The Return Of The Hygiene Hypothesis

 

 

Photo Credit-CDC 

 

 
# 6394

 

While I often use this blog to promote better hand and respiratory hygiene, I must confess to a fascination with the hygiene hypothesis.

 

For those unfamiliar with it, this is  multi-faceted and controversial theory that proposes that some diseases common to modern man may come about due to a lack of exposure to various biological agents (bacteria, viruses, and even parasites)  . . . particularly in early childhood.

 

Research over the past decade has increasingly linked the use of household cleaners (bleach, disinfectants, carpet cleaners, etc) and other chemicals (turpentine, insecticides, etc) to childhood onset asthma and allergies (see MedNews Today Asthma in kids linked to household cleaning products and chemicals).

 

Essentially, the hygienic hypothesis says we may be trying to be `too clean’ for our own good.

 

Back in 2010, I wrote about a University of Michigan  study that addressed growing concerns over two commonly used chemicals – Triclosan and Bisphenol A (BPA) - and their possible impacts on our immune systems.

 

Study: Bisphenol A, Triclosan and The Hygienic Hypothesis

 

While my article focused mostly on BPA, Maryn McKenna took a deeper look at the use of Triclosan, and at the `hygienic hypothesis’ in her Superbug Blog entry called: Triclosan, allergies and the “hygiene hypothesis”. 

 

Very much worth reading.

 

All of which serves as prelude to a new study today, from the Johns Hopkins Children’s Center, that links antibacterial chemical exposure to a higher incidence of allergies in children.

 

First some excerpts from the press release, followed by  a link to the study, and finally a few closing comments.

 

Antibacterials in Personal-Care Products Linked to Allergy Risk in Children

MEDIA CONTACT: Ekaterina Pesheva
EMAIL: epeshev1@jhmi.edu
PHONE: (410) 502-9433

June 18, 2012

Exposure to common antibacterial chemicals and preservatives found in soap, toothpaste, mouthwash and other personal-care products may make children more prone to a wide range of food and environmental allergies, according to new research from Johns Hopkins Children’s Center.

 

Results of the NIH-funded study are published online ahead of print June 18 in the Journal of Allergy and Clinical Immunology.

 

Using existing data from a national health survey of 860 children ages 6 to 18, Johns Hopkins researchers examined the relationship between a child’s urinary levels of antibacterials and preservatives found in many personal-hygiene products and the presence of IgE antibodies in the child’s blood. IgE antibodies are immune chemicals that rise in response to an allergen and are markedly elevated in people with allergies.

 

“We saw a link between level of exposure, measured by the amount of antimicrobial agents in the urine, and allergy risk, indicated by circulating antibodies to specific allergens,” said lead investigator Jessica Savage, M.D., M.H.S., an allergy and immunology fellow at Hopkins.

 

The researchers caution that the findings do not demonstrate that antibacterials and preservatives themselves cause the allergies, but instead suggest that these agents play a role in immune system development.

<SNIP>

Children with the highest urine levels of triclosan had nearly twice the risk of environmental allergies as children with the lowest urinary concentrations. Those with highest levels of propyl paraben in the urine had twice the risk of an environmental allergy. Food allergy risk was more than twice as pronounced in children with the highest levels of urinary triclosan as in children with the lowest triclosan levels. High paraben levels in the urine were not linked to food allergy risk.

(Continue . . . )

 

The study, which appears in the Journal of Allergy and Clinical Immunology, is called:

 

Urinary levels of triclosan and parabens are associated with aeroallergen and food sensitization

Jessica H. Savage, MD, MHS, Elizabeth C. Matsui, MD, MHS, Robert A. Wood, MD, Corinne A. Keet, MD, MS

 

 

For more on the Hygiene Hypothesis,  a couple more resources to consider.

 

First, from a Scientific American podcast from April of 2011, an interview with Johns Hopkins School of Medicine researcher Kathleen Barnes, who studies this theory.

 

 

Can It Be Bad to Be Too Clean?: The Hygiene Hypothesis

Johns Hopkins School of Medicine researcher Kathleen Barnes talks about the hygiene hypothesis, which raises the possibility that our modern sterile environment may contribute to conditions such as asthma and eczema

 

 

Another, highly controversial aspect of this theory, is that intestinal parasites (ie. worms) – which have been largely eliminated in the western world - are actually beneficial, and can help prevent (or even cure) certain types of inflammatory bowel disease.

 

 

NPR (along with many other media outlets) covered this story at length back in 2010 (see Eat Your Worms: The Upside Of Parasites).

 

 

This past week, with the release of an avalanche of News From The Human Microbiome Project, we are learning just how much of our body consists of non-human microbes – which exist in or on just about every part of the human body. 

 

Over hundreds of thousands of years man has evolved to co-exist with – and  yes, even depend upon  - many of these micro organism to protect our skin, digest our food, and even produce vitamins and anti-inflammatory compounds in our intestines.

 

Chemicals (and drugs - see The Other Reason Not To Abuse Antibiotics) that can upset the balance of these naturally occurring – often  beneficial – organisms have the potential to affect our health in unexpected ways.

 

While intriguing, the Hygiene Hypothesis remains both controversial and unproven. 

