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The Effect of Handwashing with Water or Soap on Bacterial Contamination of Hands

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Handwashing is thought to be effective for the prevention of transmission of diarrhoea pathogens. However it is not conclusive that handwashing with soap is more effective at reducing contamination with bacteria associated with diarrhoea than using water only. In this study 20 volunteers contaminated their hands deliberately by touching door handles and railings in public spaces. They were then allocated at random to (1) handwashing with water, (2) handwashing with non-antibacterial soap and (3) no handwashing. Each volunteer underwent this procedure 24 times, yielding 480 samples overall. Bacteria of potential faecal origin (mostly Enterococcus and Enterobacter spp.) were found after no handwashing in 44% of samples. Handwashing with water alone reduced the presence of bacteria to 23% (p < 0.001). Handwashing with plain soap and water reduced the presence of bacteria to 8% (comparison of both handwashing arms: p < 0.001). The effect did not appear to depend on the bacteria species. Handwashing with non-antibacterial soap and water is more effective for the removal of bacteria of potential faecal origin from hands than handwashing with water alone and should therefore be more useful for the prevention of transmission of diarrhoeal diseases.
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Int. J. Environ. Res. Public Health 2011, 8, 97-104; doi:10.3390/ijerph8010097
International Journal of
Environmental Research and
Public Health
ISSN 1660-4601
www.mdpi.com/journal/ijerph
Article
The Effect of Handwashing with Water or Soap on Bacterial
Contamination of Hands
Maxine Burton, Emma Cobb, Peter Donachie, Gaby Judah, Val Curtis and
Wolf-Peter Schmidt *
Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine,
Keppel Street, London, WC1E 7HT, UK; E-Mails: m_burton5@hotmail.com (M.B.);
Emma.Cobb@lshtm.ac.uk (E.C.); Peter.Donachie@lshtm.ac.uk (P.D.); Gaby.Judah@lshtm.ac.uk
(G.J.); Val.Curtis@lshtm.ac.uk (V.C.)
* Author to whom correspondence should be addressed; E-Mail: Wolf-Peter.Schmidt@lshtm.ac.uk;
Tel.: +44-20-7927-2461; Fax: +44-20-7636-7843.
Received: 24 November 2010; in revised form: 30 December 2010 / Accepted: 31 December 2010 /
Published: 6 January 2011
Abstract: Handwashing is thought to be effective for the prevention of transmission of
diarrhoea pathogens. However it is not conclusive that handwashing with soap is more
effective at reducing contamination with bacteria associated with diarrhoea than using
water only. In this study 20 volunteers contaminated their hands deliberately by touching
door handles and railings in public spaces. They were then allocated at random to
(1) handwashing with water, (2) handwashing with non-antibacterial soap and (3) no
handwashing. Each volunteer underwent this procedure 24 times, yielding 480 samples
overall. Bacteria of potential faecal origin (mostly Enterococcus and Enterobacter spp.)
were found after no handwashing in 44% of samples. Handwashing with water alone
reduced the presence of bacteria to 23% (p < 0.001). Handwashing with plain soap and
water reduced the presence of bacteria to 8% (comparison of both handwashing arms:
p < 0.001). The effect did not appear to depend on the bacteria species. Handwashing with
non-antibacterial soap and water is more effective for the removal of bacteria of potential
faecal origin from hands than handwashing with water alone and should therefore be more
useful for the prevention of transmission of diarrhoeal diseases.
Keywords: hygiene; trial; infection
OPEN ACCESS
Int. J. Environ. Res. Public Health 2011, 8
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1. Introduction
Diarrhoeal diseases are one of the leading causes of child death around the world [1]. The World
Health Organisation (WHO) recognises the spread of diarrhoeal diseases as a serious global
problem [2] and estimates that each year, there are more than 2.2 million lives lost due to these
infections, more than from malaria, HIV/AIDS and measles combined [1]. The majority of these
deaths are in children under 5 years of age [3]. It has been suggested that handwashing may
substantially reduce the risk of diarrhoeal diseases [4].
Promotion of improved hand hygiene has been recognised as an important public health measure
but it is unclear how much hand hygiene is required to interrupt transmission of diarrhoea pathogens.
In particular it has not been conclusively shown whether use of soap is essential to remove pathogens
from hands. Recent hygiene promotion campaigns especially in low income settings have not been
unanimous in recommending soap use [4].
