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Hand washing
Hand washing with soap and water at a sink
Other namesHandwashing, hand hygiene

Hand washing (or handwashing), also called hand hygiene, is the process of cleaning the hands with soap or handwash and water to eliminate bacteria, viruses, dirt, microorganisms, and other potentially harmful substances. Drying of the washed hands is part of the process as wet and moist hands are more easily recontaminated.[1][2] If soap and water are unavailable, hand sanitizer that is at least 60% (v/v) alcohol in water can be used as long as hands are not visibly excessively dirty or greasy.[3][4] Hand hygiene is central to preventing the spread of infectious diseases in home and everyday life settings.[5] Meta-analyses have shown that regular hand washing in community settings significantly reduces respiratory and gastrointestinal infection[6]

The World Health Organization (WHO) recommends washing hands for at least 20 seconds before and after certain activities.[7][8] These include the five critical times during the day where washing hands with soap is important to reduce fecal-oral transmission of disease: after using the toilet (for urination, defecation, menstrual hygiene), after cleaning a child's bottom (changing diapers), before feeding a child, before eating and before/after preparing food or handling raw meat, fish, or poultry.[9]

When neither hand washing nor using hand sanitizer is possible, hands can be cleaned with uncontaminated ash and clean water, although the benefits and harms are uncertain for reducing the spread of viral or bacterial infections.[10] However, frequent hand washing can lead to skin damage due to drying of the skin.[11] Moisturizing lotion is often recommended to keep the hands from drying out; dry skin can lead to skin damage which can increase the risk for the transmission of infection.[12]

Steps and duration

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Poster about when to wash hands to raise awareness about hygiene. This poster can be used to raise awareness on that topic amongst school children.

The United States Centers for Disease Control and Prevention (CDC) recommends the following steps when washing one's hands for the prevention of transmission of disease:[13]

  1. Wet hands with warm or cold running water.[13] Running water is recommended because standing basins may be contaminated, while the temperature of the water does not seem to make a difference, however some experts suggest warm, tepid water may be superior.[1][failed verification][disputed – discuss]
  2. Lather hands by rubbing them with a generous amount of soap, including the backs of hands, between fingers, and under nails.[13] Soap lifts pathogens from the skin, and studies show that people tend to wash their hands more thoroughly when soap is used rather than water alone.[1]
  3. Scrub for at least 20 seconds.[13] Scrubbing creates friction, which helps remove pathogens from skin, and scrubbing for longer periods removes more pathogens.[1]According to the CDC, scrubbing with soap for at least 20 seconds is necessary to remove most germs effectively, regardless of water temperature.[14]
  4. Rinse well under running water.[13] Rinsing in a basin can recontaminate hands.[1]
  5. Dry with a clean towel or allow to air dry.[13] Wet and moist hands are more easily recontaminated.[1]

The most commonly missed areas are the thumb, the wrist, the areas between the fingers, and under fingernails. Artificial nails and chipped nail polish may harbor microorganisms.[12]

[edit]

There are five critical times during the day where washing hands with soap is important to reduce fecal-oral transmission of disease: after using the toilet (for urination, defecation, menstrual hygiene), after cleaning a child's bottom (changing diapers), before feeding a child, before eating and before/after preparing food or handling raw meat, fish, or poultry.[9] Other occasions when proper hand washing techniques should be practiced to prevent the transmission of disease include before and after treating a cut or wound; after sneezing, coughing, or blowing your nose; after touching animal waste or handling animals; and after touching garbage.[15][16]In healthcare settings, the WHO also recommends "Five Moments for Hand Hygiene"" before patient contact, before aseptic tasks, after exposure to body fluids, after patient contact, and after contact with patient surroundings.[17]

Public health

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Health benefits

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Building a culture of handwashing with children can create a change in culture with widespread public health benefits.