 

Good hand hygiene, avoidance of infection, and general cleanliness remain essential parts of staying healthy, and no one is seriously suggesting we indulge in geophagy (eating dirt), intentionally ingest worms, or move down into the sewers to enhance our immune system.

 

But there is increasing evidence to suggest that our modern mania for cleanliness - particularly with the use of chemicals like triclosan and parabens – may exact an unexpected cost on our overall health.

 

How much of a penalty is involved, and whether the tradeoff is worth it, are questions that are yet to be answered.

»» Read More

Our First Line Of Defense

 

Photo Credit PHIL (Public Health Image Library)

 

 

# 5992

 

One of the concepts well illustrated during the initial outbreak of the H1N1 `swine flu virus’ in 2009 was that – until a vaccine could be developed, produced, and deployed – our only real defenses against any emerging infectious disease are NPIs; non pharmaceutical interventions.

 

Which is why flu hygiene (covering coughs/sneezes, disposing of tissues, washing hands often, and staying home when sick) was heavily promoted to the public during the pandemic.

 

Healthcare settings, where large numbers of vulnerable people are gathered in close proximity, are also the place that those infected with a new virus are likely to show up first.

 

Making the use of NPIs all the more important, to protect not only the staff, but other patients as well.

 

This morning we’ve a couple of studies that look at attitudes towards, and actually implementation of, NPIs and basic infection control procedures by both medical students and healthcare providers.

 

The most basic of NPIs is handwashing, and despite it having been more than 160 years since Ignaz Semmelweis published his work on the importance of hand hygiene, compliance rates in healthcare settings remain disturbingly low.

 

This is a subject we’ve visited many times before, including:

 

Giving Germs A Helping Hand 

Hand Hygiene Among Doctors Exposed

A Movement With Five Moments

Despite increased awareness and concern over HAIs (Hospital Acquired Infections), global handwashing campaigns, and the proliferation of hand sanitizing dispensers there remain serious gaps in this most basic infection control practice.

 

In the American Journal of Infection Control we’ve a study that surveyed beliefs of 1st year medical students over when it was appropriate to wash you hands when interacting with a patient.

Beliefs about hand hygiene: A survey in medical students in their first clinical year

Karolin Graf, MD, Iris F. Chaberny, MD, Ralf-Peter Vonberg, MD

Medical students were asked regarding knowledge and beliefs on hand hygiene before entering the clinical phase of education. By this, we noticed a lack of knowledge concerning the correct indications for hand disinfection. Regardless of previous experience in hospitals, the medical students expected that the compliance towards hand hygiene would be worse in more experienced physicians and senior consultants—who are often considered to be role models for medical students.

 

While this study is behind a pay wall, we do get additional details from a press release from Elsevier Health Services.

 

Elsevier Health Sciences

2 out of 3 medical students do not know when to wash their hands

Washington, DC, December 1, 2011 -- Only 21 percent of surveyed medical students could identify five true and two false indications of when and when not to wash their hands in the clinical setting, according to a study published in the December issue of the American Journal of Infection Control, the official publication of APIC - the Association for Professionals in Infection Control and Epidemiology.

 

Three researchers from the Institute for Medical Microbiology and Hospital Epidemiology at Hannover Medical School in Hannover, Germany collected surveys from 85 medical students in their third year of study during a lecture class that all students must pass before bedside training and contact with patients commences. Students were given seven scenarios, of which five ("before contact to a patient," "before preparation of intravenous fluids," "after removal of gloves," "after contact to the patient's bed," and "after contact to vomit") were correct hand hygiene (HH) indications. Only 33 percent of the students correctly identified all five true indications, and only 21 percent correctly identified all true and false indications.

(Continue . . . )

 

 

The next stop is a study that appears in the SHEA journal Infection Control and Hospital Epidemiology that shows that the inadequate use of masks by healthcare workers during the opening days of the 2009 pandemic put them at greater risk of contracting the virus.

 

 

Transmission of 2009 Pandemic Influenza A (H1N1) Virus among Healthcare Personnel-Southern California, 2009.

Jaeger JL, Patel M, Dharan N, Hancock K, Meites E, Mattson C, Gladden M, Sugerman D, Doshi S, Blau D, Harriman K, Whaley M, Sun H, Ginsberg M, Kao AS, Kriner P, Lindstrom S, Jain S, Katz J, Finelli L, Olsen SJ, Kallen AJ.

Source

Epidemic Intelligence Service, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.

We’ve a press release from SHEA with the details.

 

Study finds inadequate mask use among health care workers early in 2009 H1N1 outbreak

Inadequate use of masks or respirators put health care workers at risk of 2009 H1N1 infection during the earliest stages of the 2009 pandemic in the U.S., according to a study published in the December issue of Infection Control and Hospital Epidemiology, the journal of the Society of Healthcare Epidemiology of America.

 

The study, led by the Centers for Disease Control and Prevention (CDC), tracked 63 Southern California health care workers who had contact with six of the first eight laboratory-confirmed 2009 H1N1 cases in the U.S. Because these contacts happened before the 2009 H1N1 outbreak had been widely reported, the cases shed light on how well health care workers protect themselves before a direct epidemiological threat becomes evident.

