are elderly, with generally lower levels of immunity often exacerbated by
other illnesses, such as diabetes mellitus or malignant disease. Other “at risk” groups
increasingly cared for in the home include: the very young; patients taking
immunosuppressive drugs; patients using invasive systems; and HIV/AIDS patients.
A survey of the USA and three European countries (Germany, The Netherlands and
the UK), suggests that 1 in 5 to 1 in 7 of the population belongs to an “at risk” group.
The healthcare continuum
There is mounting political pressure to control MRSA, C. difficile, norovirus and other
infections in healthcare facilities. Healthcare professionals now realise that their
ability to manage the problem is hampered by the ongoing entry of people to
hospitals and clinics, either as patients or visitors, who are already infected through
community or family contacts. They are thus looking for ways to manage this issue.
A framework for good hygiene practice in the home: the IFH approach
Targeted home hygiene
Microbiological research focusing on the home has now given us a better
understanding of how infectious diseases are spread in this environment and how the
risks can be reduced. These data have been used by IFH to develop a risk
management approach to hygiene known as targeted hygiene. This approach means
implementing hygiene measures at key places and times in order to break the chain
of infection in the home.
Better home hygiene the IFH way: understanding critical control points
Targeted hygiene begins with the principle that pathogenic species (germs) are
introduced continually into the home primarily by people, food, and domestic animals.
Sites where stagnant water accumulates (e.g. sinks, U-bends, toilets, cleaning cloths,
facecloths) readily support microbial growth and can also become a primary reservoir
of infection. Within the home there is a chain of events that has 5 links, all of which
have to be in place for an infection to pass from its original source to a recipient
(Figure 1).
Page 3/12
Fig 1 - Critical control points in the chain of infection.
Surprisingly, the basic principle that one cannot get infected unless pathogens are
present in the home, and that if one or more links in the chain of infection are broken
an infection cannot take hold, is often not appreciated. Breaking the chain of infection
can be achieved by good hygiene, which includes adherence to hand hygiene
recommendations, and cleaning and disinfecting contaminated environmental
surfaces, particularly high frequency touch surfaces, and surfaces which come into
contact with food.
The risk assessment approach is applicable to all types of infections, including
gastrointestinal, respiratory and skin and eye infections, and shows us that the major
target sites for preventing the spread of all these infections in the home are the
hands, hand contact surfaces, food contact surfaces, and cleaning cloths and
utensils.
The role of hands and hand hygiene in home hygiene
As a vector for transmission of infectious disease the hands are probably the single
most important transmission route for all types of infection. They come into direct
contact with the known portals of entry for pathogens (the mouth, nose and
conjunctiva of the eyes) and are thus the last line of defense.
Breaking the chain of infection is not just about targeting critical surfaces such as the
hands, it is also about doing it at the right time. In some cases it is obvious (e.g. after
toilet visits) but in others it is not (e.g. after touching door, tap and toilet flush
handles).
Based on the risk assessment approach, the most critical situations where hand
hygiene is needed are:
 After using the toilet (or disposing of human or animal faeces)
 After changing a baby’s diaper (nappy) and disposing of the faeces
 Immediately after handling raw food (e.g. chicken, meat)
 Before preparing and handling cooked/ready-to-eat food
 Before eating food or feeding children.
Hand hygiene is also important:
Page 4/12








After contact with contaminated surfaces (e.g. rubbish bins, cleaning cloths,
food-contaminated surfaces)
After handling pets and domestic animals
After wiping or blowing the nose or sneezing into the hands
After handling soiled tissues (self or others, e.g. children)
After contact with blood or body fluids (e.g. vomit)
Before and after dressing wounds
Before giving care to an “at risk” person
After giving care to an infected person.
Hand hygiene and infectious disease: disrupting the link
Effective hygiene procedure is of central importance in breaking the chain of infection
transmission via the hands. Since the “infectious dose” for many common pathogens
such as Campylobacter, norovirus and rhinovirus can be very small (1–500 cells or
particles), it is clear that, where there is risk of transmission via the hands, the aim
should be to get rid of as many of these organisms as possible. Organisms can be
removed from the hands by:
 Soap or detergent-based cleaning (physical removal)
 Hand disinfectant, handrub or hand sanitiser (microbes killed in situ).
Handwashing using soap or detergent and water mechanically dislodges organisms.
To be fully effective, however, it must be applied using a rubbing process that
maximises release of microbes from the skin and a rinsing process that washes away
the dislodged organisms. A summary assessment of the relative effectiveness of
hand hygiene procedures based on the currently available data is given in Table 1.