Hand washing has many significant health benefits, including minimizing the spread of influenza, COVID-19, and other infectious diseases;[18][19] preventing infectious causes of diarrhea;[20] decreasing respiratory infections;[21] and reducing infant mortality rate at home birth deliveries.[22] A 2013 study showed that improved hand washing practices may lead to small improvements in the length growth in children under five years of age.[23] In developing countries, childhood mortality rates related to respiratory and diarrheal diseases can be reduced by introducing simple behavioral changes, such as hand washing with soap. This simple action can reduce the rate of mortality from these diseases by almost 50%.[24] Interventions that promote hand washing can reduce diarrhea episodes by about a third, and this is comparable to providing clean water in low income areas.[25] 48% of reductions in diarrhea episodes can be associated with hand washing with soap.[26]

Handwashing with soap is the single most effective and inexpensive way to prevent diarrhea and acute respiratory infections (ARI), as automatic behavior performed in homes, schools, and communities worldwide. Pneumonia, a major ARI, is the number one cause of mortality among children under five years old, taking the lives of an estimated 1.8 million children per year. Diarrhea and pneumonia together account for almost 3.5 million child deaths annually.[27] According to UNICEF, turning handwashing with soap before eating and after using the toilet into an ingrained habit can save more lives than any single vaccine or medical intervention, cutting deaths from diarrhea by almost half and deaths from acute respiratory infections by one-quarter. Hand washing is usually integrated with other sanitation interventions as part of water, sanitation, and hygiene (WASH) programmes. Hand washing also protects against impetigo which is transmitted through direct physical contact.[28]

Adverse effects

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A small detrimental effect of handwashing is that frequent hand washing can lead to skin damage due to the drying of the skin.[11] A 2012 Danish study found that excessive hand washing can lead to an itchy, flaky skin condition known as contact dermatitis, which is especially common among health-care workers.[29]Frequent use of alcohol based hand sanitizers can also contribute to skin irritation and dryness, although this effect may be reduce by formulation that include moisturizers.[30]

Behavior change

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Hand cleaning station at the entrance of the Toronto General Hospital, Canada

In many countries, there is a low rate of hand washing with soap. A study of hand washing in 54 countries in 2015 found that on average, 38.7% of households practiced hand washing with soap.[31]

A 2014 study showed that Saudi Arabia had the highest rate of 97%; the United States near the middle with 77%; and China with the lowest rate of 23%.[32]

Several behavior change methodologies now exist to increase uptake of the behavior of hand washing with soap at the critical times.[33][34]

Group hand washing for school children at set times of the day is one option in developing countries to engrain hand washing in children's behaviors.[35] The "Essential Health Care Program" implemented by the Department of Education in the Philippines is an example of at scale action to promote children's health and education.[36] Deworming twice a year, supplemented with washing hands daily with soap, brushing teeth daily with fluoride, is at the core of this national program. It has also been successfully implemented in Indonesia.[37]

Substances used

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Soap and detergents

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Removal of microorganisms from skin is enhanced by the addition of soaps or detergents to water.[38] Soap and detergents are surfactants that kill microorganisms by disorganizing their membrane lipid bilayer and denaturing their proteins. It also emulsifies oils, enabling them to be carried away by running water.[39]

Solid soap

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Solid soap, because of its reusable nature, may hold bacteria acquired from previous uses.[40] A small number of studies which have looked at the bacterial transfer from contaminated solid soap have concluded transfer is unlikely as the bacteria are rinsed off with the foam.[41] The CDC still states "liquid soap with hands-free controls for dispensing is preferable".[42]

Antibacterial soap

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Antibacterial soaps have been heavily promoted to a health-conscious public. To date, there is no evidence that using recommended antiseptics or disinfectants selects for antibiotic-resistant organisms in nature.[43] However, antibacterial soaps contain common antibacterial agents such as triclosan, which has an extensive list of resistant strains of organisms. So, even if antibiotic resistant strains are not selected for by antibacterial soaps, they might not be as effective as they are marketed to be. Besides the surfactant and skin-protecting agent, the sophisticated formulations may contain acids (acetic acid, ascorbic acid, lactic acid) as pH regulator, antimicrobially active benzoic acid and further skin conditioners (aloe vera, vitamins, menthol, plant extracts).[44]