 

The investigation found that 9 of the health care workers tracked became infected with the 2009 H1N1 virus, likely from contact with infected patients. Twenty of the 63 health care workers reported that they had worn a mask or respirator at least once when in contact with patients, and no one from that group became infected with 2009 H1N1. Meanwhile, 43 workers reported never using a mask around patients, and all 9 infections occurred in workers from this group.

 

Overall, mask and respirator use was disappointingly low, the researchers report. Only 19 percent reported using a mask during every patient encounter. Use was especially low among outpatient workers, who also made up the majority of those who became infected with 2009 H1N1.

 

"The findings highlight the challenge of getting health care personnel to routinely wear Personal Protective Equipment," Jenifer Jaeger, MD, MPH, Associate Pediatrician, Massachusetts General Hospital, said. "The study also suggests that greater attention to infection control and preparedness, particularly among outpatient workers, is needed."

 

 

The irony here is that once the threat of a new viral threat became apparent, there were difficulties in providing enough PPEs (Personal Protective Equipment) - including masks and respirators - to healthcare workers in some parts of the country.

 

In June of 2009  the CDC’s MMWR (Morbidity and Mortality Weekly Report) (Volume 58, No. 23) reported hospitals weren’t doing enough to identify potential influenza cases, to isolate them, and to protect their staff (see HCPs At Risk).

 

A month later the California Nurses Association/ National Nurses Organizing Committee (CNA/NNOC) filed a complaint against one hospital, which I reported on in California Nurses Association Statement On Lack Of PPE and Report: Nurses File Complaint Over Lack Of PPE.

 

In August 2009 I reported on Nurses Protest Lack Of PPE’s in San Francisco.  And in October, I wrote CNA/NNOC Plan Protest Over Inadequate H1N1 Protection.

 

And to this, we must also add the ongoing debate over what constitutes adequate PPE protection.

 

Ideally, the well-protected HCW (Health Care Worker) working in an infectious environment would be wearing an N95 respirator, gloves, gown and eye protection.

 

 

But during the opening months of the 2009 pandemic, it became obvious that our world faced a shortage of N95 respirators, and so strategies were adopted to maximize their use.

 

In some cases nurses were issued only one N95 mask to be used for an entire 8 hour shift, and told to don it only when in direct contact with a potentially infected patient.

 

In other venues, HCWs were issued surgical masks in lieu of N95s, despite the recommendation at the time from the CDC that N95 masks were the preferred level of protection.

 

Over the past two years we’ve seen dueling studies that alternately show surgical masks to be a reasonable protective barrier against respiratory viruses  . . . or pretty much useless.

 

Take your pick.

 

Which is why last January the IOM (Institute of Medicine) released, through the National Academies Press, an extensive, 200+ page update on the use of PPEs  that essentially calls for better science on which to base our decisions regarding the right kind of protection for HCWs.

 

We were very lucky that the 2009 pandemic virus wasn’t any more transmissible, or virulent, than it turned out to be. 

 

While instilling good infection control practices is imperative in normal times, the less talked about side to this story is that during a serious global pandemic threat sometime in the future, providing adequate PPEs to healthcare workers may prove to be a major challenge.

»» Read More

Study: Flu Hygiene Reduces Respiratory Infections In School Setting

 

 

# 5980

 

 

We’ve another study that – despite returning somewhat mixed results – once again suggests the importance of maintaining good `flu hygiene’ during cold & flu season.

 

During the 2007-2008 flu season 10 Pittsburg elementary schools (grades K- 5) took part in a study where half of the schools served as controls, and half (5) were selected as `intervention’ schools.

 

Children in the intervention schools watched a special video on flu prevention, and were introduced to the `WHACK the Flu’ concepts.

 

WHACK stood for:

 

(W)ash or sanitize your hands often;

(H)ome is where you stay when you are sick;

(A)void touching your eyes, nose, and mouth;

(C)over your coughs and sneezes; and

(K)eep your distance from sick people.

 

This message was reinforced continually over the study period, and hand sanitizer dispensers were installed in each classroom and in major common areas of the intervention schools.

 

The goal was to encourage a minimum of 4 uses a day; upon arrival, before and after lunch, and prior to departure. Students were also encouraged to wash their hands and/or use the hand sanitizer as needed during the day.

 

Teachers were surveyed during the year regarding compliance rates among the students. Parents of students who were absent for more than one day received a phone call, and those who reported their child to have an ILI (influenza-like-Illness) received a home health visit where nasal swabs were obtained and tested for both influenza A & B.

 

The bottom line: at the intervention schools total student absences were reduced by 26% and lab confirmed influenza A infections were reduced by 52%.

 

Curiously, rates of influenza B were not reduced in this study, although the reasons why are less than clear.  In their discussion, the authors suggest several possible reasons, including:

 

The observation of no effect on influenza B could be attributed to differences in the basic biology and epidemiology of influenza B compared with A or to the fact that influenza B infections occurred late in the season, after compliance with the intervention possibly had waned.

 

A quick Google search returned a pdf of the full study online at this link.

 

Below you’ll find some excerpts from the abstract which may be read at the following link:

 

Pediatr Infect Dis J. 2011 Nov;30(11):921-6.