Target organism
Effectiveness of
handwashing (15-30 secs)
Gram-positive and
Gram negative
bacteria
C. difficile
Enveloped viruses:
+++
Effectiveness of alcohol-based
products containing 62%
ethanol (30 sec exposure)
++++
+++
++
Influenza,
parainfluenza
Non-enveloped
viruses:
No data available
+++ to ++++
No data available
++ to ++++*
++
++ to +++
No data available
++ to +++
No data available
+ to +++
No data available
+
rhinovirus (cold virus)
rotavirus
norovirus (based on
testing against murine
norovirus used as
surrogate test strain
for norovirus)
adenovirus,
Page 5/12
hepatitis A
*effectiveness against rhinovirus varies according to strain
++++ = high activity (3-4 log reduction); +++ = good activity (2-3 log reduction); ++ = moderate
activity (1-2 log reduction); + = poor activity (<1 log reduction)
Table 1. Relative effectiveness of hand hygiene procedure based on in vitro
laboratory tests and in vivo testing with volunteer panels.
Handwashing with soap
The accepted procedure for handwashing with soap is as follows:
 Ensure a supply of liquid soap, warm running water, clean hand
towel/disposable paper towels and a foot-operated pedal bin
 Always wash hands under warm running water
 Apply soap
 Rub hands together for 15–30 seconds, paying particular attention to
fingertips, thumbs and between the fingers (see Figure 2)
 Rinse well and dry thoroughly.
Fig. 2 - How to wash hands correctly.
Tests carried out under controlled conditions have shown that handwashing can
reduce the numbers of bacteria and some viruses on the hands by up to 2–3 log
within 30–60 seconds. However, the efficacy of handwashing as practiced in the
community has not been systematically assessed. It seems unlikely that many
people observe the method and duration of handwashing required to achieve the
results observed under laboratory conditions. Furthermore, microbiological data
Page 6/12
suggest that handwashing alone will not ensure the removal of some pathogens
(particularly Salmonella but also some viruses).
Alcohol-based hand sanitisers (ABHS)
Alcohol-based hand sanitisers (ABHS), also known as alcohol-based hand rubs, are
formulations which contain either ethanol, 1-propanol, 2-propanol, or a combination
of these products. Their antimicrobial activity is based on their ability to denature
proteins. Solutions containing 62–95% alcohol are most effective – higher
concentrations are less effective because proteins are not easily denatured in the
absence of water. ABHS which are available to consumers are usually based on
ethanol at a concentration of 62% v/v.
Data from in vivo panel tests, indicate that ethanol rubs show activity against
vegetative bacteria which is at least as good, if not better, than that achieved by
handwashing with soap; log reductions for ethanol against bacteria obtained after a
30-second contact period are of the order 3.4-3.7 or more, compared with 1.8-2.8 for
a 30-second handwashing process. Although ethanol hand sanitisers are less
effective against viruses such as hepatitis A virus, when compared to bacteria, in vivo
panel test data indicates that in many cases their efficacy against rotavirus,
adenovirus, norovirus and rhinovirus is actually at least equivalent to that of
handwashing.
Other waterless hand sanitisers/hand rubs
In response to evidence which increasingly suggests that hands can play a
significant role in transmission of respiratory viruses, a novel waterless hand sanitiser
formulation has been developed which is designed for use in conjunction with
handwashing, or in situations in the home and community settings where access to
handwashing facilities is limited to reduce the transmission of cold and also flu
viruses. The formulation is a pyroglutamate/succinate buffering system, in a topical
foam formulation, which is designed to hold pH close to 3.0. The formulation also
contains an acrylate polymer that physically traps viral particles and reduces transfer
from hands to the nasal mucosa or conjunctiva of the eye where they can cause
infection. The effect is thus achieved through a combination of virus entrapment and
low pH inactivation of the virus. An important feature of this formulation is that the
action is sustained on hands for a few hours after application. This helps protect
against ongoing exposure to respiratory viruses which, is a constant risk throughout
our daily routine rather than a “discrete event-related” risk such as the risk associated
with food handling or toilet visits. Although formulated for use against rhinovirus 10, in
vitro suspension tests show that this formulation is effective not only against
rhinovirus-39, but also against human coronavirus, influenza A, Avian influenza A
and respiratory syncytial virus.
What are the recommendations for good hand hygiene?
When selecting the appropriate option for hand hygiene there are thus three
possibilities:
 Handwashing with soap
 Use of ABHS or other effective waterless-based sanitisers
 Handwashing followed by the use of ABHS.
A framework for making the appropriate choice according to the particular situation is
outlined in Figure 3.
Page 7/12
Fig. 3 - Choosing the most appropriate hand hygiene procedure.