A 2007 meta-analysis from the University of Oregon School of Public Health indicated that plain soaps are as effective as consumer-grade anti-bacterial soaps containing triclosan in preventing illness and removing bacteria from the hands.[45] Dissenting, a 2011 meta-analysis in the Journal of Food Protection argued that when properly formulated, triclosan can grant a small but detectable improvement, as can chlorhexidine gluconate, iodophor, or povidone.[46][47]

Warm water

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Hot water that is still comfortable for washing hands is not hot enough to kill bacteria. Bacteria grow much faster at body temperature (37 °C). WHO considers warm soapy water to be more effective than cold, soapy water at removing natural oils which hold soils and bacteria.[48] But CDC mentions that warm water causes skin irritations more often and its ecological footprint is more significant.[1] Water temperatures from 4 to 40 °C do not differ significantly regarding removal of microbes. The most important factor is proper scrubbing.[49]

Contrary to popular belief, scientific studies have shown that using warm water has no effect on reducing the microbial load on hands.[49][50] Using hot water for handwashing can even be regarded as a waste of energy.[51]

Antiseptics (hand sanitizer)

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Hand disinfection procedure according to the German standard DIN EN 1500
Main article: Hand sanitizer

In situations where hand washing with soap is not an option (e.g., when in a public place with no access to wash facilities), a waterless hand sanitizer such as an alcohol hand gel can be used. They can be used in addition to hand washing to minimize risks when caring for "at-risk" groups. To be effective, alcohol hand gels should contain not less than 60%v/v alcohol. Enough hand antiseptic or alcohol rub must be used to thoroughly wet or cover both hands. The front and back of both hands and between and the ends of all fingers must be rubbed for approximately 30 seconds until the liquid, foam or gel is dry. Finger tips must be washed well too, rubbing them in both palms.[52]

A hand sanitizer or hand antiseptic is a non-water-based hand hygiene agent. In the late 1990s and early part of the 21st century, alcohol rub non-water-based hand hygiene agents (also known as alcohol-based hand rubs, antiseptic hand rubs, or hand sanitizers) began to gain popularity. Most are based on isopropyl alcohol or ethanol formulated together with a thickening agent such as Carbomer (polymer of acrylic acid) into a gel, or a humectant such as glycerin into a liquid, or foam for ease of use and to decrease the drying effect of the alcohol.[53] Adding diluted hydrogen peroxide increases further the antimicrobial activity.[54]

Hand sanitizers are most effective against bacteria and less effective against some viruses. Alcohol-based hand sanitizers are almost entirely ineffective against norovirus (or Norwalk) type viruses, the most common cause of contagious gastroenteritis.[55]

US Centers for Disease Control and Prevention recommend hand washing with soap over hand sanitizer rubs, particularly when hands are visibly dirty.[56] The increasing use of these agents is based on their ease of use and rapid killing activity against micro-organisms; however, they should not serve as a replacement for proper hand washing unless soap and water are unavailable. Despite their effectiveness, non-water agents do not cleanse the hands of organic material, but simply disinfect them. It is for this reason that hand sanitizers are not as effective as soap and water at preventing the spread of many pathogens, since the pathogens remain on the hands.[citation needed]

Wipes

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Hand washing using hand sanitizing wipes is an alternative during traveling in the absence of soap and water.[57] Alcohol-based hand sanitizer should contain at least 60% alcohol.[58]

Ash or mud

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Many people in low-income communities cannot afford soap and use ash or soil instead. The World Health Organization recommended ash or sand as an alternative to soap when soap is not available.[59] Use of ash is common in rural areas of developing countries and has in experiments been shown at least as effective as soap for removing pathogens.[60] However, evidence to support the use of ash to wash hands is of poor quality. It is not clear if washing hands with ash is effective at reducing viral or bacterial spreading compared to washing with mud, not washing, or with washing with water alone.[10] One concern is that if the soil or ash is contaminated with microorganisms it may increase the spread of disease rather than decrease it,[61] however, there is also no clear evidence to determine the level of risk.[10] Like soap, ash is also a disinfecting agent because in contact with water, it forms an alkaline solution.[62]

