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Developing hygiene practice for the home – the
IFH risk-based approach to home hygiene
(targeted hygiene)
This leaflet has been put together to provide a summary of the IFH targeted
approach to home hygiene - what do we mean by targeted hygiene and what does it
involve? 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 hygiene and/or those who are responsible for providing guidance to
the public on coping with hygiene.
Hygiene at home
The home is the centre of our lives. Whatever we do, be it travelling or going to
school or going to work, we always come back to the home. There is a constant
movement of people to and from the home. This means that there is also a constant
flow of infectious microbes in and out of the home. We regard the home as a place
where we feel safe and comfortable, as a retreat from the outside world, a place
where we can entertain and relax. But when it comes to the prevention of disease,
we should also view home as a setting in which infections can be readily transmitted.
Within the home Infected family members are one of the key sources of infection.
Infected people may show no symptoms and may spread infection unknowingly to
other family members. People can continue to harbour and shed germs after
symptoms have ceased.
Food is another major source of pathogenic microbes in the home. We tend to view
food as benign - we don’t think of foodstuffs as vehicles of infection. Raw foods of
animal origin, as purchased for consumption in the home, are the most likely foods to
be contaminated with pathogens, i.e. raw meat and poultry, raw eggs, unpasteurised
milk, and raw shellfish, but raw vegetables and other foods can also be sources of
infection. Poor food handling practices can lead to serious illness. There is the
potential for everything that touches raw food, including meat and fruit and
vegetables, to become contaminated. In situations where the water source or water
supply is contaminated, this may also be a source of infection in the home.
Contaminated water is a particular problem in low income communities in developing
countries.
The home is also where we keep domestic animals. These animals can carry and
excrete disease-carrying organisms in their faeces such as Salmonella and
Campylobacter, all of which can lead to infectious intestinal disease. In some
situations insects can bring pathogens into the home, particularly in tropical
countries. Fungal spores can enter the home via the air.
In the home, good hygiene plays an important part in reducing the burden of
infectious diseases. Fundamental to developing infection prevention policy for the
home is the need to recognise that this is an environment where all human activities
occur including food and water hygiene, hand hygiene, and hygiene related to care of
vulnerable groups. In most developing countries, disposal of human and animal
excreta and other types of waste is often also, either partly or wholly, the
responsibility of the family and community.
In many/most countries, public health is currently structured such that the separate
aspects of hygiene – food hygiene, personal hygiene, handwashing, safe disposal of
human and other waste, pandemic flu preparedness, patient empowerment etc - are
dealt with by separate agencies. This means that the information which the family
receives is fragmented, largely rule-based and sometimes conflicting. If things are to
change we must recognise that fragmented, rule-based knowledge is not enough to
meet the challenges we currently face. Hand hygiene, for example is a central
component of all hygiene issues, and it is only by adopting a holistic approach that
the causal link between hands and infection transmission in the home can be
properly addressed. There is therefore a need for the various agencies to work in
partnership in order to promote an approach to hygiene which is holistic and familycentred rather than issue oriented.
Adopting a holistic approach provides the opportunity for a rational approach to home
hygiene based on risk assessment. IFH believes that to deliver hygiene policy with
real health benefits, a risk-based approach must be developed and promoted for the
home.
Developing a risk-based approach to home hygiene
The approach that IFH has adopted for developing home hygiene practice is based
on risk assessment and management. Applied to the home, this has come to be
known as “targeted hygiene”. In essence, targeted hygiene means identifying the
high-risk sites and situations for transmission of pathogens in the home, and
targeting hygiene measures where and when it matters to reduce our exposure to
these organisms. Risk management is the standard approach for controlling
microbial risks in food and other manufacturing environments, and is becoming
accepted as the optimum means to prevent such risks in home and hospital settings.
Targeted hygiene starts from the principle that pathogens are introduced continually
into the home, by people (who may have an infection or may be asymptomatic),
contaminated food and domestic animals, and sometimes in water or via the air.