Recommendations for hand hygiene in “standard risk” situations
In “standard risk” situations in the home and community (i.e. situations not specifically
regarded as “high risk”) either handwashing or an ABHS may be chosen, the decision
depending on practical considerations. For example, handwashing is obviously an
option only where there is access to soap and water, whilst use of ABHS is not an
option when hands are heavily soiled.
Recommendations for hand hygiene in situations of increased risk
There will always be situations within the home in which there is increased risk, either
because there is a known source of infection or someone who is at increased risk of
becoming infected (Table 2). These “at-risk” situations may be everyday situations
(e.g. handling raw meat). They may also relate to “non-routine” situations (e.g. caring
for persons at increased risk of infection due to immunosuppressive drug treatment).
In all of these “increased risk” situations, handwashing followed by the use of an
ABHS is encouraged.
Page 8/12
Routine day-to-day situations
Non-routine situations
Increased risk from
source of infection
in the home
Increased risk from
infected family
members
People at increased
risk of infection
Family members
infected with colds,
flu, norovirus,
Salmonella, Shigella,
etc.
Patients home from
hospital or outpatients
including people with
catheters, wounds,
etc.
People undergoing
drug treatment;
people with underlying
illness (e.g. diabetes,
HIV).
Handling of raw meat,
poultry, fish, fruit and
vegetables.
Family members or
pets who are
colonised or infected
with bacteria (e.g.
Salmonella, C.
difficile, MRSA).
People who are
otherwise healthy
but at increased
risk of infection
Young babies, the
elderly, pregnant
women.
People in poor living
conditions.
Table 2 - Increased risk situations in the home.
Additional considerations
When attempting to promote behavioural changes, one of the key factors is
“removing barriers to action”. Common barriers to compliance with correct
handwashing technique include lack of convenient access to a sink and water and
lack of time e.g. when caring for a baby or a sick person at home. A key benefit of
ABHS is that they can substitute for traditional handwashing in “out-of-home” settings
such as offices and public places and enable people to adopt good hand hygiene in a
variety of situations. Promoting use of ABHS has the potential to get people to
undertake hand hygiene more frequently and at critical times. In response to
concerns about the possibility of a flu pandemic, the Centers for Disease Control
recommend the use of ABHS for use as an alternative to handwashing.7 In the event
of a flu pandemic, it would be particularly important to encourage people to adopt
good hand hygiene in public places.
The framework proposed in this document should not be regarded as promoting
“either handwashing or ABHS”. The fundamental aim is to encourage more people to
undertake hand hygiene procedures wherever possible at critical times to prevent
infectious disease transmission.
Hygiene is more than handwashing
Because so much attention has been paid to the importance of handwashing, there is
a danger that people may believe that this is all they need to do to avoid infectious
disease. However, hygienic cleaning of contact surfaces is also vitally important.
Pathogens are continuously transferred into our home environment from people (e.g.
through coughing and sneezing, in vomit or faeces, on skin scales), pets (e.g. fur,
faeces) and contaminated raw foods (e.g. chicken, meat). Pathogens from these
sources can survive for some time on hands and other surfaces and are readily
spread around the home via hands, hand and food contact surfaces, cleaning cloths,
and so on. Since people do not always wash their hands when they should – and
since we cannot wash our hands all the time – these surfaces pose a continuous and
significant contamination risk.
Page 9/12
Combining hand hygiene with hygienic cleaning of critical contact surfaces in the
home is therefore an important part of the IFH targeted approach to home hygiene.
As part of its work to promote good home hygiene practice IFH has produced
“Guidelines for prevention of infection and cross infection in the domestic
environment” and “Recommendations for selection of suitable hygiene procedures for
use in the domestic environment”. These IFH documents give detailed guidance on
hand hygiene and home hygiene, including food hygiene, general hygiene, personal
hygiene, care of pets, and so on. IFH has also produced a teaching/self learning
resource on home hygiene designed to present home hygiene theory and practice in
simple, practical language which can be understood by those with relatively little
infection-control training or background.
Getting people to wash their hands at the right time and in the right way
Evidence suggests that a public health campaign that generated even a modest
improvement in hand hygiene practice could produce a significant health impact in
the community. A number of approaches are now being adopted for improving hand
hygiene compliance, including social marketing techniques and interactive/
participatory community programmes. However, in order to be effective, the overall
communication strategy should be given careful consideration.
The success of any public campaign will depend on people learning to practice hand
hygiene not only more frequently, but also at the right time and in the right way. For
example, since visible soiling is an unreliable indicator of the presence of pathogens
on the hands, people are unlikely to wash their hands at the correct time unless they
have been taught to do so, or have some awareness of the chain of infection
transmission in the home, i.e. they know when their hands are likely to be
contaminated.
