International Scientific Forum on Home Hygiene

Hand hygiene in the home and community January 2009

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 number of 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. 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 illnesses impose an enormous burden on the community. In the UK it has been estimated that there are around 4.7 million foodborne illnesses every year.1 In the USA there are approximately 76 million foodborne illnesses, responsible for 500,000 hospital admissions and 9000 deaths.2 In 2003 a WHO report concluded that about 40% of foodborne illness outbreaks in the European Region over the previous decade had been caused by food consumed in private homes3 – 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 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.2 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 developing countries, diarrhoeal disease is a major health problem. The 2008 WHO World Health Report states that 80% of cases of diarrhoea worldwide are attributable to unsafe water, inadequate sanitation or insufficient hygiene. These cases result in 1.5 million deaths each year, most being the deaths of children. Intervention studies suggest that the risk of infectious intestinal disease can be reduced by up to 50% or more by handwashing.4

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. 5

Skin and wound infections There is an increasing amount of evidence to suggest that the transmission of skin- wound and eye infections can occur via contaminated hands. The danger posed by methicillin-resistant Staphylococcus aureus (MRSA) infection in healthcare settings 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 CA- MRSA) 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 in- homecare, 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 Page 2/12 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 as visitors, who have already been 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 five links, all of which have to be in place for an infection to pass from its original source to a recipient (Figure 1).

Fig 1 - Critical control points in the chain of infection.

/12 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.

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:  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) Page 4/12  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 Effectiveness of alcohol-based handwashing (15-30 secs) products containing 62% ethanol (30 sec exposure) Gram-positive and +++ ++++ Gram negative bacteria C. difficile +++ ++ Enveloped viruses:

Influenza, No data available +++ to ++++ parainfluenza Non-enveloped viruses: No data available ++ to ++++* rhinovirus (cold virus) ++ ++ to +++ rotavirus No data available ++ to +++ norovirus (based on testing against murine norovirus used as surrogate test strain No data available + to +++ for norovirus) No data available + adenovirus, 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.

/12 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 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 Page 6/12 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, and in some cases better than 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 rhinovirus6, 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.

/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.

/12 Routine day-to-day situations Non-routine situations Increased risk from People who are Increased risk from People at increased source of infection otherwise healthy infected family risk of infection in the home but at increased members risk of infection Handling of raw meat, Young babies, the Family members Patients home from poultry, fish, fruit and elderly, pregnant infected with colds, hospital or outpatients vegetables. women. flu, norovirus, including people with Family members or People in poor living Salmonella, Shigella, catheters, wounds, pets who are conditions. etc. etc. colonised or infected People undergoing with bacteria (e.g. drug treatment; Salmonella, C. people with underlying difficile, MRSA). illness (e.g. diabetes, HIV).

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.

/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 person- to-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.

/12 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/0196- 6553/PIIS0196655307005950.pdf

IFH Guidelines and Training Resources on Home Hygiene 2. Guidelines for prevention of infection and cross infection the domestic environment. International Scientific Forum on Home Hygiene. Available from: http://www.ifhhomehygiene.org/ IntegratedCRD.nsf/70f1953cec47d5458025750700035d86/92111ae3 8986bfbb802574dd003fc2c1?OpenDocument 3. Recommendations for selection of suitable hygiene procedures for use in the domestic environment. International Scientific Forum on Home Hygiene. Available from: http://www.ifhhomehygiene.org/ IntegratedCRD.nsf/70f1953cec47d5458025750700035d86/24401f93 5e57e79e802574e200391c43?OpenDocument 4. 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.ifhhomehygiene.org/ IntegratedCRD.nsf/70f1953cec47d5458025750700035d86/24eb0634 5354d067802574e1005a075d?OpenDocument 5. Home Hygiene - prevention of infection at home: a training resource for carers and their trainers. International Scientific Forum on Home Hygiene. Available from: http://www.ifhhomehygiene.org/ IntegratedCRD.nsf/571fd4bd2ff8f2118025750700031676/9aaaeb306 bb3c50c80257522004b4fdc?OpenDocument 6. 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: http://www.ifhhomehygiene.org/ IntegratedCRD.nsf/571fd4bd2ff8f2118025750700031 676/19155ab46073e67f8025752200546d83?OpenDocument

References 1. Food Standards Agency. A Report of the Study of Infectious Intestinal Disease in England. London: HMSO; 2000. 2. Mead PS, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, et al. Food- related illness and death in the United States. Emerg Infect Dis. 1999;5(5):607- 25. 3. WHO Regional Office for Europe. Several foodborne diseases are increasing in Europe. Press Release EURO/16/03. Available from: http://www.euro.who.int/mediacentre/PR/2003/20031212_2. [Accessed 10 July 2007.] 4. 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

/12 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/0196- 6553/PIIS0196655307005950.pdf 5. Health impact of handwashing. WELL fact sheet 2006. Available from: http://www.lboro.ac.uk/well/resources/fact-sheets/fact-sheets- htm/Handwashing.htm. 6. 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. 7. Centers for Disease Control and Prevention. Avian Influenza (Bird Flu). Available from: http://www.cdc.gov/flu/avian/index.htm. [Accessed 10 July 2007.]