Additionally, sites where stagnant water accumulate such as sinks, toilets, baths,
tiled surfaces, waste pipes, damp cleaning and face cloths readily support microbial
growth and can become primary reservoirs of infection; although species are mostly
those which represent a risk to vulnerable groups. In many homes, there will also be
at least one family member who is more susceptible to infection for one reason or
another.
Within the home, there is a chain of events, as described in Figure 1 that results in
transmission of infection from its source to another person. Limiting the exit and entry
of pathogens from and into the human body involves a whole range of activities such
as good respiratory hygiene, care of wounds, etc. Thorough cooking and safe
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storage of food and household water treatment and safe storage are also part of
targeted hygiene. In low income communities where sanitation is inadequate, it may
be necessary for the family and community to take responsibility for safe disposal of
faeces. Safe disposal of household waste may also be the responsibility of the family.
In communities where public water supplies are unsafe and/or inadequate, provision
of safe water for the family through “household water treatment and safe storage”
also becomes the responsibility of the family.
Fig. 1 – The chain of infection transmission in the home.
To formulate a risk-based approach to breaking the “spread of germs” link, sites and
surfaces in the home are categorised into four main groups: reservoir sites,
reservoir/disseminators, hands and hand and food contact surfaces and other
surfaces. Risk assessment for each site or surface is then determined by assessing
the “frequency of occurrence” of pathogenic contamination at that site, together with
the “probability of transfer” from that site such that family members may be exposed.
This means that, even if a particular site is highly likely to be contaminated, unless
there is a probability of transfer from that site, the risk of infection transmission is low.
From this it is possible to determine the “critical control points” for preventing spread
of infection. The data suggest that:
 For reservoir sites such as the sink waste pipes or toilets, although the probability
of contamination (potentially pathogenic bacteria or viruses) is high, the
probability of transfer is limited, unless there is a particular risk situation (e.g. a
family member with enteric infection and fluid diarrhoea, when toilet flushing can
produce splashing or aerosol formation that can settle on contact surfaces around
the toilet).
 By contrast, for reservoir sites such as wet cleaning cloths, not only is there high
probability of contamination, but, by the very nature of their usage, they carry a
high risk of spreading contamination to other surfaces and to the hands.
 For the hands, and also hand contact and food preparation surfaces, although the
probability of contamination is, in relative terms, lower, it is still significant, for
example, particularly following contact with contaminated food, people, pets or,
for hands, with other contaminated surfaces such as door-, faucet- and toilet-flush
handles. Since there is a constant risk of spread from these surfaces, hygiene
measures are important for these surfaces.
 For other surfaces (floors, walls, furniture etc) risks are mainly due to
pathogens such as S. aureus and C. difficile that survive under dry conditions.
Because the risks of transfer and exposure are relatively low, these surfaces
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are considered low risk, but where there is known contamination, for example,
soiling of floors by pets, crawling infants may be at risk. Cleaning can also recirculate dust-borne pathogens onto hand and food contact surfaces.
Overall, this approach allows us to rank these various sites and surfaces (Figure 2)
according to the level of risk; this suggests that the “critical control points” for
breaking the chain of infection are the hands, together with hand and food contact
surfaces, cleaning cloths and other cleaning utensils. However, although this is a
useful “rule of thumb” ranking, it is not a constant. For example, although risks from
toilets, sinks, floors etc, relate mainly to the relatively lower risk of transfer from these
sites to hands, hand and food contact surfaces and cloths, this risk can increase
substantially where an infected family member has fluid diarrhoea, or where a floor
surface is contaminated with vomitus, urine or faeces.
Fig. 2 - Ranking of sites and surfaces in the home based on risk of transmission of
infections
Talking about “critical control points” is perhaps too abstract because it gives no
indication of “when” it is necessary to apply hygiene practices. It is better illustrated
by talking about these critical points in relation to the daily life tasks and situations
which combine to protect us from infection. Appropriate times are those associated
with activities such as food and water hygiene, respiratory hygiene, toilet hygiene,
laundry hygiene and so on. For example
Food Hygiene – the main source of contamination is raw contaminated food .