Mass social marketing of single rule-based hygiene messages, although effective in
altering behaviour, may not be adequate given the complexity and shifting nature of
the infectious disease threat. For example, hand hygiene rules for food hygiene need
to be very different from those designed to prevent the spread of respiratory tract or
skin infections – risks associated with food handling are largely confined to defined
periods of time, whereas the risk of respiratory tract and skin infections (and personto-person transmission of gastrointestinal infection) is ongoing and involves many
daily activities. Similarly, in the event of a flu pandemic, telling people to “wash hands
frequently” is unlikely to be effective unless people have some idea of the times when
their hands are likely to be contaminated with flu virus. We therefore need an
approach founded on an awareness of the chain of infection transmission and how it
varies for different groups of infections.
Hygiene education needs to be consistently incorporated into hand hygiene
promotion programmes if people are to properly understand the risks and adapt their
behaviour accordingly. Although it may be convenient to address various public
hygiene issues (e.g. food hygiene, cold and flu hygiene, care of people who are ill)
one-by-one, we should always remember that hand hygiene is of central importance.
It is only by adopting a holistic approach to home hygiene that we can develop hand
hygiene awareness that can be adapted to meet all the needs of the community.
Page 10/12
IFH Guidelines and Training Resources on Home Hygiene
 Guidelines for prevention of infection and cross infection the domestic
environment. International Scientific Forum on Home Hygiene. Available from:
http://www.ifh-homehygiene.com/best-practice-care-guideline/guidelinesprevention-infection-and-cross-infection-domestic
 Guidelines for prevention of infection and cross infection the domestic
environment: focus on issues in developing countries. International Scientific
Forum on Home Hygiene. Available from: http://www.ifh-homehygiene.org/bestpractice-care-guideline/guidelines-prevention-infection-and-cross-infectiondomestic-0
 Recommendations for suitable procedure for use in the domestic environment
(2001). International Scientific Forum on Home Hygiene. http://www.ifhhomehygiene.org/best-practice-care-guideline/recommendations-suitableprocedure-use-domestic-environment-2001
 Home hygiene - prevention of infection at home: a training resource for carers and
their trainers. (2003) International Scientific Forum on Home Hygiene. Available
from:
http://www.ifh-homehygiene.com/best-practice-training/home-hygiene%E2%80%93-prevention-infection-home-training-resource-carers-and-their
 Home Hygiene in Developing Countries: Prevention of Infection in the Home and
Peridomestic Setting. A training resource for teachers and community health
professionals in developing countries. International Scientific Forum on Home
Hygiene. Available from: www.ifh-homehygiene.org/best-practice-training/homehygiene-developing-countries-prevention-infection-home-and-peri-domestic. (Also
available in Russian, Urdu and Bengali)
This fact sheet was last updated in 2015
Further reading
1
Bloomfield SF, Aiello A, Cookson B, O’Boyle C, Larson EL. The effectiveness of
hand hygiene procedures in reducing the risks of infections in home and
community settings including handwashing and alcohol-based hand sanitizers.
American Journal of Infection Control. 2007;35:supplement 1,S27-64.
http://download.journals.elsevierhealth.com/pdfs/journals/01966553/PIIS0196655307005950.pdf
2
http://www.food.gov.uk/science/researchpolicy/chiefsci/csreps/
3
http://www.cdc.gov/foodborneburden/
Rocourt, J, Moy G, Vierk, R, Schlundt, J. The present state of foodborne disease
in OECD countries. Food Safety Department, World Health Organization, Geneva,
Switzerland. 2003. Available at:
http://www.who.int/foodsafety/publications/foodborne_disease/en/OECD%20Final
%20for%20WEB.pdf. Accessed 10/11/2011
Mead PS, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, et al. Foodrelated illness and death in the United States. Emerg Infect Dis. 1999;5(5):607-25.
The Longitudinal study of infectious intestinal disease in the UK (IID2 study):
incidence in the community and presenting to general practice Tam CC,
Rodrigues LC, Viviani L, et al. Gut (2011). doi:10.1136/gut.2011.238386.
http://www.food.gov.uk/news-updates/news/2011/4805/iid2
http://www.who.int/mediacentre/factsheets/fs330/en/
Health impact of handwashing. WELL fact sheet 2006. Available from:
http://www.lboro.ac.uk/well/resources/fact-sheets/fact-sheetshtm/Handwashing.htm
4
5
6
7
8
9
Page 11/12
10
Turner RB, Biedermann KA, Morgan JM, Keswick B. Ertel KD, Barker MF. Efficacy
of organic acids in hand cleansers for prevention of rhinovirus infections.
Antimicrobial Agents and Chemotherapy 2004;48(7);2595-8.
Page 12/12