Hand washing with soap

A pupil washing his hands with soap in ceremonial event for Global Handwashing Day 2008 in Jakarta, Indonesia

Handwashing with soap (HWWS) is among the most effective and inexpensive ways to prevent diarrheal diseases and pneumonia, which together are responsible for the majority of child deaths. This behavior is projected to become a significant contribution to meeting the Millennium Development Goal of reducing deaths among children under the age of five by two-thirds by 2015. October 15 has been appointed to become Global Handwashing Day in accordance with year 2008 as the International Year of Sanitation by the United Nations.

Hands often act as vectors that carry disease-causing pathogens from person to person, either through direct contact or indirectly via surfaces. Humans can spread bacteria by touching other people's hand, hair, nose, and face. Hands that have been in contact with human or animal feces, bodily fluids like nasal excretions, and contaminated foods or water can transport bacteria, viruses and parasites to unwitting hosts. Hand washing with soap works by interrupting the transmission of disease.

Washing hands with water alone is significantly less effective than washing hands with soap in terms of removing germs. Although using soap in hand washing breaks down the grease and dirt that carry most germs, using soap also means additional time consumed during the massaging, rubbing, and friction to dislodge them from fingertips, and between the fingers, in comparison with just using water for handwashing. Effective hand-washing with soap takes 8 – 15 seconds, followed by thorough rinsing with running water.

Disease prevention in handwashing with soap

Handwashing can prevent diarrheal disease (which can include shigellosis, typhoid and cholera), acute respiratory infections (including SARS and bird flu), helminth infections (especially ascariasis), and eye infections.

F- Diagram of disease transmission and control. Source: Wagner and Lanoix

In a research published by British Medical Journal on November 2007, physical barriers, such as regular handwashing and wearing masks, gloves and gowns, may be more effective than drugs to prevent the spread of respiratory viruses such as influenza and SARS. In the case of such respiratory diseases, washing your hands is especially important before touching your eyes, nose or mouth. The finding was published as Britain announced it was doubling its stockpile of antiviral medicines in preparation for any future flu pandemic. The researchers found that simple, low-cost physical measures should be given higher priority in national pandemic contingency plans. Other evidence suggests that the use of vaccines and antiviral drugs will be insufficient to interrupt the spread of influenza says the report. Handwashing and wearing masks, gloves and gowns were effective individually in preventing the spread of respiratory viruses, and were even more effective when combined. However, further trials needed to evaluate the best combinations. Another study, published in the Cochrane Library journal on 2007, finds handwashing with just soap and water to be a simple and effective way to curb the spread of respiratory viruses, from everyday cold viruses to deadly pandemic strains.

Other research conducted by the World Bank regarding health policy shows that health measures like hand washing with soap did not get enough promotion compared to the promotion of influenza drugs by medical staff. This was worse for people living in isolated locations who were difficult to reach by mass media (like radio and TV).

• Diarrheal disease. A review of more than 30 studies found that handwashing with soap cuts the incidence of diarrhea by nearly half. Diarrheal diseases are often described as water-related, as the pathogens come from fecal matter and make people ill when they enter the mouth via hands that have been contact with feces, contaminated drinking water, unwashed raw food, unwashed utensils or smears on clothes. Research shows handwashing with soap breaks the cycle and is effective in reducing diarrhea cases in comparison to other interventions. Reduction in diarrheal morbidity (%) per invention type shows that handwashing with soap (44%), point of use water treatment (39%), sanitation (32%), hygiene education (28%), water supply (25%), source water treatment (11%).
• Acute respiratory infection. Handwashing reduces respiratory infections by two ways: by removing respiratory pathogens that are found on hands and surfaces and by removing other pathogens (in particular, entreric viruses) that have been found to cause not only diarrhea, but also respiratory symptoms. A study in Pakistan found that handwashing with soap reduce the number of pneumonia-related infection in children under the age of five by more than 50 percent.
• Intestinal worm, skin infections, and eye infections. Hand washing with soap also reduces the incidence of skin diseases; eye infections like trachoma and intestinal worms, especially ascariasis and trichuriasis.

Critical times in hand washing with soap

Here are some critical times to clean your hands:

• Before and after meals and snacks
• Before caring for young children
• After touching a public surface
• Before and after preparing food, especially raw meat, poultry, or seafood
• After using the restroom
• When hands are dirty
• After touching animals
• When you or someone around you is ill

Awareness of hand washing with soap

Handwashing is likely to be especially important where people congregate (schools, offices), where ill or vulnerable people are concentrated (hospitals, nursing homes), where food is prepared and shared and in homes, especially where there are young children and vulnerable adults.