Targeted food hygiene involves
- Safe cooking and safe storage of food AND preventing cross contamination via hands, surface and cloths immediately
after handling raw foods and before handling ready to eat foods
Toilet hygiene – the main source of contamination is “poo” from infected and healthy
people. Targeted toilet hygiene involves:
- Washing hands after toilet visits
- Keeping the toilet clean – including hand touch surfaces (flush handle,
seat, lid etc)
- Cleaning and drying cleaning utensils after use
- Washing hands after cleaning the toilet
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Targeted hygiene also means applying a suitable hygiene procedure at appropriate
times to interrupt the chain of infection transmission. Since the “infectious dose” for
many common pathogens such as Campylobacter, norovirus and rhinovirus can be
very small (1–500 particles or cells), one must argue that, in situations where there is
risk, a “hygienic cleaning” procedure should be used which eliminates as many
organisms as possible from critical surfaces.
Hygienic cleaning can be done in one of two ways, either by soap or detergent-based
cleaning with rinsing or by using a disinfectant/cleaner which inactivates the
pathogens in situ.
In many situations (e.g. handwashing) a “hygienically clean” surface can be achieved
by soap and water alone, but recent studies suggest that this process is only
effective if accompanied with thorough rinsing. Wiping a surface with a cloth (or mop)
will merely move organisms around the surface and onto the cloth and hands to be
transferred to other surfaces. This means that, in some situations, we should not be
afraid to use of a disinfectant. Waterless hand sanitisers should also be
recommended for situations where access to soap and water for handwashing is
limited. To ensure the elimination of pathogens from clothing and household linens,
ideally they should be laundered either at 60ºC or at 40ºC using a bleach-containing
laundry product.
The key to targeted hygiene is that it recognises that good hygiene is not a “once
weekly deep down clean”, it needs to be an ongoing part of our daily lives where
hygiene measures are targeted where and when necessary.
In devising hygiene policy for the home, it is important to bear in mind that the home
is the residence for a range of family members, from infants and children to the
elderly and infirm, and from the fit and healthy to those whose immune system may
not be functioning fully. Illness, pregnancy, certain drug therapies, stress, poor
nutrition, smoking and alcohol can all lead to an individual becoming
immunocompromised. And the immunocompromised are more vulnerable to
infectious disease. The elderly and the very young in homes worldwide are more
vulnerable to infections due to either ageing or immature immune systems. It is
especially important that we protect them from infectious disease through the
adoption of good hygiene practices in the home. For family members who are at
greater risk of infection, if hygiene practices are not correctly carried out, the risk of
infection is much greater.
IFH Guidelines, Recommendations and Training Resources on Home Hygiene
As part of our work in promoting hygiene, the IFH has produced a set of “Guidelines
for Home Hygiene” together with “Recommendations for Selection of Suitable
Hygiene Procedures” These are based on the risk-based approach, and cover all
aspects of home hygiene including food hygiene, general hygiene, personal hygiene,
care of pets etc. Using the guidelines and recommendations as the basis, IFH (in
collaboration with the UK Infection Prevention Society and the Water Supply and
Sanitation Collaborative Council) has also produced teaching resources on home
hygiene (one of which focuses on the developed world, the other on issues in
developing countries) which present home hygiene theory and practice in simple
practical language which can be understood by community workers with relatively
little infection control background. These documents are tabulated in Table 1. All of
these materials are downloadable from the IFH website.
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Table 1 - IFH guidelines, recommendations and training resources on home hygiene
(available from www.ifh-homehygiene.org).
Guidelines on home
hygiene
Recommendations
for
selection
of
hygiene procedures
Teaching/selflearning resources
Guidelines for prevention of infection and cross infection the
domestic environment. International Scientific Forum on Home
Hygiene.