Reduction in the incidence of influenza A but not influenza B associated with use of hand sanitizer and cough hygiene in schools: a randomized controlled trial.

Stebbins S, Cummings DA, Stark JH, Vukotich C, Mitruka K, Thompson W, Rinaldo C, Roth L, Wagner M, Wisniewski SR, Dato V, Eng H, Burke DS.

(EXCERPT)

RESULTS:

A total of 3360 children participated in this study. Using reverse-transcriptase polymerase chain reaction, 54 cases of influenza A and 50 cases of influenza B were detected. We found no significant effect of the intervention on the primary study outcome of all laboratory-confirmed influenza cases (incidence rate ratio [IRR]: 0.81; 95% confidence interval [CI]: 0.54, 1.23). However, we did find statistically significant differences in protocol-specified ancillary outcomes.

Children in intervention schools had significantly fewer laboratory-confirmed influenza A infections than children in control schools, with an adjusted IRR of 0.48 (95% CI: 0.26, 0.87). Total absent episodes were also significantly lower among the intervention group than among the control group; adjusted IRR 0.74 (95% CI: 0.56, 0.97).

CONCLUSIONS:

NPIs (respiratory hygiene education and the regular use of hand sanitizer) did not reduce total laboratory-confirmed influenza. However, the interventions did reduce school total absence episodes by 26% and laboratory-confirmed influenza A infections by 52%. Our results suggest that NPIs can be an important adjunct to influenza vaccination programs to reduce the number of influenza A infections among children.

In the full paper, the authors conclude:

 

This study demonstrated that a set of NPIs can be implemented successfully on a large scale within urban schools to reduce absenteeism and the incidence of influenza A.

 

Furthermore, the results provide support for currently recommended respiratory hygiene behaviors during seasonal and pandemic influenza outbreaks and should be included as part of an overall prevention strategy to reduce the burden of influenza among school-aged children.

 

 

While useful interventions during any flu season, these techniques are even more important during an outbreak of a novel virus – such as we saw in 2009.  

 

Since vaccines typically take months to develop and even longer to deploy, simple, easy to implement NPIs (Non-pharmaceutical Interventions) such as these – while not a panacea - will undoubtedly form an important part of our initial response to any influenza epidemic.

»» Read More

Of Mice and Men - And The Hygienic Hypothesis

 

 

# 5142

 

 

Note: The `Hygienic Hypothesis’ – while something I personally find fascinating to write about - remains an unproven theory, and so what follows needs to be taken in that light.

 

Similarly, mouse studies, while often useful in medical research, don’t always predict what happens in human physiology.

 

 

In the past several weeks the hygienic hypotheses has made headlines a number of times, something I covered late last month in Study: Bisphenol A, Triclosan and The Hygienic Hypothesis, and Maryn McKenna wrote about here and here.

 

In brief, the `Hygienic Hypothesis’ is a theory that suggests some of the allergies and autoimmune diseases common to modern man come about due to a lack of exposure to certain biological agents (bacteria, viruses, and even parasites)  . . . particularly in early childhood.

 

Research over the past decade has increasingly linked the use of household cleaners (bleach, disinfectants, carpet cleaners, etc) and other chemicals (turpentine, insecticides, etc) to childhood onset asthma and allergies (see MedNews Today Asthma in kids linked to household cleaning products and chemicals).

 

Essentially, the hygienic hypothesis says we may be trying to be `too clean’ for our own good.

 

One of the more controversial aspects of this theory is that intestinal parasites (ie. worms) – which have been largely eliminated in the western world - are actually beneficial, and can help prevent (or even cure) certain types of inflammatory bowel disease.

 

NPR (along with many other media outlets) covered this story at length a couple of weeks ago (see Eat Your Worms: The Upside Of Parasites).

 

Today, a new study appears in the Journal of Clinical Investigation, that lends additional support to the hygienic hypothesis.

 

It looks at the protective effects of certain types of viral infections in suckling mice against adult onset asthma. Before you scoff, this research has a pretty impressive pedigree.

 

A link, and a couple of excerpts from the abstract (follow the link to read it in its entirety) follow:

 

Influenza infection in suckling mice expands an NKT cell subset that protects against airway hyperreactivity

Ya-Jen Chang, Hye Young Kim, Lee A. Albacker, Hyun Hee Lee, Nicole Baumgarth, Shizuo Akira, Paul B. Savage, Shin Endo, Takashi Yamamura, Janneke Maaskant, Naoki Kitano, Abel Singh, Apoorva Bhatt, Gurdyal S. Besra, Peter van den Elzen, Ben Appelmelk, Richard W. Franck, Guangwu Chen, Rosemarie H. DeKruyff, Michio Shimamura, Petr Illarionov, Dale T. Umetsu

J. Clin. Invest. 2010; doi:10.1172/JCI44845

Infection with influenza A virus represents a major public health threat worldwide, particularly in patients with asthma. However, immunity induced by influenza A virus may have beneficial effects, particularly in young children, that might protect against the later development of asthma, as suggested by the hygiene hypothesis.

