The Effectiveness Of Hand-washing In Removing Bacterial Presence

Medical dramas flood the television with visions of perfect surgeons, smiling nurses, and catastrophes that are often solved with the span of a few hours. Ideal physicians are presented in medical dramas like Grey’s Anatomy, House M.D., and The Good Doctor. Every time the doctor does anything medical related they wash their hands, but that doesn’t occur in reality. Whenever I have gone in for a physical, the doctor ‘washes’ their hands quickly or rubs on a foam hand sanitizer, then starts their procedure. Hand-washing is the first thing any medical student learns in med school, so why is there this obvious lack of hygienic duties? This epidemic of unhygienic practices is not localized to medical professions. As a member of the food industry, I was required to take a 2-hour contamination and food-borne disease prevention course. In the course, it went over food safety, foodborne illnesses, proper personal hygiene in the workplace, food storage procedures, and cleaning and sanitization. The course was a joke, it showed little animations of “Veronica Virus” and “Barry Bacteria” to teach safety. Ultimately, the course was an overview of hand-washing practices. Normally, washing your hands would be common sense, but food safety offices feel required to reeducate their members. Hand-washing should be a common occurrence, however, the public still denies hand hygiene practices and diseases run rampant through communities. This paper will examine the frequency and effectiveness of hand-washing in the healthcare setting and among the public.

Bacteria Characteristics

Bacteria are considered to be any of a group of microscopic single-celled organisms that live in enormous numbers in almost any environment on Earth, from deep-sea vents to deep below the Earth's surface to the digestive tracts of humans and animals. (Rogers & Kadner, 2019) Without bacteria, soil would not be fertile, and dead organic material would decay much more slowly. Some bacteria are widely used in the preparation of foods, chemicals, and antibiotics. Among their other beneficial roles, microbes synthesize vitamins, break down food into absorbable nutrients, and stimulate our immune systems. Bacteria provide important functions for a variety of events on Earth that are necessary for life.

Most prokaryotes reproduce by a process of binary fission, where the cell grows in volume and size until it divides in half to release two identical daughter cells. Each daughter cell can continue to grow at the same rate as its parent. A group of environmental bacteria reproduces by budding. In this process, a small bud forms at one end of the mother cell or on filaments called prosthecae. As growth proceeds, the size of the mother cell remains the same, but the bud enlarges. When the bud is about the same size as the mother cell, it separates. One difference between fission and budding is that in budding the mother cell often has different properties from the offspring. Bacteria reproduction is relatively simple and is asexual in nature.

Outside of nutrients and water, each species of bacteria has a specific environmental preference. Preferences include optimal pH levels, temperature range, amount of light, concentration of necessary gases such as oxygen and carbon dioxide, and the atmospheric pressure of the location. Most common bacteria grow well at or near a neutral pH of 6.0 to 8.0. Temperatures also vary, with most thriving in the range between 40 degrees Fahrenheit and 140 F. Some bacteria that need oxygen for metabolic processes can use the normal 10 to 12 percent available in the atmosphere, however, in the cases of some other bacteria it may be fatal. While all bacterial species have an optimal environment for growth, they are flexible enough to adapt to conditions that are less than ideal. Many pathogenic bacteria are highly adaptable and can survive in a variety of environments, from the surface of a hand to the kitchen sink. This allows for the eventual transmission to a host more effectively.

Many bacteria make us sick in the same manner that viruses do, but they also have other strategies at their disposal. Some bacteria will multiply so rapidly that they congest host tissues and natural flora to disrupt daily function. Sometimes they can kill the host’s cells and tissues immediately or they are able to make toxins that can paralyze, destroy cells’ metabolic processes, or trigger a massive immune reaction that is itself harmful and possibly destructive.

Soap’s Method of Cleaning

Most bacteria will attach itself to the natural oil in our skin. Destroying the oil with a dissolving agent like alcohol or kerosene will remove the related pathogens. Normally, oil and water don't mix, so they separate into two different layers. The soap breaks up the oil into smaller droplets, which can then mix with the water. Soap is effective because of the inversion of hydrophilic and hydrophobic ends of soap molecules. Hydrophobic ends of soap molecules will attach themselves to the oil. Hydrophilic ends stick out into the water, causing a drop of oil to form suspended in the water. Smaller drops of grease and dirt are to then be washed away by the running water when you rinse your hands. Agents like Triclosan and Triclocarban are added to soaps and sanitizers to inhibit the growth of various bacteria, as well as some viruses and fungi. However, further research has suggested that antibacterial soaps are no better than regular soaps at preventing illness or reducing bacteria.

