What’s better, washing with soap and water and drying with paper towel, or using a sanitizer?

About 10 years ago the consensus was leaning toward sanitizers because of convenience and mobility. But new studies questioning the effectiveness of various sanitizers means handwashing has become fashionable yet again.

Are sanitizers better than nothing? Probably, in places like hospitals, but not so much on farms where organic matter – dirt and poop – rapidly reduce the effectiveness of sanitizers.

In the wake of an outbreak of cryptosporidium linked to a live lambing event in Wales that has sickened at least 13, the U.K. Health Protection Agency (HPA) has warned anyone who is visiting an open farm over the Easter weekend not to rely on sanitizing hand gels or wipes to protect themselves or their children against germs that may be present in animal dirt around the farm.

Although the risk of becoming unwell is very low in light of the millions of farm visits every year there are, on average, around three outbreaks of gastrointestinal disease which are linked to visits to petting farms. The route of infection in these outbreaks is generally through contact with germs from animal droppings. These germs can be ingested when people, especially children, put their fingers in their mouths.

To reduce the risk of illness, both adults and children should thoroughly wash their hands using soap and water after they have handled animals or touched surfaces at the farm and always before eating or drinking. Hand gels can't remove contamination in the manner that soap and water can.

Research published by the HPA of a review of 55 outbreaks of intestinal disease linked to petting farms between 1992 and 2009 showed that one of the risk factors associated with illness was the reliance on hand gels instead of handwashing. Over the 17 year period of the study, 1,328 people were reported to have fallen ill following a farm visit, of whom 113 were hospitalised. Illness ranged from mild through to severe diarrhoea and occasionally more serious conditions.

Over half of the 55 outbreaks in the study, 30 (55 per cent) were caused by E. coli O157 (VTEC O157) and a further 23 (42 per cent) were caused by cryptosporidium. The remaining two (three per cent) outbreaks were caused by a type of salmonella.
Other risk factors noted in the research are which have been linked to outbreaks include bottle feeding lambs and thumb sucking by children. The full research paper can be found in Emerging Infectious Diseases 2010 Gormley et al. 'Transmission of Cryptosporidium spp. at petting farms, England and Wales' http://www.cdc.gov/ncidod/eid/

Hand gels have their use in areas which are generally clean, for example offices or hospitals, but are not effective in killing bugs such as E. coli or cryptosporidium which can be found in animal droppings and on contaminated surfaces around farms.

Except there may be some BS in the cleanest offices.

The U.S. Food and Drug Administration (FDA) reported yesterday that some hand sanitizers and antiseptic products come with claims that they can prevent MRSA (methicillin-resistant Staphylococcus aureus) infections.

Don’t believe them. These statements are unproven, says FDA.

“Staphylococcus aureus itself is a very aggressive organism,” says Edward Cox, M.D., M.P.H., director of FDA’s Office of Antimicrobial Products. “It’s often associated with patients in hospitals who have weakened immune systems, but the bacterium can also cause significant skin infections and abscesses in a normal, healthy person. And it can get into the bloodstream and, less frequently, may involve the heart valve, which is very difficult to treat.”

But this antibiotic-resistant strain is even more difficult to treat. “With MRSA, a number of the antibiotic drugs we typically used often don’t work, so we lose treatment options we used to rely upon,” says Cox.

FDA is cracking down on companies that break federal law by promoting their products as preventing MRSA infections and other diseases without agency review and approval.

“Consumers are being misled if they think these products you can buy in a drug store or from other places will protect them from a potentially deadly infection,” says Deborah Autor, compliance director at FDA’s Center for Drug Evaluation and Research.

FDA wants consumers to watch out for unproven product claims, too—whether they buy a product from a retail store or through the Internet.

Examples of unproven claims found on product labels are
* kills over 99.9% of MRSA
* helps prevent skin infections caused by MRSA and other germs
* is effective against a broad spectrum of pathogens, including MRSA

One company claims that its hand sanitizing lotion prevents infection from the bacterium E. coli and the H1N1 flu virus. And another firm claims its “patented formulation of essential plant oils” kills the bacterium Salmonella. These claims are also unproven and, therefore, illegal.

“FDA has not approved any products claiming to prevent infection from MRSA, E. coli, Salmonella, or H1N1 flu, which a consumer can just walk into a store and buy” says Autor. “These products give consumers a false sense of protection.”

Whenever there’s an outbreak of norovirus or some other tummy upset that forces large numbers of students to call in sick, check the bathrooms.

Are the tools for proper handwashing – running water, soap and paper towel – actually available?

And while a report titled, A Response to School Toilets: Best Practice Guidance for Primary and Secondary Schools in Wales, may not make exciting bathroom reading, continual attention to hygiene basics consistently reduces the numbers of people barfing.

Consumer Focus Wales (CFW) made the same point today, arguing that children face an increased risk of contracting and spreading deadly bugs because councils will not be forced to check school toilet hygiene.

As part of the South Wales E.coli public inquiry, Professor Hugh Pennington recommended that every council should have a program of audits to ensure all schools have adequate toilet and handwashing facilities.

Jennie Bibbings, CFW’s senior policy advocate, said: “In the current financial climate school toilets might be a low priority but hygiene standards could suffer and the risk of illness among school children increases.

The public inquiry into the 2005 E. coli O157 outbreak in South Wales heard shocking evidence about the state of school toilets. In some of the schools in the outbreak area there was no running hot water or even soap for children to wash their hands.

Peter Clarke, Wales’ first Children’s Commissioner, had highlighted concerns about the lack of soap and toilet paper in some schools in 2004 – a year before butcher William Tudor caused the E.coli O157 outbreak.