 

Herein, we show that infection of suckling mice with influenza A virus protected the mice as adults against allergen-induced airway hyperreactivity (AHR), a cardinal feature of asthma.

 

<SNIP>

 

These findings suggest what we believe to be a novel pathway that can regulate AHR, and a new therapeutic strategy (treatment with glycolipid activators of this NKT cell population) for asthma.

 

Basically researchers infected 2-week old (suckling) mice and 8-week old (adult) mice with with the A/Mem71 (H3N1) influenza virus. Six weeks later both cohorts were tested for susceptibility to an asthma-like reaction.

 

Mice that were infected at 2-wks of age were protected against an asthma-like reaction.

 

Those infected as adults were not.

 

 

The reason given for this protective effect was an increase in certain types of NKT (natural killer T-cells) in baby mice post-infection, something which was not observed in the influenza-challenged adult mice.

 

Interestingly, the researchers also found that a molecule produced by the stomach bacteria Helicobacter pylori also produced a protective affect against asthma in adult mice, giving hopes for a new avenue of research into better treatments.

 

The article is lengthy, technical, and  open access. I’ve only scratched the bare surface with this overview. Those interested in learning more should follow this link to read the entire study.

 

Before anyone decides to eat worms, stop bathing, or move down to the city sewers for their health . . . remember:

 

The hygienic hypothesis is still just a theory.

»» Read More

And Yet, They Still Call It Wellington

 

 

# 4713

 

 

An interesting report this morning out of New Zealand on the results of an observational study during the recent pandemic. 

 

They looked at how well the public covered their coughs and sneezes at three Wellington locations; a train station, a hospital and a shopping mall

 

And the answer is . . . not particularly well.

 

The results of this study were presented this past week at an International Conference on Emerging Infectious Diseases in Atlanta, Ga.

 

This from the Livescience website.

 

1 in 4 Don't Cover Coughs and Sneezes

By LiveScience Staff

posted: 09 July 2010 12:04 pm ET

During the H1N1 flu (also known as swine flu) pandemic, public health campaigns urged individuals to practice good hygiene habits, but few heeded the advice, according to a new study.

 

About one out of every four people that researchers observed in public settings failed to cover their mouth when they coughed or sneezed, and less than 5 percent of people covered their mouth using methods recommended by health officials.

 

"This study showed a low prevalence of recommended respiratory hygiene behaviors suggesting that hygiene messages promoted in mass media campaigns have not been seen and/or have not been readily adopted by the public in this city," said Nick Wilson of Otago University Wellington in New Zealand, an author on the study.

 

(Continue . . . )

 

It’s a good article, so read the whole thing.

 

A disappointing result, given the level of public service announcements in play at the time.

 

The authors caution that these results may not translate to other regions, but I’ve no reason to believe that the residents of New Zealand are any less fastidious or hygienic than those living in other developed countries.

 

Last September I wrote an essay called `Being A Sneeze Guard’, where I told of my encounter at a local grocery store checkout line with a sneezing, coughing, and decidedly unrepentant cashier.

 

And several months before the pandemic began, I wrote a piece called `Doing The Hand Jive’, which looked at a 2007 market research study on hand washing by  HarrisInteractive. 

 

They conducted telephone interviews, and then discreetly staked out public restrooms at 6 venues in 4 American cities to observe how many people actually washed their hands before leaving the restroom.

 

While nine in ten (92%) adults surveyed claimed they always washed their hands after using public restrooms; just over three in four (77%) were observed doing so (down from 83% in 2005).

 

Men were less likely to wash their hands than women, with only 66% stopping to wash, as opposed to 88% of women.

 

Something to think about the next time someone offers to shake hands with you.

 

Which is why I’ve carried one of those little bottles of alcohol gel with me for years. 

 

The CDC has some excellent resources on handwashing, including this video called `Put Your Hands Together'.

(Click for CDC Video on Hand Hygiene)

 

A collection of Hand Washing posters can be found at:

Suitable For Framing

 

As far as the best way to cover your coughs and sneezes?

 

This short video made by a group of students at the Johns Hopkins School of Public Health shows us how.

 

 

 

It doesn’t take a pandemic strain of flu to ruin your whole day, and for tens of thousands of people each year, `regular’ flu proves quite deadly.

 

Good health habits, such as washing our hands and covering our coughs and sneezes are things we need to do every day so that they become second nature to us.

»» Read More

Hand Hygiene Isn’t Just For Flu

 

 

 

# 4402

 

 

Last summer and fall many people adopted – at least temporarily – increased hand washing (and alcohol sanitation) as a preventative against the H1N1 `swine’ flu.

 

Hand hygiene was widely promoted by the CDC, and other public health venues, as something everyone could do to reduce their chance of getting sick.

 

As a compulsive hand-washer (a trait I picked up as a paramedic back in the 1970s, a time before we routinely wore latex gloves!), my habits didn’t really change, although I probably used the alcohol gel more often when I was away from home.

 

But for many people this habit, unlike the germs on their hands, didn’t stick.

 

With the swine flu threat widely perceived as diminishing, people don’t seem to be quite as diligent about hand hygiene as they were a few months ago.  

A pity, because good hand hygiene can prevent a lot of illnesses.