A number of studies have compared different hand hygiene methods in hospital settings [5]. In
contrast, few studies have been published on the effect of hand hygiene on bacterial contamination of
hands in the community. Hoque and colleagues found that a wide variety of hand cleansing means in
poor settings (soap, ash, mud) are effective in reducing the contamination with coliform bacteria on
hands [6,7]. In a small randomised trial the same author reported that soap may be more effective than
water in reducing the presence of coliform bacteria on hands [6].
Luby and colleagues found that a simple microbiological method with three fingers directly
imprinting a MacConkey agar for thermotolerant coliforms was unable to distinguish between
households who were given soap during a large randomized handwashing trial and control households
[8]. They concluded that the method was unsuitable for the evaluation of handwashing practices.
However, the lack of difference in bacterial contamination may have been due to lack of compliance
with the intervention. We thought that a proof-of-principle trial was needed where participants would
be given specific tasks to contaminate their hands in a naturalistic setting and where handwashing was
done under supervision.
We conducted a randomised controlled trial to determine whether non-antibacterial soap is better at
reducing bacteria of potential faecal origin than water only. A further goal was to clarify whether a
simple microbiological test that can be applied to large groups in a relatively short time [9,10] would
be able to distinguish people who practice handwashing from those who don’t.
2. Experimental Section
This study was carried out between July and August 2009. Overall, 20 volunteers were taken to a
large, frequently visited British museum, or asked to travel on a bus or the underground. They were
asked to deliberately wipe their hands over hand contact surfaces such as handrails, door handles and
seats with the aim of contaminating their hands with whatever bacteria were present. Using a
pre-determined random sequence, not known to the participants during self-contamination, participants
were then asked to wash their hands with soap, to use water only or not to wash at all. Each volunteer
underwent this sequence 24 times, 8 times for each of the three hand hygiene approaches (soap, water,
no handwash). Participants assigned to handwashing were asked to wash their hands as they would
Int. J. Environ. Res. Public Health 2011, 8
99
normally do, without instructions on length of time or thoroughness. The volunteers allocated to
handwashing were then provided with a paper towel to dry their hands. A wet NaCl-soaked charcoal
swab was then wiped across the fingers of the dominant hand of the participant. The participants were
finally given an alcohol gel to clean their hands (78% total alcohol content, Ethanol 71% / Propanol
29%, Softalind Viscorub, Braun-Melsungen). The swabs were returned to the laboratory within
5 hours of being taken. In total, 480 samples were collected; 160 after handwashing with plain soap,
160 after handwashing with water alone and 160 with no handwashing. During the experimental phase
we measured the amount of time taken to conduct handwashing with and without soap, once for
each volunteer.
Upon arrival at the laboratory the swabs were immediately cut into a universal tube containing
10 mL of Purple MacConkey broth using aseptic techniques. The swabs were incubated at 35 °C
for 48 hours. All samples were then streaked onto the MacConkey agar No.3 and Bile Aesculin agar.
MacConkey agar No. 3 is a selective media which can differentiate between coliforms and non-lactose
fermenters, whilst inhibiting gram-positive cocci. These plates were incubated for 18–24 hours
at 35 °C. For all other colonies produced on MacConkey agar No. 3 and those which were spot indole
negative, a gram stain, catalase and oxidase test was carried out followed by an API 20E biochemical
test to determine the identity of the bacteria. Bile Aesculin agar is a differential medium for the
isolation of Enterococcus spp. and group D Streptococcus and inhibition of other gram positive
bacteria. These plates were incubated at 37 °C for 18–24 hours. Enterococcus and Group D
Streptococcus spp. are able to hydrolyse the aesculin to form aesculetin, producing a brown/black
complex. Any white colonies on Bile Aesculin agar were presumed to be Staphylococcus spp. and any
black colonies were tested with Lancefield group D antisera. Agglutination indicated a positive result
for Enterococcus spp.
The prevalence of bacterial contamination in the three study arms (soap, water, no handwash) was
compared using logistic regression. Since the same volunteers repeatedly underwent testing,
within-subject correlation was accounted for by the use of generalised estimating equations (GEE)
with robust standard errors. If the cell numbers were too low for conducting regression analysis,
Fishers exact test was used instead, ignoring clustering (the design effect was found to be low,
see results).