Available
from:
http://www.ifhhomehygiene.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/best-practicecare-guideline/guidelines-prevention-infection-and-crossinfection-domestic-0
Recommendations for suitable procedure for use in the
domestic environment (2001). International Scientific Forum
on Home Hygiene. http://www.ifh-homehygiene.org/bestpractice-care-guideline/recommendations-suitable-procedureuse-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/homehygiene-%E2%80%93-prevention-infection-home-trainingresource-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/bestpractice-training/home-hygiene-developing-countriesprevention-infection-home-and-peri-domestic. (Also available
in Russian, Urdu and Bengali)
Targeted hygiene – the evidence base
The targeted approach to home hygiene was developed following a detailed review
of the scientific evidence base relating to the home and environment. The evidence
paper is detailed in a series of review papers which can be downloaded from the IFH
website:
 The chain of infection transmission in the home and everyday life settings, and
the role of hygiene in reducing the risk of infection. 2012. http://www.ifhhomehygiene.com/best-practice-review/chain-infection-transmission-home-andeveryday-life-settings-and-role-hygiene
 Hygiene procedures in the home and their effectiveness: a review of the
scientific evidence base (2008). International Scientific Forum on Home Hygiene.
http://www.ifh-homehygiene.org/best-practice-review/hygiene-procedures-homeand-their-effectiveness-review-scientific-evidence-base
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
Bloomfield, SF, Aiello AE, Cookson B, O’Boyle C, Larson, EL, The effectiveness
of hand hygiene procedures including handwashing and alcohol-based hand
sanitizers in reducing the risks of infections in home and community settings”
American Journal of Infection 2007;35, suppl 1:S1-64
The need to balance risks against benefits of hygiene
In recent years we have seen increasing attention given by the media to risks
associated with hygiene. These include the perceived risk of being too clean,
concerns about toxic and environmental effects of cleaning and disinfectant products,
and the possibility of links between disinfectant use and development of antibiotic
resistance.
Although experts now agree that the term “hygiene hypothesis” is a misnomer, there
is still a strong “collective mindset” that dirt is “good” and hygiene somehow
“unnatural”. Although there is good evidence that microbial exposure in early
childhood may help to protect against allergies, there is no evidence that we need
exposure to harmful microbes (pathogens) or that we need to suffer a clinical
infection. There is no evidence that reduced exposure to pathogens through hygiene
measures such as handwashing, food hygiene etc. is linked to increased
susceptibility to allergies. A consensus is now developing amongst experts that the
answer lies in more fundamental changes in lifestyle that have led to decreased
exposure to largely non harmful organisms, such as the normal microbiota of humans
and animals, microbes found in the general environment and helminths (worms). The
data suggests that these exposures are important for development of immunoregulatory mechanisms. There is still much uncertainty as to which “lifestyle” factor/s
are involved. There is also no evidence to suggest, as is often stated in the media,
that we need to get regular infections to boost our general immunity to infection.
More details of this issue can be found in: Bloomfield SF, Stanwell-Smith R, Rook
GA. The hygiene hypothesis and its implications for home hygiene, lifestyle and
public health: summary. International Scientific Forum on Home Hygiene.
http://www.ifh-homehygiene.org/best-practice-review/hygiene-hypothesis-and-itsimplications-home-hygiene-lifestyle-and-public
Another key question is whether use of disinfectants (products which contain
microbiocides which inactivate microbes) is encouraging the emergence of
“superbugs” which are resistant to antibiotics. Although laboratory experiments
demonstrate links between exposure to biocides and increased resistance to
antimicrobials, as yet there is no evidence that use of disinfectants in the community
is linked to emergence and spread of antibiotic resistance.
In view of these concerns, targeted hygiene makes sense, in that it offers the means
to address issues such as the hygiene hypothesis because it maximises protection
against infectious microbes, whilst otherwise allowing normal exposure to nonharmful microbes.
This fact sheet was last updated in 2015
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