 

New England Journal of Medicine

 

Maryn McKenna had a great blog more than a year ago (see This is what hand hygiene looks like), utilizing the above graphic.  The petri dish on the left depicts MRSA bacteria from a health care worker’s hand. 

The blank culture on the right is what you get after using alcohol foam sanitizer.   

 

Good hand hygiene matters.

 

In recent weeks we’ve heard of a rise in Norovirus outbreaks (see Norovirus: The Gift That Keeps On Giving) around the country. 

 

The primary route of infection is the fecal-oral route (although it can also be airborne), and the best intervention is . . . you guessed it . . .  washing your hands.

 

Unfortunately, unlike with many other bacteria and viruses, alcohol gel doesn’t do a particularly good job of killing the norovirus.  

 

(Note: Norwalk and Norovirus both refer to the same RNA virus (family Caliciviridae) that that are responsible for numerous outbreaks of non-bacterial gastroenteritis around the world.)

 

    Appl Environ Microbiol. 2010 Jan;76(2):394-9. Epub 2009 Nov 20.

Effectiveness of liquid soap and hand sanitizer against Norwalk virus on contaminated hands.

 

Liu P, Yuen Y, Hsiao HM, Jaykus LA, Moe C.

(EXCERPTS)

The purpose of this study was to screen sodium hypochlorite and ethanol for efficacy against Norwalk virus (NV) and expand the studies to evaluate the efficacy of antibacterial liquid soap and alcohol-based hand sanitizer for the inactivation of NV on human finger pads.

 

. . . sodium hypochlorite concentrations of >or=160 ppm effectively eliminated RT-qPCR detection signal, while ethanol, regardless of concentration, was relatively ineffective . . .

 

Despite the promise of alcohol-based sanitizers for the control of pathogen transmission, they may be relatively ineffective against the HuNoV, reinforcing the need to develop and evaluate new products against this important group of viruses.

 

When dealing with Norovirus, hand washing with soap and water is clearly the way to go.

 

While the effectiveness of hand washing against what is presumed to be a mostly-airborne/large droplet vectored virus like influenza is debatable, good hand hygiene can prevent a lot of other illnesses.    

 

Pandemic or not, it is always a healthy habit to keep.

»» Read More

Canada Stresses Hand Hygiene, Vax Arrives Next Month

 

# 3815

 

 

With H1N1 vaccine beginning to roll out in the US this week, expected to ship next week in the UK, and already going into the arms of Australians and Chinese, Canadian officials are in the unenviable position of explaining why a vaccine won’t become available there until November at the earliest.

 

In recent weeks Canadian Health officials have come increasingly under fire - adjusting their seasonal vaccination plans in light of a controversial unpublished study linking it to increased H1N1 infection -and managing a public relations gaff after sending a large number of body bags to a remote First Nations reserve in Manitoba.

 

The November timetable for the vaccine has recently become fodder for news stories and editorials.

 

According to Canada's chief public health officer, Dr. David-Butler Jones, the Swine Flu virus isn’t circulating as widely in Canada this fall as it is in the United States, which he believes gives them more time to act.

 

Meanwhile, Federal Health Minister Leona Aglukkaq is extolling the virtues of hand washing, insisting that 80% of common infections, including influenza, can be spread by contaminated hands.

 

This runs contrary to a recent study reported in the CMAJ  (see Sanitized For Your Protection) that argued that their was `no evidence’ that frequent hand washing would prevent the spread of influenza – a report whose significance Minister Aglukkaq is downplaying. 

 

This report from Sharon Kirkey, of the Canwest News Service.

 

 

Canada trailing U.S. in rollout of H1N1 vaccine

By Sharon Kirkey, Canwest News Service

October 8, 2009 9:56 AM

As health officials in the U.S. prepare to release tens of millions of doses of human swine-flu vaccine, Canadian health officials are teaching Canadians how to wash their hands.

 

The contrast is raising renewed questions about whether the vaccine will be made available in time to protect Canadians from a second wave of the pandemic.

 

Canada's chief public health officer said Wednesday that 35 per cent or more of the country could become sick with H1N1. But the largest vaccination program in the nation's history is not scheduled to begin before the first week of November, when the first doses of vaccine will go to those at highest risk of serious illness, including adults under 65 with chronic health conditions and health-care workers involved in pandemic response.

 

(Continue . . .)

 

The advice being offered on flu hygiene by Canadian officials isn’t much different from what our own CDC/HHS has been suggesting for months.  

 

While hand washing may be of limited value in controlling influenza, it is proactive, reasonably easy to do, and undoubtedly lessens the transmission of some germs and viruses. 

 

It is certainly a habit worth encouraging.

 

The problem is, that in the absence of having anything else to offer, public health officials tend to `oversell’ it as a flu preventative. This is a problem I wrote about several weeks ago in The Flaw In The Ointment.

I am sympathetic to the plight of public health officials, however. 

 

They have to say something.  They need to give the public something they can reasonably do, that empowers them and makes them feel at least somewhat in control of their fate during a pandemic.

 

Hand washing may not be a panacea, but until you can get a vaccine, it undoubtedly beats doing nothing.

 

Which reminds me . . .  where’s my hand sanitizer?

