The art of hand hygiene as a concept in everyday life has not been around as long as we may think. It is only in the last century that the first public health campaigns were launched and “handwashing moved from being something doctors did to something everybody had been told to do” according to Nancy Tomes, a distinguished professor of history at Stony Brook University, New York.
In 1848, Ignaz Semmelweis, a Hungarian doctor working at Vienna General hospital, identified that by washing their hands and equipment between patients on a maternity ward the death rates reduced from 18% down to about 1%. However, his findings were met with resistance and the doctors of the day did not truly believe that they could be the source of infection and so handwashing was not universally adopted.
Florence Nightingale, following her time in military hospitals in the Crimean war, returned to the UK and revolutionised nursing with her work. Hand hygiene and sanitisation was a cornerstone of practices driven forward by Nightingale and thankfully became common practice within hospitals. However, it would be another 40 years before hand hygiene became common practice outside of the medical profession.
Over the next 40 years, driven by the work of Pasteur and Lister an understanding of germs and germ theory developed. With these developments attitudes to hygiene gradually shifted and by the 1880’s and early 1900’s the act of handwashing had transitioned from something only doctors did to something we all should do. However, I do not believe that until this Coronavirus pandemic and Boris Johnson emerged from the Cobra meeting on the 2nd March 2020 announcing that we should wash our hands to the tune of Happy Birthday that the true impact of handwashing was realised by many of today’s population in the UK.
In fact, research by Miryam Wahrman in the American Journal of Infection Control in 2009 suggested that “After urinating, 69% of women washed their hands, and only 43% of men,” she says. “After defecation, 84% of women and 78% of men washed their hands. And before eating – a critical time to wash your hands – 10% of men and 7% of women washed their hands.” (https://resani.com/tag/sanitizing/page/2/). So why was the act of handwashing so low? We can see a trend after the second world war where an increase in vaccinations and antibiotic use resulted in a decline in disease related deaths in the 20th Century, this period coincided with a decline in public health messages around hand hygiene. As a result people began to place less importance in the basics of hand hygiene. A rising trend began within some circles that germs and microbiology must be embraced to keep us healthy was observed – the table was starting to swing in the opposite direction.
It is true that we have to find a happy balance between allowing our bodies to build up natural resistance to pathogens whilst also protecting ourselves with the simple, free, basic hygiene practices such as handwashing, a task taking only 15 seconds to complete. Statistics have shown that over the winter months of 2020 and start of 2021 we have seen lower than average rates of typical communicable and respiratory diseases, such as the Influenza, Laryngitis and the Common Cold (Royal College of General Practitioners, Communicable and Respiratory disease report – week 7 of 2021). https://www.rcgp.org.uk/-/media/Files/RSC/WeeklyReport_Winter_wk07_2021.ashx?la=en
There are several factors contributing to reduced rates of communicable disease transmission observed over the past months, the lockdowns, social distancing measures and mask wearing will have all played a significant role. The increased awareness and practice of hand hygiene will also have played its part. To what extent each factor has contributed may never truly be known as the interrelated factors are complex and difficult to unravel. The rebounding of these infections that have been suppressed as, almost, a side effect of the pandemic will be scrutinised closely by healthcare professionals as our communities return to relative normality with COVID-19 vaccine delivery continuing apace. The question that is very difficult to answer is … what impact did simple handwashing make to the control of COVID-19 infection? And, possibly more importantly, what difference can we make to both the transmission of COVID-19 and other communicable disease transmission in the future by maintaining the practice that has become so widespread? If we all got a bit tighter on our hand hygiene could we reduce the cases of all infections such as COVID-19, flu and so on forever.
One study, published in Epidemics in 2017, found significant effects from handwashing, compared with nonsignificant effects from facemask use in preventing pandemic influenza infection. It was discovered that if you washed your hands five to 10 times more than usual, “that would reduce your risk by a quarter” https://www.sciencedirect.com/science/article/pii/S1755436516300858
For hand hygiene to be effective we must ensure that we are doing it right. Hand sanitisers have become commonplace in our busy lives making hand hygiene easier and faster, however, we have to recognise that there are limitations. Hand sanitiser (alcohol gel) is not effective on all pathogens, for instance alcohol gel is not effective against C.Diff (within the class of bacteria called Bacilli), and dirty hands are not ‘cleaned’ by putting alcohol gel on them and rubbing them together. This is where good old soap and water must play a part – so how does soap and water kill the pathogens? According to Wahrman, soap is hydrophobic as are cell membranes and the covering on virus membranes. When the cell membrane or virus covering is exposed to the soap the interaction creates a disruption in the cell structure effectively killing it. Additionally, the soap can help break the bonds between the pathogens and our skin so when we rinse our hands, we send the pathogens down the drains. https://resani.com/tag/sanitizing/page/2/
Public Health England recommends that we should be following the 13 step approach to effective handwashing and that effective handwashing should take at least 15 seconds. Check out the latest handwashing poster here:
Vaccines are now being rolled out on a phenomenal scale with over 17 million people in the UK having had their first dose of an approved COVID-19 vaccine (DHSC, 1/3/2021). The 4th COVID-19 vaccine will hopefully be approved and available in the UK in the coming months improving the diversity of vaccines available to medical professionals in the current fight against the pandemic in the UK and globally. However, I worry that with increasing vaccination we become complacent and forget about the importance of fundamental basic hand hygiene once again, as happened after the end of the second world war. It is simple, easy, free and only takes 15 seconds but, crucially, it may just save a life – it is effective handwashing.