3. Results and Discussion
Table 1 shows the different organisms isolated in the three study arms. Enterococcus spp. were the
most common bacteria found, followed by Enterobacter spp. Figure 1 shows the effect of
handwashing with soap or water only on contamination, compared to no handwashing. Overall,
handwashing with water alone reduced the prevalence of bacteria substantially. Handwashing with
soap was more effective in reducing the prevalence of contamination and specifically of Enterococcus
spp. There was a trend that handwashing with soap was also more effective in reducing the prevalence
of other species and of multiple isolates, but the statistical support was low (Figure 1).
Int. J. Environ. Res. Public Health 2011, 8
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Table 1. Organisms found after self-contamination of hands, and handwashing with either
soap, water only, or no handwashing.
Faecal Bacteria No Handwashing Water only Soap and water
Enterococcus spp. 46 (29%) 24 (15%) 4 (3%)
Enterobacter amnigenus 14 (9%) 4 (3%) 4 (3%)
Enterobacter cloacae 13 (8%) 5 (3%) 2 (1%)
Shigella spp. 2 (1%) 1 (1%) 0 (0%)
Klebsiella spp. 5 (3%) 2 (1%) 1 (1%)
E. coli spp. 0 (0%) 0 (0%) 1 (1%)
Pantoea spp. 0 (0%) 2 (1%) 1 (1%)
Multiple isolations 10 (6%) 2 (1%) 0 (0%)
Any bacteria 70 (44%) 36 (23%) 13 (8%)
Total 160 (100%) 160 (100%) 160 (100%)
The effect of repeated measurements in the same individual was low: the design effect (the factor
by which a sample size needs to be increased to achieve the same statistical power as an unclustered
study) ranged from 1.2 to 1.3 (depending on the comparison group).
Participants were asked to wash their hands as long and as thorough as they would normally do.
The length of time required to carry out handwashing was measured once for each method in all
volunteers. Participants took on average 12 seconds (standard deviation 2.8) to wash their hands with
water alone, and 14 seconds (standard deviation 2.3) to wash their hands with water and soap
(p = 0.02).
Thus, handwashing with soap took them only slightly longer than handwashing with water alone. It
seems unlikely that this small difference can explain the large difference in the removal of bacteria.
Soap on its own appears to have an effect on the removal of bacteria of potential faecal origin,
independent of the possibility that soap use may cause people to wash their hands longer.
Unlike the study by Hoque and colleagues our trial was conducted in an experimental (albeit
naturalistic) setting, where volunteers deliberately contaminated their hands. Additional testing
showed that this approach increased the prevalence of contamination from around 10% to over 40% of
individuals. It also improved control over the conduct of the experiment, but may affect
generalisability, as the study primarily aimed at providing a proof of principle. However, we believe
that the superior effect of soap on the removal of bacteria compared to water alone as the principal
finding of our study is unlikely to depend on the setting.
Not all of the bacteria isolated in our study are known to cause disease in humans. Surprisingly, we
found few E. coli on hands which may be due to their short survival time in the environment. Overall,
the effect of soap appeared to be independent of the type of bacteria (Figure 1), a view which is
supported by the study by Hoque and colleagues who found a similar effect of hand hygiene on
unspecified faecal coliform bacteria [6]. However, the power of our study to detect differences
between species was low.
Int. J. Environ. Res. Public Health 2011, 8
101
Figure 1. Effect of handwashing with water alone or soap and water compared to no
handwashing. P-values derived from logistic regression adjusted for within-person
correlation, except * where p-value was derived from Fishers exact test ignoring
within-person correlation. The design effect due to within-person clustering was low
(around 1.2–1.3). Note different y-axis scales in top vs. bottom panels.
44%
23%
8%
0%
10%
20%
30%
40%
50%
NoHandwashing Wateronly Soapandwater
Allorganisms
p< 0.001
p< 0. 001
p< 0.001
29%
15%
3%
0%
10%
20%
30%
40%
50%
NoHand washin g Wate ronly Soapandwater
Enterococcusspp
p< 0. 001
p= 0.008
p= 0.001
9%
6%
0%
10%
20%
NoHandwashing Wateronly Soapandwater
nonEnterococcusspp
p= 0.001
p= 0. 003
p= 0.24
6%
1% 0%
0%
10%
20%
NoHand washin g Wate ronly Soapandwater
multiple isolations
p= 0. 002*
p= 0.022
p= 0.50*
We used plain non-antibacterial soap for the experiment. Future studies could address whether
antibacterial soap is more effective in removing pathogens from hands. However, Luby and colleagues
conducted a large double-blind randomised trial in Pakistan and found antibacterial soap no more
effective in reducing diarrhoea than normal soap [11]. It is still not clear whether or in what
circumstances anti-bacterial soaps offer a health advantage [12].