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Sanitized For Your Protection

 

 

# 3792

 

 

Although the advice from the CDC, HHS, and just about every other public health agency around to globe to `wash your hands often’ is undoubtedly sage counsel, and can protect you against a wide range of illnesses and disease, there  appears to be little evidence that it will prevent the spread of influenza.

 

Oh, I still wash (or sanitize) my hands incessantly.  And I will continue to do so, but I’ve been a inveterate hand washer for decades.  No doubt a habit instilled in me from working as a paramedic during a time when latex gloves were rarely worn.

 

The scientific evidence supporting the notion that hand washing will prevent you from getting the flu, however, is scant to non-existent.

 

Sorry, I don’t make up the facts.  I just report them.

 

This is of course distressing to public health officials who have made hand washing the mainstay of their pandemic advice.  Something I wrote about last month in The Flaw In The Ointment.

Yesterday, the CMAJ (Canadian Medical Association Journal) ran an article about the disconnect between the advice being offered by public health officials, and the currently available science.

 

 

October 1, 2009

Conflict emerges over value of handwashing as a preventive flu transmission measure

Prominent microbiologist Dr. Donald Low argues that the Public Health Agency of Canada's hand hygiene recommendations "are not evidence-based."

Photo Credit: ©2009 Jupiterimages Corp.

 

There’s no evidence that good hand hygiene practices prevent influenza transmission, according to a Council of Canadian Academies report commissioned by the Public Health Agency of Canada.

 

 

But N95 particulate respirator-type masks are a proven “final layer of protection” against even the smallest viral particles of influenza, says the Influenza Transmission and the Role of Personal Protective Respiratory Equipment: An Assessment of the Evidence report prepared by an expert panel on influenza and personal protective respiratory equipment, chaired by Dr. Donald Low, microbiologist-in-chief at Mount Sinai Hospital in Toronto, Ontario.

 

Despite those 2007 findings, PHAC still recommends handwashing as the primary preventive measure against flu transmission. The agency also states on its website that there is no evidence that wearing masks “will prevent the spread of infection in the general population. Improper use of masks may in fact increase the risk of infection.”

 

Moreover, PHAC states in an email to CMAJ that “there is substantial evidence to support hand hygiene as a basic premise of infection prevention and control measures.” The agency also indicated that its hand hygiene recommendations are based on a combination of expert opinion and evidence, including a recent Cochrane Collaboration systematic review (BMJ 2009;339:b3675).

 

But the contradictory evidence and recommendations on preventive measures and other pandemic (H1N1) 2009 issues leaves Canadian doctors at a loss as to the best advice to provide patients, says College of Family Physicians of Canada President Dr. Sarah Kredentser.

 

(Continue . . . )

 

 

While I personally believe that hand washing may prevent at least some flu transmission, I readily concede that most influenza is transmitted through large droplet or aerosol routes.  

 

And I suspect most public health officials, if cornered, would agree. 

 

Hand washing is probably of limited value in preventing the spread of influenza.

 

But you have to have something to tell the public.  Hand washing is simple, easy to do (for most of us), and has proven benefits as part of basic disease prevention and hygiene. 

 

Like the `duck & cover’ drills of my childhood during the 1960s, hiding under your (civil defense approved!) school desk during an H-Bomb attack may not really help, but it couldn’t hurt. 

 

I am sympathetic to public health agencies who must distill the science (which isn’t always complete, or clear) down to simple, easy to follow advice for the public.

 

They must take into account practical considerations – such as costs and availability - as well as the scientific evidence.  Not an easy task when it comes to something as complicated as an influenza pandemic.  

 

But I admit to being a tad uncomfortable with how hand washing is being `oversold’ by public health officials as a pandemic flu preventative measure.

 

While washing your hands, covering your coughs and sneezes, staying home when you are sick, and getting the vaccine when it becomes available are all good ideas, nothing says you have to stop there.

 

Which is why I view the advice from public health agencies as a solid foundation upon which to base my personal pandemic and disaster plans, but not as the total solution. 

 

I’ve made no secret of the fact that I advocate going the extra mile when it comes to preparedness.   That a 72-hour kit is a nice start, but you really need at least 2-weeks worth of supplies in your home, along with a proper first aid kit, a weather radio, and other emergency supplies. 

 

I’ve also endorsed the stockpiling (and use) of facemasks and respirators when caring for flu victims in your household.  

 

Admittedly, not everyone can do these things, and so public health officials sometimes find them difficult to recommend.   But that doesn’t mean you shouldn’t go the extra mile if you are able to.

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Being A Sneeze Guard

 

 

# 3721

 

 

Ninety days after the declaration of the first pandemic in more than 40 years, you’d think that most people would be aware of their own coughing and sneezing habits . . . particularly among those who are dealing with the public. 

 

But the message apparently isn’t getting out the way it should.  At least, if an incident that happened to me this afternoon is any indication.

 

I’ve just returned from my local (major chain) grocery store. 

 

 

While paying for my goods, the cashier began counting out money.   She then COUGHED into her free hand - and barely skipping a beat -continued counting out my change . . .

 

. . .  I started to say something but was interrupted as this lady SNEEZED (loudly and wetly) into her free hand, wiped her hand on her pants leg, and then blithely resumed counting my change.