Technologies and design aspects

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Low-cost options when water is scarce

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A school girl using a Veronica Bucket in Ghana for handwashing

Various low-cost options can be made to facilitate hand washing where tap-water and/or soap is not available e.g. pouring water from a hanging jerrycan or gourd with suitable holes and/or using ash if needed in developing countries.[63]

In situations with limited water supply (such as schools or rural areas in developing countries), there are water-conserving solutions, such as "tippy-taps" and other low-cost options.[64] A tippy-tap is a simple technology using a jug suspended by a rope, and a foot-operated lever to pour a small amount of water over the hands and a bar of soap.[65]

Low-cost hand washing technologies for households may differ from facilities for multiple users.[66] For households, options include tippy taps, bucket/container with tap (such as a Veronica Bucket), conventional tap with/without basin, valve/tap fitted to bottles, bucket and cup, camp sink.[66] Options for multiple users include: adapting household technologies for multiple users, water container fitted to a pipe with multiple taps, water container fitted to a pipe with holes.[66]

Advanced technologies

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Several companies around the globe have developed technologies that aim to improve the hand washing process. Among the different inventions, there are eco-friendly devices that use 90% less water and 60% less soap compared to hand washing under a faucet.[67][68] Another device uses light-based rays to detect contaminants on the hands after they have been washed.[69]

Certain environments are especially sensitive to the transmission of pathogenic microorganisms, like health care and food production. Organizations attempting to prevent infection transmission in these environments have started using programmed washing cycles that provide sufficient time for scrubbing the hands with soap and rinsing them with water. Combined with AI-powered software, these technological advancements turn the hand-washing process into digital data, allowing individuals to receive insights and improve their hand hygiene practices.[70][71][72]

A nurse uses a smart hand washing device.

Drying with towels or hand driers

[edit]
Further information: Hand dryer

Effective drying of the hands is an essential part of the hand hygiene process. Therefore, the proper drying of hands after washing should be an integral part of the hand hygiene process in health care.[2]

The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) are clear and straightforward concerning hand hygiene, and recommend paper towels and hand dryers equally. Both have stressed the importance of frequent and thorough hand washing followed by their complete drying as a means to stop the spread of pathogens, like COVID-19. Specifically, the World Health Organization recommends that everyone "frequently clean [their] hands..." and "dry [them] thoroughly by using paper towels or a warm air dryer." The CDC report that, "Both [clean towels or air hand dryers] are effective ways to dry hands."

A study in 2020 found that hand dryers and paper towels were both found to be equally hygienic hand-drying solutions.[73]

However, there is some debate over the most effective form of drying in public toilets. A growing volume of research suggests paper towels are much more hygienic than the electric hand dryers found in many public toilets. A review in 2012 concluded that "From a hygiene standpoint, paper towels are superior to air dryers; therefore, paper towels should be recommended for use in locations in which hygiene is paramount, such as hospitals and clinics."[2]

Jet-air dryers were found to be capable of blowing micro-organisms from the hands and the unit and potentially contaminating other users and the environment up to 2 metres (6.6 feet) away.[74] In the same study in 2008 (sponsored by the paper-towel industry the European Tissue Symposium), use of a warm-air hand dryer spread micro-organisms only up to 0.25 metres (0.82 feet) from the dryer, and paper towels showed no significant spread of micro-organisms. No studies have found a correlation to hand dryers and human health, however, making these findings inconsequential.

Accessibility

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A community handwashing facility in Rwanda with sinks for people of different heights. During the COVID-19 pandemic in Rwanda handwashing was part of a system of public health measures encouraged to reduce transmission.

