Handwashing
Keeping hands clean is one of the most important steps we can take to avoid getting sick and spreading germs to others. Many diseases and conditions are spread from person to person by not washing hands with soap and clean, running water.
Although handwashing with soap and water has been a sign of personal hygiene for centuries, the link between handwashing and disease prevention wasn't established until the 1800s. In ancient times, washing hands before and after meals was a sign of good manners and social status. However, early hospitals had little understanding of hygiene, and the mortality rate for patients was three to five times higher than those cared for at home.26
Hospitals then had little idea of the significance of hygiene; thus, they were often mocked as disease-producing incubators or as “houses of death.” Many of the ill and dying were kept in wards with no ventilation or access to clean water; hospitals were found to offer only the most basic care. Doctors did not routinely wash their hands until the mid-1800s, and they would proceed straight from dissecting a corpse to delivering a baby, providing the basis for the spread of puerperal fever (postpartum infection). Despite advances in modern medicine, healthcare providers still face the issue of infection outbreaks caused by patient care. While the body of scientific data supporting hand hygiene as the key strategy to prevent the spread of pathogens is substantial, we highlight that achieving this crucial, long-awaited breakthrough was a hard task throughout history.27
The significance of hand washing in patient care was conceptualized in the early 19th century. Antoine Germain Labarraque (28 March 1777 – 9 December 1850) was a French chemist and pharmacist, notable for formulating and finding important uses for Eau de Labarraque or Labarraque's solution, a solution of sodium hypochlorite widely used as a disinfectant and deodorizer. Labarraque provided the first evidence that hand decontamination can markedly reduce the incidence of puerperal fever and maternal mortality.
Ignaz Semmelweis, a Hungarian doctor working at Vienna General Hospital, is known as the father of hand hygiene. In 1846, he noticed something about the two maternity clinics in his hospital, which had an alternate-day admission policy. The first clinic was attended by medical students and doctors, who moved straight from autopsy rooms to the maternity ward and had an average maternal mortality rate due to puerperal fever of about 10 percent.28
The women in his hospital were much more likely to develop a fever and die compared to the women giving birth in the adjacent midwife-run maternity ward. He decided to investigate, seeking differences between the two wards. Based on this observation, he developed a theory that those performing autopsies got ‘cadaverous particles’ on their hands, which they then carried from the autopsy room into the maternity ward. Midwives did not conduct surgery or autopsies, so they were not exposed to these particles.
As a result, Semmelweis imposed a new rule mandating handwashing with chlorine for doctors. The rates of death in his maternity ward fell dramatically. This was the first proof that cleansing hands could prevent infection. However, the innovation was not popular with everyone: some doctors were disgruntled that Semmelweis was implying that they were to blame for the deaths and they stopped washing their hands, arguing in support of the prevailing notion at that time that water was the potential cause of disease. Semmelweis tried to persuade other doctors in European hospitals of the benefits of handwashing but to no avail.29
A few years later in Scutari, Italy, the Crimean War brought about a new handwashing champion, Florence Nightingale. At a time when most people believed that infections were caused by foul odors called miasmas, Florence Nightingale implemented handwashing and other hygiene practices in the war hospital in which she worked. While the target of these practices was to fight the miasmas, Nightingale’s handwashing practices resulted in a reduction in infections.30
Florence Nightingale (1820–1910), known as the The Lady with the Lamp, should also be credited with recognizing the need for excellent cleanliness. She was the driving force behind the mid-nineteenth century hospital reform movement. She rose to fame because of her contributions to the Crimean War (1853–1856). At that time, it was customary for two soldiers to die of sickness for every soldier killed on the battlefield, from illnesses like dysentery, diarrhea, typhoid, and malaria. Soldiers from small, secluded rural communities who had never experienced general childhood diseases such as measles and mumps compounded the issue. They lacked immunity to these dangerous, debilitating, and deadly illnesses. The overcrowded and unclean circumstances in the hospital increased outbreaks of these illnesses. Florence Nightingale's humanitarian endeavor during the war was a great success, and she was able to persuade the world of the importance of increasing hygiene and sanitation. She began to professionally train nurses to care for patients in hospital wards. Nightingale urged nurses to wash their hands and faces regularly throughout the day, demonstrating a long-standing appreciation for the effectiveness of hand hygiene. By the time she returned to her home country of England, she was a national hero.31
The hand hygiene practices promoted by Semmelweis and Nightingale were not widely adopted. In general, handwashing promotion stood still until the 1980s, when a string of foodborne outbreaks and healthcare-associated infections led to public concern that the United States Centers for Disease Control and Prevention identified hand hygiene as an important way to prevent the spread of infection. In doing so, they heralded the first nationally endorsed hand hygiene guidelines, and many more have followed.32
Handwashing vs. Hand Sanitizer
As we know, our hands can be a critical vector in transmitting infectious organisms. Infectious viruses can live on surfaces for several days and are easily transferred between surfaces to hands upon contact.
Good hand hygiene is a simple preventative strategy that most people can easily do. When we touch our face, the infectious pathogens can now enter the body through mucus membranes in our mouths, eyes, and nose, and travel to the throat and lungs. Given that the average person touches their face approximately 20 times per hour and is particularly likely to rub their nose or eyes, it is clear why hand hygiene is a useful method to help prevent illness, including COVID-19.33
Many studies have shown the effectiveness of hand hygiene in preventing the transmission of infectious pathogens, including respiratory diseases. There are options for good and reliable hand hygiene products, the most obvious being soap and hand sanitizer.
Soap is an amphiphile, meaning it is a chemical compound possessing both water-loving and fat-repelling (hydrophilic) and fat-loving, water-repelling (lipophilic) properties. Public health systems across the globe recommend thorough handwashing with soap and water as the first defense against disease transmission. In the specific case of COVID, soap dissolves the lipid membrane surrounding the coronavirus particle, causing the virus to fall apart and die before it can enter a host cell and replicate. Handwashing with soap also dislodges dead microbes and viral cells from the hands and washes them down the drain. This reduces the likelihood of infection by touching your face and reduces the possibility of cross-contamination of surfaces.34
In 1966, a student nurse in Bakersfield, California named Lupe Hernandez first dreamed up the idea of hand sanitizer. The story goes that Hernandez realized alcohol delivered through a gel could clean hands in a situation where there was no access to soap and warm water. Recognizing the commercial potential of her idea, she contacted an inventions hotline she had heard about on television to see about registering the patent. 35
Effective handwashing depends on access to a clean running water supply; therefore, hand sanitizer can prove a valuable disease prevention tool in populations with limited water supplies. In 2023, it was estimated that over a quarter of the world’s population does not have access to basic safe and clean water. 36
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