And his successor Mr Towler again highlighted the sub-standard facilities in his third annual report last year.

“Currently I’m seeing inequality across the country with some schools having made considerable improvement while other pupils feel so strongly about it they refuse to use the toilet during the school day.”

Consumer Focus Wales said it should also include standards for staff facilities because successive food hygiene inspection reports have revealed variable performance among school canteens in the provision of hand washing facilities.”

I’m confused with these conflicting handwashing studies.

And, as Les Nessman of WKRP in Cinncinatti said, when I get confused, I watch television. It somehow makes things simple. Television is never confusing.

This morning it was alcohol-based sanitizers didn’t do much to limit the spread of the H1N1 virus, but worked well against cold viruses (the sanitizers also sorta suck against norovirus).

Later today, it was the results of another of those creepy make-grad-students-hang –out-in-public-bathrooms studies, to see if people actually wash their hands, which found that 85 per cent of adults washed their hands in public restrooms, the highest number since the studies began in 1996.

But it's a far cry from the 96% of adults who say they always wash their hands in public restrooms, based on a separate telephone survey conducted at the same time.

Men do a lot worse than women overall — just 77% scrubbed up, compared with 93% of women.

The study was sponsored by the American Society for Microbiology and the American Cleaning Institute (formerly the Soap and Detergent Association). It involved discreetly observing 6,028 adults in public restrooms in August to see whether they washed their hands.

Great. More people are attempting to wash their hands. But are they doing it correctly? Does any attempt count, or only if handwashing is done according to government prescriptions. What is the best way to wash hands? Can’t people with PhDs agree?

No.

A study by researchers at the University of Bradford and published in the current Journal of Applied Microbiology evaluated three kinds of hand drying and their effect on transfer of bacteria from the hands to other surfaces: paper towels, traditional hand dryers, which rely on evaporation, and a new model of hand dryer, which rapidly strips water off the hands using high velocity air jets.



In this study the researchers quantified the effects of hand drying by measuring the number of bacteria on different parts of the hands before and after different drying methods. Volunteers were asked to wash their hands and place them onto contact plates that were then incubated to measure bacterial growth. The volunteers were then asked to dry their hands using either hand towels or one of three hand dryers, with or without rubbing their hands together, and levels of bacteria were re-measured.

The researchers found the most effective way of keeping bacterial counts low, when drying hands, was using paper towels. Amongst the electric dryers, the model that rapidly stripped the moisture off the hands was best for reducing transfer of bacteria to other surfaces.

Yet tomorrow’s N.Y. Times reports it’s a draw, and that “the best available evidence suggests that as far as germs go, the method of drying is less important than the amount of time invested: the longer the better.”

So my pants would be fine as long as I used them enough.

Dr. O. Peter Snyder at the St. Paul-based Hospitality Institute of Technology and Management summarized key aspects of handwashing and drying in a paper available at, http://www.hi-tm.com/Documents/Safehands.html. Snyder says that after hands are washed and rinsed, they must be thoroughly dried.

Blow dryers should not be used because they accumulate microorganisms from toilet aerosols, and can cause contamination of hands as they are dried by the drier (Knights, et al., 1993; Redway,et al., 1994).

Snyder notes that it is also apparent that many individuals do not dry their hands thoroughly when using a blow drier; hence, moisture, which is conducive to microbial growth, remains on hands, or people dry their hands on their clothing.

Proper handwashing requires access to the proper tools – and that means vigorously running water, soap and paper towel.

We’ve reviewed the literature on handwashing and how best to motivate people to wash hands, and conclude in a paper to be published shortly that,

“Although the role of hand hygiene in preventing infectious disease is well recognized, studies repeatedly show that compliance remains low. … Education and training have been cited often as essential to developing and maintaining hand hygiene compliance but, with few exceptions, this approach has not produced sustained improvement. … Hand hygiene was enhanced by provoking emotive sensations of discomfort, unpleasantness and disgust. Evidence suggests handwashing is a ritualized behavior mainly carried out as self-protection from infection and that patterns of handwashing behavior are likely established in childhood. Therefore, interventions that focus on culture, perception and behavior change may prove to be the most successful. How that success is measured must be carefully considered, as there is no standardized method for measuring hand hygiene compliance and current techniques have significant limitations.”
 

“Hot water for handwashing has not been proved to remove germs better than cold water.”

That’s the conclusion of The Claim column in tomorrow’s N.Y. Times science section.

We’ve been saying for a couple of years that water temperature is not a critical factor -- water hot enough to kill dangerous bacteria and viruses would scald hands -- so use whatever is comfortable. Warmer water may be better at removing oils and stuff, but not the things that make people sick.

The Times story says,

In its medical literature, the Food and Drug Administration states that hot water comfortable enough for washing hands is not hot enough to kill bacteria, but is more effective than cold water because it removes oils from the hand that can harbor bacteria.

But in a 2005 report in the Journal of Occupational and Environmental Medicine, scientists with the Joint Bank Group/Fund Health Services Department pointed out that in studies in which subjects had their hands contaminated, and then were instructed to wash and rinse with soap for 25 seconds using water with temperatures ranging from 40 degrees Fahrenheit to 120 degrees, the various temperatures had “no effect on transient or resident bacterial reduction.”

They found no evidence that hot water had any benefit, and noted that it might increase the “irritant capacity” of some soaps, causing contact dermatitis.

“Temperature of water used for hand washing should not be guided by antibacterial effects but comfort,” they wrote, “which is in the tepid to warm temperature range. The usage of tepid water instead of hot water also has economic benefits.”