An ABC News report on low handwashing rates among physicians cited the book Freakonomics: "Studies have shown that hospital personnel wash or disinfect their hands fewer than half the times they should," Levitt and Dubner write. "And doctors are the worst offenders, more lax than either nurses or aides." In fact, one Australian study reported a hand washing compliance rate of only 9 percent. Medical personnel who fail in this regard continue to exhibit the same sort of general arrogance that dismissed the clear evidence presented by Ignaz Semmelweiss from 1847 onwards. Just as in Semmmelweiss' time, although it is clearly demonstrable that disease transmission can readily be prevented by hand washing with soap, medical practitioners often failed to do so because of lack of time, rough paper towels for drying, inconveniently located sinks and hands chapped by frequent washing with drying soaps. A handwashing campaign begun in New York City public hospitals has drastically reduced the number of serious infections, such as blood infections and pneumonia, contracted by hospital patients.

Around the world, the observed rates of handwashing with soap at critical moments range from zero percent to 34 percent. The belief that washing with water alone to remove visible dirt is sufficient to make hands clean is commonplace in most countries. In Ghana the drive to use soap for mothers was generally successful because it felt good to remove dirty matter from hands, refreshing, one way of caring for children, and enhancing their social status.

We could talk about germs until we were blue in the face, and it didn’t change behaviors

— Dr. Curtis (director of the Hygiene Center at the London School of Hygiene & Tropical Medicine),

Hand washing with soap around the world

Schoolchildren washing their hands before eating lunch

Pupils learning to wash their hands in front of the class as a show case in Medan, Indonesia

• In U.S. a study shows that one-third of men didn't bother to wash their hands after using the toilet, compared with 12 percent of women in public restrooms. The study was based on observations of more than 6,000 people in four big cities in 2007. Although in an interactive survey 92 percent of Americans said they usually or always wash their hands after using the bathroom, researchers for the American Society for Microbiology found that only 77 percent actually do, when it comes to public restrooms: a six percent decline from a similar study in 2005.
• In Ghana, people buy a lot of soap, yet almost all used it for cleaning clothes, washing dishes, and bathing. In a baseline study, 75 percent of mothers claimed to wash hands with soap after toilet use, but structured observation showed that only 3 percent did so, while 32 percent washed their hands with water only. On 2003 Dr. Val Curtis studied hundreds of mothers and their children; she discovered that previous health campaigns had failed because mothers often didn’t see symptoms like diarrhea as abnormal, but instead viewed them as a normal aspect of childhood. The studies also revealed an interesting paradox: Ghanaians used soap when they felt that their hands were dirty — after cooking with grease, for example, or after traveling into the city — and hand-washing habit was prompted by feelings of disgust and showed that parents felt deep concerns about exposing their children to anything disgusting. Commercials that began running in 2003 didn’t really sell soap use; they sold disgust instead. In one 55-second television commercial, soapy hand washing was shown only for 4 seconds with a clear message that toilet cues worries of contamination, disgust, and cues soap. The ad was a radical different approach from most public health campaigns because it didn't mention of sickness, just the "yuck" factor. By 2006, Ghanaians surveyed by members of Curtis’s team reported a 13 percent increase in the use of soap after the toilet. Another measure showed even greater impact: reported soap use before eating went up 41 percent.
• In Malawi an approach to handwashing with soap was done by UNICEF in honoring the right of children to participate in a process of developing and instituting national standards for sanitation facilities and hygiene promotion in primary schools. National review teams interviewed children on what they liked and disliked about their sanitation facilities and hygiene education programs. The children's candid and perceptive answers were used to modify the technical designs and approach to the behavior change. A comic book from the children's feedback was designed for grades five to eight. Since August 2008, a cheerful, animated character called ‘SOPO’ uses the slogan ‘Did You Wash Your Hands?’ to promote hand-washing with soap at four critical times: after defecation, after cleaning a child, before feeding a child and before preparing food. The proportion of women currently following these recommendations in Malawi is negligible. Paradoxically, Malawians have better access to safe water and soap than most others in Africa. Three-quarters of the population has access to piped water, a public tap, a borehole or a protected well or spring. A third of all households have soap or washing powder or liquid. Yet diarrhea continues to be a major cause of sickness and death among young children. On average, a Malawian child will experience six bouts of diarrhea a year, and 20 percent of deaths in infants and children under the age of five are due to diarrhea. The main causes are the use of contaminated water, as well as unhygienic practices in food preparation and excreta disposal.
• In Pakistan a study found that children in communities that received intensive handwashing interventions were half as likely to get diarrhea or pneumonia than children in similar communities that did not receive the intervention.
• In the United Kingdom, a study by researchers from the London School of Hygiene and Tropical Medicine found that over a quarter of people tested at bus and train stations had fecal bacteria on their hands. The study found more people with traces of fecal bacteria in the North of England than the South, and that manual workers had cleaner hands than other people tested.

See also

• Global Handwashing Day