The bacteriological methods used in this study provide no quantification of bacterial load, unlike a
study by Hoque and colleagues [7]. Quantifying the effect of different hand washing procedures on
bacterial load may be particularly helpful for studies in poor settings with poor sanitation facilities,
where the environmental contamination with faecal organisms is much higher [13-15]. We also tested
a semi-quantitative finger-print method used previously in Thailand [15] not unsimilar to the method
used by Luby and colleagues [8] but found that contamination levels were too low to provide
consistent results. Therefore we decided to use a qualitative method.
Int. J. Environ. Res. Public Health 2011, 8
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It seems reasonable to assume that handwashing with soap is also more effective in reducing
bacterial load compared to water alone. Future studies could address the effect of different hand
hygiene procedures on removing gastro-intestinal or respiratory viruses such as influenza A. Hands
have been implicated especially in the spread of Norovirus [16]. Viral studies are more difficult to
conduct as viruses may not be as present in the environment as often as are bacteria of faecal origin,
but they may be possible for example if patients with laboratory confirmed infection are recruited as
volunteers. Alternatively, healthy volunteers may experimentally contaminate their hands with
cultured viruses before undergoing different hand hygiene regimes, as was done in a recent study on
influenza A H1N1 [17]. This study found that handwashing with soap was better at removing influenza
A H1N1 than several hand sanitizers. Handwashing with water alone was not tested.
4. Conclusions
The results demonstrate that handwashing with non-antibacterial soap is much more effective in
removing bacteria from hands than handwashing with water only. Although handwashing with water
alone reduced the presence of bacteria on hands substantially, the study supports the policy of many
current hand hygiene campaigns promoting the use of soap [18,19]. The strong association between
hand hygiene method and bacterial contamination of hands found in our study suggests that the
prevalence of faecal indicator bacteria may also be used to monitor changes in hygiene behaviour in
the general population, for example following hygiene promotion campaigns.
Hygiene behaviour is difficult to measure because people tend to change their behaviour under
observation or over-report desired practices [15,20]. We have previously shown that our test kit can be
used to study associations between hygiene relevant behaviours and hand contamination [9]. We found
that test results positive for bacteria of potential faecal origin were more common in people frequently
shaking hands, reporting soil contact or those scoring low on a hygiene score based on self-report [9].
The microbiological method used in this and our earlier studies [9,10] is relatively simple and of low
cost (around $3.80). Its suitability for large scale use in the evaluation of handwashing campaigns in
low income settings where handwashing should be most beneficial remains to be investigated. A
sophisticated laboratory infrastructure may not be required to conduct testing. However, modifying the
method to allow semi-quantitative or quantitative analysis may be necessary if contamination rates are
high [15].
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distributed under the terms and conditions of the Creative Commons Attribution license
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... The hand is the extremity of the superior 6 limb, hence, serves as a medium for the transfer of microorganisms from one location to the other and from one person to another. Close environments, doorknobs and other inanimate objects serving as resting vehicles of transmission all contribute to increased infection rates among these groups (Dodrill et al., 2011). ...
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A social marketing approach used both qualitative and quantitative methods to develop a hygiene behaviour intervention in rural north-east Thailand. Behaviours were preselected from a previous study and the intervention was designed to promote hand washing, especially before feeding a baby, cooking, eating, and after defaecation or cleaning a baby's bottom, and dish washing immediately after eating. A bacteriological indicator (enumerating faecal streptococci using a finger impression technique) was developed to measure changes in hand washing behaviour and observation (spot checks) of dirty dishes to indicate dish washing practice. There was a significant improvement in both behaviours and a significant reduction in diarrhoeal disease as a result of the intervention. Furthermore, both indicators were retrospectively found to be positively related to diarrhoeal disease incidence. However, receiving and being able to recall the intervention messages was not necessarily sufficient to ensure behaviour change, as some adults found it difficult to change old habits. Villages showing the greatest improvement tended to have a stronger sense of community than others and to have more people actively involved in the intervention.