Making hand washing facilities accessible (inclusive) to everyone is crucial to maintain hand washing behavior.[66]: 27  Considerations for accessibility include age, disability, seasonality (with rains and muddiness), location and more. Important aspects for good accessibility include: Placement of the technology, paths, ramps, steps, type of tap, soap placement.[66]: 27 

Medical use

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Medical hand-washing became mandatory long after Hungarian physician Ignaz Semmelweis discovered its effectiveness (in 1846) in preventing disease in a hospital environment.[75] There are electronic devices that provide feedback to remind hospital staff to wash their hands when they forget.[76] One study has found decreased infection rates with their use.[77]

Method

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Medical hand-washing is for a minimum of 15 seconds, using generous amounts of soap and water or gel to lather and rub each part of the hands.[78] Hands should be rubbed together with digits interlocking. If there is debris under fingernails, a bristle brush may be used to remove it. Since pathogens may remain in the water on the hands, it is important to rinse well and wipe dry with a clean towel.[79] After drying, the paper towel should be used to turn off the water (and open any exit door if necessary). This avoids re-contaminating the hands from those surfaces.

The purpose of hand-washing in the health-care setting is to remove pathogenic microorganisms ("germs") and avoid transmitting them. The New England Journal of Medicine reports that a lack of hand-washing remains at unacceptable levels in most medical environments, with large numbers of doctors and nurses routinely forgetting to wash their hands before touching patients, thus transmitting microorganisms.[80] One study showed that proper hand-washing and other simple procedures can decrease the rate of catheter-related bloodstream infections by 66%.[81]

Video demonstration on hand washing

The World Health Organization has published a sheet demonstrating standard hand-washing and hand-rubbing in health-care sectors.[82] The draft guidance of hand hygiene by the organization can also be found at its website for public comment.[48] A relevant review was conducted by Whitby et al.[83] Commercial devices can measure and validate hand hygiene, if demonstration of regulatory compliance is required.

The World Health Organization has "Five Moments" for washing hands:

  • before patient care
  • after environmental contact
  • after exposure to blood/body fluids
  • before an aseptic task, and
  • after patient care.

The addition of antiseptic chemicals to soap ("medicated" or "antimicrobial" soaps) confers killing action to a hand-washing agent. Such killing action may be desired before performing surgery or in settings in which antibiotic-resistant organisms are highly prevalent.[84]

To 'scrub' one's hands for a surgical operation, it is necessary to have a tap that can be turned on and off without touching it with the hands, some chlorhexidine or iodine wash, sterile towels for drying the hands after washing, and a sterile brush for scrubbing and another sterile instrument for cleaning under the fingernails. All jewelry should be removed. This procedure requires washing the hands and forearms up to the elbow, usually 2–6 minutes. Long scrub-times (10 minutes) are not necessary. When rinsing, water on the forearms must be prevented from running back to the hands. After hand-washing is completed, the hands are dried with a sterile cloth and a surgical gown is donned.[citation needed]

Further information: Jewelry hygiene

Effectiveness in healthcare settings

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Microbial growth on a cultivation plate without procedures (A), after washing hands with soap (B) and after disinfection with alcohol (C)

To reduce the spread of pathogens, it is better to wash the hands or use a hand antiseptic before and after tending to a sick person.

For control of staphylococcal infections in hospitals, it has been found that the greatest benefit from hand-cleansing came from the first 20% of washing, and that very little additional benefit was gained when hand cleansing frequency was increased beyond 35%.[85] Washing with plain soap results in more than triple the rate of bacterial infectious disease transmitted to food as compared to washing with antibacterial soap.[86]

Comparing hand-rubbing with alcohol-based solution with hand washing with antibacterial soap for a median time of 30 seconds each showed that the alcohol hand-rubbing reduced bacterial contamination 26% more than the antibacterial soap.[87] But soap and water is more effective than alcohol-based hand rubs for reducing H1N1 influenza A virus[88] and Clostridioides difficile spores from hands.[89]

Interventions to improve hand hygiene in healthcare settings can involve education for staff on hand washing, increasing the availability of alcohol-based hand rub, and written and verbal reminders to staff.[90] There is a need for more research into which of these interventions are most effective in different healthcare settings.[90]

Developing countries

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World map for SDG 6 Indicator 6.2.1b in 2022: "Share of the population with basic handwashing facilities on premises"[91]