Studies on Healthcare Facilities

There are roughly between 2 to 10 million bacteria on your fingertips and elbows. Nearly 80 percent of illness-causing germs are spread by your hands. In 1938, Price established that bacteria recovered from the hands could be divided into two categories, resident or transient. The resident flora consists of microorganisms residing under the surface level cells of the stratum corneum and can also be found on the surface of the skin. Resident microbes has two main protective functions: microbial antagonism and the competition for nutrients in the ecosystem. In general, resident flora is less likely to be associated with infections, but may cause infections in sterile body cavities, the eyes, or on non-intact skin. In an effort to alleviate this, guidelines for hand-washing have been issued by health organizations to limit the amount of nosocomial infections or hospital acquired infections.

An observational study by the World Health Organization (WHO) was conducted for approximately 60 days from August 2015 to October 2015 to access healthcare workers compliance with the WHO’s prescribed five moments of hand hygiene as it relates to patient care and to determine the various levels of healthcare workers who fail to uphold such prescribed practices. Hand hygiene compliance was monitored using the hand hygiene observation tool developed by the WHO. An unidentified observer was used for monitoring compliance with hand hygiene. The study was conducted at the Babcock University Teaching Hospital in Ilishan-Remo, Nigeria. The observations occurred during routine care at this suburban teaching hospital. The hospital is a 140-bed facility that provides for both a local and a university community. The hospital consists of both single and multiple room units and shared rooms for inpatients with eleven outpatients clinics. Observation on hand hygiene was conducted at the inpatients and outpatients units and also within the wards and the ICU.

A total of one hundred and seventy six observations were recorded from healthcare personnel. The highest number of observations was seen in the surgery (40), ICU (34), followed by the Emergency Department (33) and Internal Medicine (32). With regards to overall compliance in the observance of hand hygiene, 10 of the hospital staff were found to be compliant before touching the patient while 165 were non compliant, 48 performed hand hygiene after touching the patient compared to the 128 that did not, 91 performed hand hygiene before and invasive procedure while 71 did not. In addition, 105 washed their hands after removing gloves as opposed to 66 that did not and 72 personnel observed hand hygiene after contact with body fluids and 40 did not. 

The findings, however, from the study show that the rates of compliance in the local center are still low. The reasons for this could potentially stem from a lack of an educational program on hand hygiene; unfortunately, healthcare workers in developing hospitals believe such hygiene programs to be unneeded and unnecessary. Despite the various advancements in infection control, healthcare workers still do not fully comply with the recommended hand hygiene practices. The observation results was that several personnel did not perform hand hygiene before conducting an invasive procedure but rather ignored the procedure and donned their gloves. This contradicts the fact that for healthcare workers, hand hygiene was essentially for their own protection and not that of the patient or the environment.

A variety of factors have been documented as a reason why healthcare workers do not sanitize their hands before and after patient contact. Some of which may include a large workload, insufficient time, forgetfulness, lack of running water, and unavailability of alcohol-based cleaners. Hand hygiene has, as a result, been promoted as one of the tools that will help to lessen this rise in antimicrobial resistance due to its physical nature of cleaning. This behavioral pattern is also seen in the study with low levels of compliance with the WHO prescribed five moments of hand hygiene. A troubling trend is the extreme noncompliance rates of hand hygiene after touching the patient as the hands of healthcare workers could become a human repository of pathogens among patients. Microorganisms that cause healthcare-associated infections are constantly evolving and as such their antimicrobial resistance rates are higher in the hospital compared to the community due to increased exposure. Dangerous microorganisms can be introduced into the local community via three methods: Healthcare workers, discharged patients, or the relatives of such patients who visit the hospital.

Healthcare-associated infections are an important cause of fatality and mortality in medical practice and pose a challenge in efficient healthcare delivery. One of the most easily identified routes of transmission of nosocomial infections is the hands of healthcare workers. Healthcare-associated infections are an obstacle to both physicians and patients, as they lead to complications in treatment, overall increased in hospital stays, increased healthcare costs and may result in death. At the moment, the situation in developing countries is such that hand-washing facilities are below the standard. The unavailability of sufficient sinks or running water also inhibits proper hand hygiene. However, this is now being addressed with the use of alcohol-based hand rubs. An active surveillance system should be instituted to rapidly detect cases of healthcare-associated infections and to prevent any future infections.

Likewise, in 2012, a different study found the same results. Healthcare workers (HCWs) were discovered ignoring hand-washing practices. A total of 200 participants including 50 doctors, 50 medical students, 50 nurses, and 50 attendants from the Department of Anaesthesia and Department of Medicine were taken from the Chhatrapati Shivaji Subharti Hospital in Meerut, India. The hand impressions of the participants were taken, and hand cleaning of each participant was done by a preparation of a 70% isopropyl alcohol-based hand rub. The hand impressions from the participants were taken again afterwards.

