How much Handwashing is Important

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Many people have come to believe, incorrectly, that antibiotics, which kill many types of bacteria, are the most important defense against disease.

For most of the 1900’s, doctors have realized that handwashing can stop the spread of disease caused by bacteria and viruses, including those that cause common colds and flu, food-borne illnesses, and nosocomial infections (infections acquired in a hospital). In fact, officials at the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, consider handwashing to be the first line of defense against infectious diseases, which remain the leading cause of death and illness worldwide, as well as the third leading cause of death in the United States.

Despite the increase in the use of disease-fighting antibiotics, people are dying from infectious diseases in record numbers. According to a report by the CDC, between 1980 and 1992 in the United States, there was a 58 percent increase in deaths caused by infectious diseases. This increase, according to health experts, was due in large part to a lack of personal hygiene among the public and health-care workers.

How disease is spread

It is impossible to avoid all germs. Some disease-causing microorganisms are transmitted by inhaling small particles that circulate in the air. Other diseases are spread through direct contact with infected animals. The majority of infectious diseases, however, are spread by direct contact with germs from an infected person.

Many diseases are transmitted by bodily secretions on contaminated hands. Intestinal-tract infections, for example, are usually spread from person-to-person through exposure to germs in the feces, through what is called fecal-oral transmission. This means that germs leave the body of the infected person in the feces, get on the hands of that person who does not wash them, and are then passed to an object handled by that person. The next person touches that object and the germs enter their body when the person touches their mouth. In most situations, this happens when objects, including toys, hands or fingers, or food and water, are contaminated with undetectable amounts of feces and are then placed in the mouth. Salmonella, hepatitis A, and infectious diarrhea are among the illnesses linked to fecal-oral transmissions.

According to CDC estimates, fecal-oral transmission is responsible for about 25 percent of all food-borne illness outbreaks. The main vehicle of transmission is bacteria commonly called E.coli (Escherichia coli). The bacteria can cause acute bloody diarrhea and death in humans, especially the young, the elderly, and the frail.

Contaminated hands

Nearly 40 infectious diseases are transmitted by feces and other secretions on contaminated hands. Most of these diseases are caused by bacterial or viral pathogens (any organism or substance that is capable of causing a disease). Bacteria and viruses enter the body through natural openings, such as the nose or mouth, or through breaks in the skin.

There are thousands of kinds of bacteria, most of which are harmless to human beings. However, some kinds of bacteria—which may be spread from person-to-person via the air or by touch—can cause diseases in human beings. These diseases include cholera, gonorrhea, leprosy, pneumonia, syphilis, tuberculosis, typhoid fever, and whooping cough.

Viruses, both handborne and airborne, cause such diseases as chicken pox, measles, influenza, and the common cold. A virus is a microscopic organism that lives in a cell of another living thing. Viruses produce disease in an organism by damaging its cells. Some viruses and bacteria can live for hours on the fingers and up to several days on a telephone, a desk, or any other surface. The germs can then be picked up by uninfected people when they touch that surface and then touch their eyes, mouth, or nose.

Infectious diseases that may be spread by contaminated hands

  • Bacterial meningitis
  • Chickenpox
  • Common cold
  • Diphtheria
  • Influenza
  • Measles
  • Mumps
  • Pneumonia

Handwashing through history

The simple act of preventing the spread of germs through proper bathing and handwashing seems like common sense in 1998. But before the clear link between personal hygiene and the spread of infectious diseases was understood, religious beliefs, cultural attitudes, or technology—rather than health concerns—influenced personal cleanliness. Without the aid of powerful antibiotics and an understanding of proper hygiene, our ancestors regularly fell prey to deadly armies of microinvaders.

Primitive people lived in hunting societies and were perpetually on the move. As a result, primitive people were at little risk of developing infectious diseases that afflicted the dense and stationary populations yet to come. As people developed agricultural and permanent settlements they crowded together in close living quarters. They had increased contact with human feces, allowing for a wide variety of intestinal parasites to move person-to-person.

Some early civilizations adopted hygienic practices while other societies shunned them. Ancient Greek civilizations prized cleanliness, and in Rome by the early fourth century, bathing at least once a week was considered a basic social duty. Rome had 11 elaborate public bathhouses, more than 1,350 public fountains, and many hundreds of private baths. During the Middle Ages (A.D. 400-1500), Roman and Greek advances in bathing and personal hygiene were either forgotten, ignored, or deliberately suppressed.

Illnesses in unsanitary societies

A lack of proper sanitation conditions and poor personal hygiene eventually led to disastrous health consequences throughout the world. Fleas present on rats, which thrived in human waste, caused an epidemic plague known as the Black Death, which ravaged Europe and Asia in the mid-1300’s, killing about 40 million people. The Great Plague, an epidemic of the bubonic plague, swept through the slums of London in 1665, killing 100,000 people in just one year.