In developing countries, hand washing with soap is recognized as a cost-effective, essential tool for achieving good health, and even good nutrition.[36] However, a lack of reliable water supply, soap or hand washing facilities in people's homes, at schools and the workplace make it a challenge to achieve universal hand washing behaviors. For example, in most of rural Africa hand washing taps close to every private or public toilet are scarce, even though cheap options exist to build hand washing stations.[64] However, low hand washing rates can also be the result of engrained habits rather than due to a lack of soap or water.[92]

Hand washing at a global level has its own indicator within Sustainable Development Goal 6, Target 6.2 which states "By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations.[91] The corresponding Indicator 6.2.1 is formulated as follows: "Proportion of population using (a) safely managed sanitation services and (b) a hand-washing facility with soap and water" (see map to the right with data worldwide from 2017)."

Promotion campaigns

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The promotion and advocacy of hand washing with soap can influence policy decisions, raise awareness about the benefits of hand washing and lead to long-term behavior change of the population.[93] For this to work effectively, monitoring and evaluation are necessary. A systematic review of 70 studies found that community-based approaches are effective at increasing hand washing in LMICs, while social marketing campaigns are less effective.[94]

Poster used in Africa for raising awareness about hand washing after using the toilet with simple low-cost hand washing device

One example for hand washing promotion in schools is the "Three Star Approach" by UNICEF that encourages schools to take simple, inexpensive steps to ensure that students wash their hands with soap, among other hygienic requirements. When minimum standards are achieved, schools can move from one to ultimately three stars.[95] Building hand washing stations can be a part of hand washing promotion campaigns that are carried out to reduce diseases and child mortality.

Global Handwashing Day is another example of an awareness-raising campaign that is trying to achieve behavior change.[96]

As a result of the ongoing COVID-19 pandemic, UNICEF promoted the adoption of a hand washing emoji.[97]

Designing hand washing facilities that encourage use can use the following aspects:[66]

  • Nudges, cues and reminders
  • Hand washing facilities should be placed at convenient locations to encourage people to use them regularly and at the right times; they should be attractive and well maintained.

Cost effectiveness

[edit]
Hand washing stands at a school in Mysore district, Karnataka, India

Few studies have considered the overall cost effectiveness of hand washing in developing countries in relationship to DALYs averted. However, one review suggests that promoting hand washing with soap is significantly more cost-effective than other water and sanitation interventions.[98]

Cost-Effectiveness of Water Supply, Sanitation and Hygiene Promotion[98]
Intervention Costs (US$/DALY)
Hand-pump or standpost 94
House water connection 223
Water sector regulation 47
Basic sanitation – construction and promotion ≤270
Sanitation promotion only 11.2
Hygiene promotion 3.4

History

[edit]
Electronic sign inside a Washington Metro station during the COVID-19 pandemic

The importance of hand washing for human health – particularly for people in vulnerable circumstances like mothers who had just given birth or wounded soldiers in hospitals – was recognized by several pioneers of medicine during the 18th and 19th century: the English obstetrician Charles White in 1777, the Scottish physician Alexander Gordon in 1795,[99] the Scottish obstetrician James Young Simpson in 1840,[100] the American physician Oliver Wendell Holmes in 1843;[101][102] the Hungarian obstetrician Ignaz Semmelweis in 1847;[102][103] and Florence Nightingale, the English "founder of modern nursing", during the Crimean War.[104] At the time, most people still believed that infections were caused by foul odors called miasmas.