 

I said, “Excuse me . . . you just sneezed into your hand, and now you are counting out my change . . .”

 

The Cashier immediately said, “I DID NOT!”

 

“Ma’am, I sorry . . . I just watched you cough and then sneeze into your hand. . .“

 

She indignantly grabbed a plastic container of hand wipes, gave her hands at least a 5 second wipe down, glowered at me, then took fresh bills from the cash register (probably contaminated, as well) and handed them to me.  

 

No doubt, the soggy ones went back into the till.

 

I walked around the store for several minutes, fuming . . . and finally asked another cashier to page the manager.   He arrived a few minutes later, and I explained what had transpired (I did not identify the cashier . . .this, I felt was a failure of Management).  

 

I asked, “Have you had any employee training sessions on sneezing and coughing etiquette?  After all . . we are in a pandemic.”

 

He was young, slightly bored, and tolerated my questions . . .but didn’t seem terribly interested.  I’m sure they get complaints from crazy old geezers like me all the time about one thing or another.

 

Yes, they’ve received `communications’ from headquarters on pandemic issues.   No, they hadn’t had an employee meeting. 

 

I asked if the `communication’ from corporate had said anything about asking employees with `flu like symptoms’ to stay home?   Or that employees should never cough or sneeze into their hands . . . but into their elbows (I demonstrated the technique).

 

He said, yes . . .it did.   

 

I suggested that he might want to hold a staff meeting on the subject, gave him my card, and  directed him to FLU.GOV for more information. 

 

My little `talk’ may not have had any effect, of course. 

 

But if we all take exception to this sort of behavior when we encounter it, and SPEAK UP ABOUT IT . . . we might begin to forge a change in our collective attitudes.

 

Ignoring this kind of blatant disregard for the health and safety of others only reinforces the idea that no-one really cares.  That it really doesn’t matter. 

 

I feel a little better for having said something.

 

At least once I’d sanitized my hands for the third time after I’d left the checkout lane.

 

But what I really wanted was a shower.

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Suitable For Framing

 

# 3712

 

 

I get some of my best blog ideas from my readers, and today is no exception.  A request from Phytosleuth sent me on a search for hand washing posters from around the net.

 

All downloadable, printable, and suitable for framing.

 

First, from the Massachusetts Department of Health and Human Services website, we get posters for adults and children, available in multiple languages.

 

Did You Wash Your Hands? Poster Size: 11" x 14"

• Did You Wash Your Hands? in Chinese (PDF) | RTF
• Did You Wash Your Hands? in English (PDF) | Word
• Did You Wash Your Hands? in French (PDF) | RTF
• Did You Wash Your Hands? in Haitian Creole (PDF) | RTF
• Did You Wash Your Hands? in Portuguese (PDF) | RTF
• Did You Wash Your Hands? in Spanish (PDF) | RTF
• Did You Wash Your Hands? in Vietnamese (PDF) | RTF

 

Handwashing Poster (Kids)

 

 

The CDC’s Germ stoppers page has a number of posters, like the one above, to remind us all to cover our coughs and sneezes, and wash our hands.

 

 

And from the USDA Food Safety website, we get this assortment of posters, also suitable for framing .

 

Use the signs and posters featured here to remind your children and staff about the importance of hand washing. Be sure to also view hand washing signs and posters for school food service professionals.

All Hands Need To Wash
Kansas State University Agricultural Experiment Station and Cooperative Extension Service.
Includes brief, motivational facts and figures about handwashing practices, handwashing procedures, and when to wash hands.

Be a Germ Buster- Wash Your Hands!  (PDF|864 KB)
Washington State Department of Health.
Uses large illustrations to show proper hand washing steps. Available in Arabic, Bengali, Chinese, English, Hindi, Korean, Nepalese, Russian, Spanish, and Turkish.

Be a Germ Stopper!
DHHS. Center for Disease Control and Prevention.
Promotional poster for preventing the spread of germs through proper hand washing.

Clean Hands Campaign Poster
American Society for Microbiology.
Reinforces the message that handwashing is the most important means of preventing the spread of infection.

Hand Hygiene Posters and Resources
Minnesota Department of Health.
Posters covering when to wash, bacterial growth on hands, cross-contamination, soap use, handwashing procedures, and general handwashing reminders.

Handwashing Posters
National Food Service Management Institute.
Several various handwashing posters covering different aspects of hand hygiene. These materials are tailored to various audiences and are also all available in Spanish.

Patient Education Materials and Resources
Massachusetts Medical Society.
Includes a handwashing procedure poster reminding people that "Handwashing is the Best Way to Prevent the Spread of Infection."

The SOPE: Handz Best Friend
The SOPE Project.
Features SOPE the dog, "Handz Best Friend." Provides brief facts about handwashing throughout the border. Available in both English and Spanish.

Wash Those Hands!
University of Nebraska Cooperative Extension.
Hand washing posters for children, older youth, and adults. Includes a matching table tent, as well as a bilingual poster in English and Spanish. Available in color or in black and white for reproduction purposes.

 

 

And thanks, Phytosleuth for being my Muse today.

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