Out of 200 samples collected from the HCWs, 95 samples showed growth of microorganisms. (Singh & Singh, 2016) Most commonly isolated microorganism was Staphylococcus aureus present in 70% of nurses, 60% of students and 40% of attendants. In the study, 95 out of 200 HCWs carried pathogens on the hand. S. aureus was isolated predominantly from 47.5% of those 95 HCWs. Among the 95 HCWs that carried S. aureus, 50 of them also carried Methicillin-resistant Staphylococcus aureus (MRSA). The presence of MRSA and staphylococcus aureus was relatively low, however, given a patient with a compromised immune system, that presence could be deadly. The prevalence rate of pathogenic bacteria was highest in nurses followed by students. Hand hygiene is critical in the healthcare environment and hygiene is an effective method of reducing the bacterial flora on the hands of HCWs.

A study from 2013 details the possible causes of hand-washing compliance in an American college town environment. Recent surveys established that American adults claim to wash their hands most frequently after using a public restroom. A poll done by QSR Magazine in 2009, concluded that 94% of 2,516 participants consistently wash their hands, while in 2010, another poll done by Harris Interactive determined that 96% of 1,006 participants stated they always washed their hands after using a public restroom. The data was self-reported and as such is deemed unreliable due to hand-washing being a socially desirable practice. Hand-washing is more likely to occur in a public setting as a result of expected cultural normalities. However, despite this potential abnormality, hand-washing has increased steadily over the years. The American Society for Microbiology and the American Cleaning Institute have been studying hand-washing practices since 1996, and have come to the conclusion that 85% of observed adults wash their hands after using public facilities in a public attraction across 5 different cities. (Harris Interactive, 2010) With the exception of one attraction, generally there was an increase in hand-washing rates across the United States.

Studies on the Public

A study conducted by Michigan State University in 2013 observes the frequency and quality of hand-washing done in a college-town environment. 12 research assistants conducted covert observations of hand hygiene. The assistants recorded time, date, gender, overall cleanliness of restroom, availability of hand-washing propaganda, and hand-washing behavior. Behaviors were categorized as no washing (leave with no wash or rinse), attempted washing (no soap available or wetting hands), and washing hands with soap. The descriptive data was evaluated using a Chi-squared to identify significant variances in the behaviors.

The Chi-squared analysis from the study revealed significant differences in behavior. For example, 12.4% of the subjects did not wash their hands compared to the morning and afternoon rates, 8.6% and 9.4& respectively. A gender difference was revealed as women properly washed with soap at 77.9% while men were at 50.3%. A slight age divide was shown as well, those believed to be older than college-age (70.3%) rose above their younger counterparts (64.8%) The data suggests that despite studies that reinforce positive hand-washing behaviors, the general public is lax on these standards and deny its seriousness. Many factors contributed to hand-washing behaviors, but generally there was a small percentage of participants that practiced good hand hygiene. A gender bias was seen as women tended to wash their hands more consistently while men tended to fall short of such practices. The study conveys that hand-washing needs to be encouraged and more attention to restroom environments may assist in the consistency of hand-washing practices.

A randomized controlled trial to determine whether non-antibacterial soap is better at reducing bacteria of potential fecal origin than water only was conducted by Burton et al. in 2011. In this study, 20 volunteers contaminated their hands deliberately by touching door handles and railings in public spaces. They were then told at random to wash their hands with just water, to wash their hands with non-antibacterial soap, and not to wash their hands. Each volunteer underwent this procedure 24 times, yielding 480 samples overall. Bacteria of potential fecal origin, mostly Enterococcus and Enterobacter spp, were found after no hand-washing in 44% of samples. Hand-washing with water alone reduced the presence of bacteria to 23%. Hand-washing with plain soap and water reduced the presence of bacteria to 8%. The effect did not appear to depend on the bacteria species. Overall, hand-washing with water alone reduced the prevalence of bacteria substantially. Hand-washing with soap was more effective in reducing the prevalence of contamination and specifically of Enterococcus spp. There was a trend that hand-washing with soap was also more effective in reducing the prevalence of other species and of multiple isolates, but the statistical support was low. Hand-washing with non-antibacterial soap and water is more effective for the removal of bacteria of potential fecal origin from hands than hand-washing with water alone and should therefore be more useful for the prevention of transmission of diarrhoeal diseases.

The results demonstrate that hand-washing with non-antibacterial soap is much more effective in removing bacteria from hands than hand washing with water only. Although hand-washing with water alone reduced the presence of bacteria on hands substantially, the study supports the policy of hand hygiene campaigns promoting the use of soap. The strong association between hand hygiene method and bacterial contamination of hands found in the study suggests that the prevalence of fecal indicator bacteria may also be used to monitor changes in hygiene behavior in the general population. Hygiene behavior is difficult to measure because people tend to change their behavior while being observed, in social situations, and over-reporting desired practices. The study found that test results positive for bacteria of potential fecal origin were more common in people frequently shaking hands, reporting soil contact or those scoring low on a hygiene score based on self-report.

Overall, hand-washing is effective in removing bacterial presence, however, there is a severe lack in participation of practices. The effects of this is what cause illness to prevail in local, tight-knit communities. 

10 Jun 2021
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