In the 1980s, foodborne outbreaks and healthcare-associated infections led the United States Centers for Disease Control and Prevention to more actively promote hand hygiene as an important way to prevent the spread of infection.[citation needed] The outbreak of swine flu in 2009 and the COVID-19 pandemic in 2020 led to increased awareness in many countries of the importance of washing hands with soap to protect oneself from such infectious diseases.[19] For example, posters with "correct hand washing techniques" were hung up next to hand washing sinks in public toilets and in the toilets of office buildings and airports in Germany.[citation needed] Research indicates that the COVID pandemic shifted social norms regarding hand washing, making it more prevalent worldwide.[105]

Society and culture

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Moral aspects

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The phrase "washing one's hands of" something, means declaring one's unwillingness to take responsibility for the thing or share complicity in it. It originates from the bible passage in Matthew where Pontius Pilate washed his hands of the decision to crucify Jesus Christ, but has become a phrase with a much wider usage in some English communities.[106]

In Shakespeare's Macbeth, Lady Macbeth begins to compulsively wash her hands in an attempt to cleanse an imagined stain, representing her guilty conscience regarding crimes she had committed and induced her husband to commit.[107]

See also

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References

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[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Hand washing

View on Grokipedia
from Grokipedia
Hand washing, also termed , constitutes a core prevention measure involving the mechanical removal of transient microorganisms, dirt, and from the skin of the hands through friction with and or alcohol-based antiseptics, thereby interrupting the fecal-oral and respiratory routes of . This practice targets the hands as primary vectors for healthcare-associated infections (HAIs) and community-acquired diseases, with establishing it as the simplest and most cost-effective intervention for reducing microbial cross-contamination. The causal efficacy of hand washing traces to mid-19th-century observations by Hungarian physician , who in linked high puerperal fever mortality in hospital maternity wards—exceeding 10%—to by attending staff; mandating hand disinfection with chlorinated lime solution reduced case fatality to under 2%, providing early quantitative demonstration of its protective impact against bacterial . Subsequent microbiological validation confirmed that proper technique achieves log reductions in bacterial load exceeding 2 on average, with soap and water outperforming sanitizers against certain enveloped viruses and spore-formers like Clostridium difficile. Systematic reviews of randomized trials further quantify benefits, showing handwashing promotion yields 12-21% reductions in acute respiratory infections and up to 30-48% for diarrheal diseases in community settings, effects attributable to direct removal rather than indirect factors like alone. Standard protocols, as delineated by bodies such as the CDC and WHO, prescribe wetting hands under running water, applying soap, vigorous lathering covering all surfaces for at least 20 seconds (including backs, thumbs, and fingertips), thorough rinsing, and drying with a clean or air dryer to avoid recontamination—steps empirically tied to maximal microbial clearance. Despite robust evidence, real-world adherence remains suboptimal, often below 50% in healthcare environments due to time constraints and behavioral inertia. In contrast, self-reported handwashing habits among U.S. adults during the COVID-19 pandemic in June 2020 were generally higher, according to CDC surveys: 94.8% reported remembering to wash hands after using the bathroom in public (similar to 95.5% in October 2019), 89.6% after using the bathroom at home (up from 85.9%), 71.2% after coughing, sneezing, or blowing nose (up from 53.3%), 74.4% before eating at home (up from 62.8%), and 85.2% reported always or often engaging in hand hygiene after contact with high-touch public surfaces, with 78.5% frequently using soap and water. These rates represented significant increases from prepandemic levels in several situations but remained below 75% in various everyday scenarios. These findings highlight implementation as the principal barrier to broader causal impact. Controversies persist regarding sanitizer equivalence to soap in non-outbreak scenarios, with data indicating inferior performance against and protozoal cysts, underscoring context-specific application over universal substitution.