The cleanliness of some cultures, like the Polynesians who had settled the Pacific Islands 2,000 years ago, could not stop the spread of diseases brought by explorers from less hygienic nations. European explorers who landed on the Polynesian islands in the late 1700’s and early 1800’s brought diseases with them that threatened the native population.

Until the late 1800’s, most Europeans and Americans lived in unsanitary conditions, and many people died at a young age from infectious diseases caused by poor hygiene as well as airborne disease. Until the 1900’s, most Americans worked, ate, and slept with microorganisms and vermin, usually lacking the time, facilities, and sometimes even the freedom to bathe. In colonial America in the 1600’s and 1700’s, for example, some states restricted bathing by law. Bathing was considered impure because it promoted nudity and, therefore, could lead to promiscuity.

The discovery of germs

By the late 1790’s, physicians believed that most diseases were airborne and were spread from person-to-person through “foul air.” It was not until scientists in the mid-1800’s, led by French chemist Louis Pasteur and German physician Robert Koch, established the germ theory of disease that humans began to understand the nature and origin of the infectious diseases that had ravaged populations since the beginning of history. Pasteur’s discovery that microbes cause illness revolutionized public health practices and sanitation.

Physicians focus on handwashing

In 1847, Hungarian physician Ignaz Semmelweis convinced his colleagues that by washing their hands before and after examining patients they were less likely to spread disease from one person to another. In the mid-1800’s, health crusaders, including Florence Nightingale and Edwin Chadwick, spoke out against the poor sanitation conditions that they believed were causing the spread of disease in London. Encouraged by discoveries of such physicians as John Snow, who in 1854 traced a cholera outbreak in central London to a single contaminated source of drinking water, social reformers championed the importance of cleanliness in preventing the spread of disease in communities and hospitals. By applying a preventive approach to treating an entire community, rather than treating just the individual, health reformers discovered a vital strategy in halting the spread of disease.

The attitudes about disease that emerged during the 1800’s dramatically influenced European and American policies on public health. Until that time, the primary goal of governmental activity in the field of public health was isolating infected people from healthy citizens. With the new attitudes of modern medicine, people realized that governments could promote health, rather than simply isolate disease.

As a result, European and American societies organized a series of local, national, and international bodies dedicated to combating the spread of infectious diseases. Governments improved sanitation, created safe water supplies, removed sewage, dug wells, and chlorinated water. People also adopted personal health habits, such as bathing and handwashing, that reduced the spread of disease.

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Cleanliness in medicine

Hospitals introduced proper hygiene requirements, including handwashing, as a routine procedure to decrease the instance of infection. As a result, people began to consider hospitals as places in which to get well, rather than places to die.

The discovery of antibiotics, drugs used primarily to fight bacteria that cause disease, greatly increased people’s ability to stop the spread of infectious disease in the 1900’s. Scientists in the first half of the century hoped that antibiotics would wipe out bacterial forms of infectious disease. By the 1990’s, public health experts were cautioning against the over-prescription of antibiotics because of the risk of bacteria becoming drug-resistant and stressing the importance of handwashing—rather than drugs—in fighting disease.

Public attitudes on handwashing

Studies have shown that less than half of people in public restrooms bother to wash their hands after using the facilities. In a 1996 survey conducted by the American Society for Microbiology, a life science membership organization in Washington, D.C., researchers from Wirthlin Worldwide, an international research firm, surveyed more than 7,000 people nationwide. People were questioned in a two-part survey conducted in person and over the phone. In the first part of the survey, researchers observed handwashing behavior in five major U.S. cities and discovered that 74 percent of the women and 61 percent of the men washed their hands in public restrooms.

However, the finding contradicted the results of the second part of the survey, in which 90 percent of the men and 98 percent of the women claimed they always washed their hands after using a public rest-room. The telephone portion of the survey also revealed that 78 percent of those surveyed claimed that they wash their hands after changing a diaper, 81 percent before handling food, 48 percent after petting an animal, 33 percent after coughing or sneezing, and 22 percent after handling money.

Another handwashing study, conducted in 1996 by the Compliance Control Center, a Washington, D.C.-based company, measured handwashing in restaurants, grocery stores, institutional food service, and health-care locations. Researchers found that employees in these public service environments failed to wash their hands, despite extensive training on the importance of frequent handwashing in the prevention of contamination and infection. An electronic handwashing verification system used in the study revealed an average of less than two washes per employee per day.

When performance data gathered by the system was then shared with management and employees, handwashing compliance increased by more than 380 percent. However, when performance feedback was later discontinued, employee handwashing practices again decreased.