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OBJECTIVE: The major objective of this study is to provide estimates of diarrhoea mortality at country, regional and global level by employing the Child Health Epidemiology Reference Group (CHERG) standard. METHODS: A systematic and comprehensive literature review was undertaken of all studies published since 1980 reporting under-5 diarrhoea mortality. Information was collected on characteristics of each study and its population. A regression model was used to relate these characteristics to proportional mortality from diarrhoea and to predict its distribution in national populations. FINDINGS: Global deaths from diarrhoea of children aged less than 5 years were estimated at 1.87 million (95% confidence interval, CI: 1.56-2.19), approximately 19% of total child deaths. WHO African and South-East Asia Regions combined contain 78% (1.46 million) of all diarrhoea deaths occurring among children in the developing world; 73% of these deaths are concentrated in just 15 developing countries. CONCLUSION: Planning and evaluation of interventions to control diarrhoea deaths and to reduce under-5 mortality is obstructed by the lack of a system that regularly generates cause-of-death information. The methods used here provide country-level estimates that constitute alternative information for planning in settings without adequate data.
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Inadequate handwashing after defecation and anal cleaning practices in the Indian subcontinent is an important source of faeco-oral transmission of enteric diseases. To better understand the process as traditionally practised, 90 women in semi-rural Bangladesh were observed washing hands after defecation. Several components of handwashing practices were identified: the cleaning agent, using left or both hands; frequency of rubbing hands, type and amount of water used to wash, and the drying of hands on the wearer's clothes. A subsequent experiment was conducted to assess the effect of currently practised handwashing and drying according to standardised procedure on faecal coliform count of hands.As a rubbing agent, soil was commonly used (40%); soap was used by 19% and was reported unaffordable by about 81% of the non-users. Good handwashing behaviour was positively associated with better social and economic indicators including education of the women observed. Both hands were unacceptably contaminated after traditional handwashing (the geometric mean count of left was 1,995 and right hand was 1,318 faecal coliform units/hand). After standardising the observed components of handwashing procedures the use of any rubbing agent, i.e. soil, ash or soap, produced similar acceptable cleaning. Use of a rubbing agent (e.g. soil, ash or soap), more rubbing (i.e. six times), rinsing with safer water (e.g. 2 litres of tubewell water) and drying with a clean cloth or in the air produced acceptable bacteriological results. Components of traditional handwashing practices were defined through careful observation, and experiments on handwashing with standardised components showed that efficient and affordable options for handwashing can be developed; this knowledge should be helpful in disease control programmes.
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The efficacy of handwashing using ash, soap, mud or plain water was tested in a group of 20 women living in a slum of Dhaka in Bangladesh. Each woman was asked to wash her hands using each of the washing agents and the efficacy of handwashing was assessed by comparing estimated faecal coliform counts from post-washing hand samples. Mud and ash were found to be as efficient as soap. Research on appropriate handwashing techniques in the light of the existing practices is suggested.
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Handwashing has been universally promoted for health interventions, but it is essential that the factors related to behaviour are understood in order to develop appropriate handwashing messages. We found the study of behaviour complex and had to combine several methods: in-depth interviewing, questionnaire; observational and bacteriological. Here we present our experiences in developing efficient handwashing options for rural Bangladesh. The components of handwashing practices after defecation of 90 rural women were studied (phase 1). During phase 1 an in-depth interview was used to design the observational and questionnaire surveys. Behaviour was observed using a semi-structured record form and the effectiveness of the acts was measured by means of bacteriological tests. A questionnaire survey was undertaken on socioeconomic and water sanitation-related variables since they influence behaviour. Then, to develop efficient handwashing options, an experimental phase (phase 2) tested the bacteriological efficacy of the components found appropriate in phase 1. The effectiveness of the handwashing practices is believed to be poor since the bacteriological counts were found to be high (faecal coliform count of the left hand 1995, and of the right hand 1318 colony forming units/hand). The practice comprised several components: use of an agent, handedness, frequency of rubbing, source and volume of rinsing water, and drying of the hands. Seventy-five per cent of the women reported that they could not afford soap. The experimental trials showed that soap, ash and soil give similar results under similar conditions of handwashing (faecal coliform counts of left hands: 195 (soap), 98 (ash), 129 (soil) and of right: 112 (soap), 54 (ash) and 89 (soil) cfu/hand). The use of multi-method techniques in the study helped to understand and develop efficient handwashing options.