ECJ EUROPEAN Cleaning Journal

Hand washing is something that most of us do several times a day without a second thought. But if more people around the world adopted this simple practice, it could save 650,000 lives a year according to hygiene experts. Ann Laffeaty finds out what makes soap and water such a magical formula.

Understanding the importance of hand washing with soap and water is by no means rocket science. But experts would have us believe that its role in our day-to-day lives is at least as important. Not only could it improve our health, they say, it could even save thousands of lives.

Arguments have raged over the years about the hygiene benefits of hand washing and the means required to carry it out successfully. In the 19th century when clean water was hard to come by, people were suspicious of water since it was associated with diseases such as typhoid. As a result, many people were unwilling to use it for hand washing.

In recent years there have been debates as to whether or not soap is a crucial factor in hand hygiene regimes, or if water alone is sufficient to reduce the bacterial load on the hands. Then there are further discussions over whether alcohol gels can take the place of soap, and whether hand drying with a towel is more hygienic than air dryers or vice-versa.

Admittedly, the arguments concerning the benefits and disadvantages of each different hand washing and drying method have generally depended on who was putting forward the argument. Manufacturers of soap, hand towels, warm air dryers and alcohol gels all have their own reasons for highlighting the benefits of their products. But according to independent speakers at a recent hand hygiene conference in London, hand washing with soap is the ultimate key to improved health and hygiene.

Delegates at the conference, which took the theme: ‘The science and behaviour behind hand washing at home, work and on the move’, were told that this simple practice could save 650,000 lives around the world each year. It could also help to prevent the spread of SARS, AIDS, cholera and pandemic flu and alleviate the effects of malnutrition, according to expert speakers.

Independent health and safety consultant Dr Lisa Ackerley told the conference that hand washing with soap could prevent the spread of respiratory illnesses including influenza which currently cause between a quarter and a half a million deaths worldwide each year. And she added that it could reduce the number of gastro-intestinal illnesses which are the cause of four per cent of deaths worldwide - most of them involving children aged five and under.

So how can soap and water alone provide such a magical formula? Dr Valerie Curtis, a reader in hygiene at the London School of Hygiene and Tropical Medicine, explained that soap provides an effective means of removing faecal matter from the hands after washroom visits.

Describing human faeces as: “perhaps the most dangerous substance known to man” she went on: “It gets into the water and the soil; it can be transmitted by flies and by people’s hands. It can also be passed on to a new host via food handled by unwashed fingers.”

She claimed that around 0.85 million deaths worldwide were caused by diarrhoea every year. “There are also between two and 3.5 billion episodes of diarrhoea every year,” she said. “The more often people have diarrhoea, the more likely they are to have a respiratory tract infection.This is a massive issue and one that we haven’t yet solved.”

No funding

According to Curtis, diarrhoea kills more children than AIDS, malaria and measles combined. “However, people don’t like to talk about it which means there is no funding,” she said. “International attention is not focused on diarrhoea or hand hygiene – it is focused on water treatment.”

She added that studies have shown the practice of hand washing using soap to be the best way of reducing the risks of diseases spread via human faeces. This was borne out by the results of a study into the effects of hand washing on child health in Karachi, Pakistan.

Emeritus professor of economics at the London School of Hygiene and Tropical Medicine Joy Townsend discussed the details of the study in which 25 squatter settlements were provided with plain soap. Hand hygiene was then promoted in these areas, whereas no soap nor hand hygiene training was provided in the 11 adjoining settlements.

“In the settlements where soap was given out there was a 50 per cent reduction in pneumonia among under-fives,” said Townsend. “There was also a 53 per cent reduction in diarrhoea in under 15s.”

Another successful outcome was recorded by global social mission manager of Unilever’s Lifebuoy brand Anita Gopal. Lifebuoy was founded 120 years ago in the fight against cholera, and it has now launched the Help a Child Reach Five campaign. This aims to prevent children in the developing world dying through poor hand hygiene-related diseases.