Handwashing and children

Studies have found that children who wash their hands four or more times a day at school or daycare are less likely to become sick with infectious diseases than children who wash less frequently. Doctors at Providence Hospital in Southfield, Michigan, reported in July 1996 that the children who frequently washed their hands lost 24 percent fewer days to colds and flu and 50 percent fewer days to stomach illness. In 1997, a study published in Family Medicine reported that handwashing greatly reduced the risk of gastrointestinal illness in children.

In a 1996 campaign sponsored by the Utah Hygiene Education Coalition, students in Utah elementary schools were taught lessons about the importance of handwashing to prevent the spread of disease. In a follow-up survey, 86 percent of the 264 teachers responding reported seeing children voluntarily washing their hands more often and exhibiting clear understanding of the importance of the practice.

Handwashing in hospitals

Studies have also shown that many doctors and nurses don’t wash their hands before examining patients, thus spreading diseases within hospitals. According to CDC estimates, hospital-acquired infections annually cause or contribute to 100,000 deaths.

Approximately 2 million out of the 35 million Americans hospitalized annually in the 1990’s became more ill after entering a hospital due to exposure to germs, according to the CDC. This in large part was due to the poor handwashing practices of health-care workers, according to the CDC. The CDC reported in 1994 that only between 14 percent and 59 percent of doctors and 25 percent to 45 percent of nurses regularly washed their hands between patients.

In 1996, scientists at Northeastern University in Boston stationed observers in the restrooms of five Boston teaching hospitals. Of the 143 people observed, which included visitors, doctors, and other health professionals, researchers found that only a minority of the people washed their hands with soap and water, and more than 30 percent did not wash their hands at all.

Some hospitals have made an effort to combat the problem by instituting strict handwashing procedures. In a patient-assisted study in 1997, about 440 patients admitted to the West Jersey Health System agreed to ask every health-care worker who entered the room if they had washed their hands. After six weeks, researchers from the University of Pennsylvania Medical Center, found that handwashing went up by 34 percent—from two washings per shift to 12—in the four participating hospitals.

Proper handwashing techniques

Even when people do wash their hands, many do not use proper washing techniques. According to a study by researchers at North-western University Medical School in Chicago, a brief handwashing using only water for five seconds did nothing to remove bacteria from the hands. A five-second wash with either antibacterial or regular soap removed more germs, but some still remained. A 30-second wash with soap was required to remove most of the pathogens from the hands. The researchers reported that on unwashed hands, as well as on other common objects in a hospital setting, one strain of antibiotic-resistant bacteria could survive for up to one hour.

Experts recommend washing your hands before and after eating; before and after handling food, particularly raw meat or fish; before and after having sexual intercourse; before treating a cut or wound; before inserting or removing contact lenses; after using the restroom; after sneezing, coughing or blowing your nose, particularly when you have a cold; after coming home from a crowded public place; after shaking hands at a party or a reception; after changing a diaper; after playing with a pet; after changing a litter box or handling garbage; and after gardening or any other activity that leaves the hands dirty.

Vigorous rubbing required

How you wash your hands is just as important as when you wash them. Plain soap and water do not actually kill infectious germs. The soap loosens the bonds that hold dirt, oil, and microorganisms to the skin and suspends them in water. Although soap loosens microorganisms on the skin and creates a slippery surface, it is the vigorous rubbing of this slippery surface that removes germs from your hands. Antibacterial soap, however, has been proven to kill some infectious germs on the skin.

When washing your hands, use a small amount of soap along with warm or hot running water. Warm or hot water is more effective than cold water in cutting through grease and other dirt on the skin’s surface. Vigorously rub your hands together for at least 15 or 20 seconds, thoroughly washing the entire surface area, including the wrists, palms, back of hands, fingers, and under the fingernails. To avoid reinfecting your hands, turn off the water faucet with a paper towel. Dry your hands by beginning with your forearms and working toward your hands and fingertips. Experts advise patting, rather than rubbing, your skin to avoid chapping and cracking.

There is no way to rid your body of all harmful germs, but handwashing can help destroy many pathogens and reduce the risk of infectious disease. Handwashing is the single most effective—and the simplest—method of combating germs and protecting yourself and others against illness.

Public health experts recommend the following steps for effective hand-washing:

  • Use warm or hot running water.
  • Use regular or antibacterial soap.
  • Rub hands together for at least 15 seconds, washing all surfaces thoroughly, including wrists, palms, back of hands, fingers, and beneath the fingernails.
  • Turn off water faucet with a paper towel to avoid reinfecting hands.
  • When drying, begin with the forearms and work toward the hands and fingertips. Pat the skin dry, rather than rubbing, to avoid chapping and cracking.
  • Apply lotion to prevent or soothe dry skin.
  • Source: U.S. Centers for Disease Control and Prevention.

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