“The age of five is critical to a child’s survival,” said Gopal. “In parts of Pakistan people don’t even name their child until they have reached this milestone.”

Changing behaviour

Lifebuoy aims to save lives by changing the hygiene behaviour of one billion people by 2015. The company has ‘adopted’ the Indian village of Thesgora and has set up a School of Five campaign in the village. Children are provided with fun activities to encourage them to improve their hand hygiene habits and expectant mothers are advised to wash their hands before touching their babies. “This seeds the idea of hand  hygiene in antenatal check-ups,” said Gopal.

Clinical trials held by the company in Mumbai show that improved hand hygiene regimes can, indeed, pay off. School attendance in the Mumbai area rose by 40 per cent after hand hygiene programmes were instigated and cases of diarrhoea fell by 25 per cent, while respiratory infections were reduced by 15 per cent.

So hand washing with soap does seem to have a quantifiable impact on health. But what makes it such a magic formula? According to experts it is a relatively simple practice to promote and soap is also widely available, even in those communities where warm air dryers and clean towels are a rarity. And crucially, hand washing with soap coupled with hand hygiene promotion is financially viable.

According to economics professor Joy Townsend, United Nations studies have shown hand hygiene promotion to be the single most cost-effective health intervention with a price tag of only US$ 5 (four euros) a day. “Providing basic sanitation, on the other hand, costs between US$ 10 and 100 (between four and 80 euros) a day,” she said.

And a large-scale urban study carried out in Burkina Faso over a three-year period also showed the health and financial benefits of hand washing with soap. Hand hygiene was promoted in more than 7,000 households during the course of the trial in a bid to reduce cases of childhood diarrhoea. Over the three-year period an estimated 100 deaths and 8,638 cases of diarrhoea were averted, while the cost of implementing the scheme was only US$ 7.3 (5.9 euros) per household per year.

“Hand hygiene programmes are therefore financially feasible and implementation costs are low compared with the savings that can be made,” said Townsend.

Anita Gopal agreed that hand washing with soap was the most practical and achievable way to reduce the number of hand hygiene-related diseases. “Diarrhoea and pneumonia are the top two killers of children, and hand washing with soap is the most cost-effective method of preventing these deaths since around 99 per cent of households have access to soap in any case,” she said.

And this availability is key to the ‘magic formula’ of soap and water. If the right tools are easily accessible – and if people are persuaded to use them – lives can be saved. But another study quoted at the conference revealed that alcohol-based hand sanitisers can also have a positive effect on hygiene if they are also readily available and if people have a strong incentive to use them.

Strategically placed

In a study carried out at three Taiwan hospitals, alcohol-based hand sanitisers were placed at strategic points around the buildings and hand hygiene training was provided for staff. Hand washing reminders were placed near point of care and financial incentives were offered to those units that demonstrated outstanding performance. To make the argument for using the sanitisers even more persuasive, fines were threatened for compliance failure.

“As a result of the scheme we estimated that 1,424 episodes of healthcare-acquired infections had been averted and compliance had improved from 43.3 per cent in 2004 to 95.6 per cent in 2007,” said Joy Townsend.

The Taiwan hospital study also proved financially viable, she said. After the costs of hand sanitisers, posters and financial incentives had been paid, the net benefit of the trial was US$ 5,289 million (4,258 million euros).

So while soap and water were considered by speakers to be the best hand hygiene solution, the key to improved global health actually lay in persuading people to clean their hands in the first place.

Experts in turn considered ways in which people could be persuaded to improve their hand hygiene practices, and delegates were told that motivations for change greatly depended on the
target audience.

“It is crucial to find out what motivates people,” said Curtis. “In some cases, people are persuaded to improve their hand hygiene by motives such as disgust and a keenness to fit in. But in order to change their hand hygiene behaviour we need to find out what is preventing them from following good hand hygiene practices in the first place.”