Procedure and Recommendations

Standard Technique

The standard technique for hand washing with and water, as recommended by the Centers for Disease Control and Prevention (CDC), involves a sequence of steps designed to remove , , and transient microorganisms from the skin. This method emphasizes thorough mechanical action through to dislodge pathogens, supplemented by soap's emulsifying properties. Begin by wetting hands with clean, running —either warm or cold—to facilitate distribution without requiring hot , which does not enhance efficacy beyond tepid temperatures. Turn off the faucet to conserve , then apply sufficient liquid, bar, or to cover all hand surfaces, as inadequate reduces lathering effectiveness. Lather hands by rubbing them together vigorously, focusing on the backs of hands, between fingers, and under nails where accumulate. Continue scrubbing for at least 20 seconds, equivalent to singing "Happy Birthday" twice, to ensure sufficient contact time for removal; studies indicate this duration achieves log reductions in bacterial counts comparable to longer washes when combined with proper technique. Rinse hands thoroughly under running water to remove soap and loosened contaminants, directing flow downward to avoid recontamination. Dry hands using a clean or air dryer, as wet surfaces promote microbial growth; towel drying is preferable in low-humidity environments for better removal of residual moisture. The (WHO) endorses a similar process but specifies six rubbing motions for healthcare settings to ensure comprehensive coverage: palm-to-palm, right palm over left dorsum with interlaced fingers (and vice versa), palms with interlaced fingers, backs of fingers to opposing palms, rotational rubbing of thumbs, and rotational rubbing of clasped fingers in the opposite palm. These steps, performed for 20-30 seconds, align with CDC guidelines for public use but provide granular instruction for high-risk contexts.

Duration and Frequency

The recommended duration for hand washing with and in settings is at least 20 seconds, a guideline supported by indicating that this length achieves substantial reduction in transient microorganisms while balancing practicality. Scientific studies corroborate that washing for 15-30 seconds removes more pathogens than shorter durations, with microbial log reductions increasing up to approximately 31 seconds in controlled evaluations of technique, though plateaus beyond this for typical loads. In healthcare environments, non-surgical hand washing follows similar 20-second protocols, whereas surgical scrubs require 2-6 minutes to ensure deeper of resident flora. Frequency of hand washing lacks a universal daily quota due to variability in exposure risks, but meta-analyses of intervention studies demonstrate that exceeding 10 episodes per day correlates with reduced incidence of respiratory s (odds ratio 0.59) and gastrointestinal illness compared to 10 or fewer. In control groups from randomized trials, baseline frequencies ranged from 1-8 washes daily, while promoted behaviors reached 4-17, yielding dose-response benefits up to a point of influenced by compliance fatigue and environmental factors. Healthcare workers may perform up to 100 cleans per shift in high-acuity settings to mitigate nosocomial transmission, though real-world adherence often falls short, underscoring the need for context-specific targeting over arbitrary totals. Empirical data emphasize opportunity-based prompting—such as after contact with bodily fluids—over rigid counts to optimize causal impact on rates without overemphasizing unattainable ideals.

Situations Requiring Hand Washing

Hand washing with and is required in situations involving potential exposure to fecal matter, bodily fluids, or environmental contaminants that harbor pathogens capable of causing gastrointestinal, respiratory, or skin infections. from studies indicates that such practices reduce diarrheal diseases by up to 30-40% and respiratory infections by 16-21% in community settings. Key situations include:
  • After using the toilet or assisting with toileting: Fecal-oral transmission of pathogens like Escherichia coli, norovirus, and hepatitis A is a primary route for infections; CDC guidelines mandate washing regardless of home or public facilities, as residual germs can persist on hands. For instance, in a realistic everyday scene following a bowel movement, a person stands at the sink washing their hands, often with messy hair and a flushed face resulting from straining during defecation, reflecting the natural, unpolished appearance common in private bathroom moments.
  • Before, during, and after food preparation: Contact with raw meats, poultry, or unwashed produce introduces bacteria such as Salmonella and Campylobacter; interrupting this chain prevents cross-contamination, with studies showing reduced foodborne illness incidence.
  • Before eating: Hands accumulate transient microbes from surfaces; washing prior to meals minimizes ingestion of pathogens, supported by randomized trials demonstrating lower infection rates.
  • After handling garbage or soiled items: Waste contains diverse microbes; post-contact washing averts transfer to mucous membranes or food.
  • After coughing, sneezing, or blowing the nose into hands: Respiratory droplets deposit viruses like influenza or SARS-CoV-2; immediate washing limits fomite-mediated spread.
  • After touching animals, their feed, or waste: Zoonotic agents such as Salmonella from pet reptiles or feces necessitate decontamination to prevent transmission.
  • Before and after treating wounds or applying medication: This avoids introducing skin flora or environmental bacteria into breaches, reducing secondary infection risk.
  • After contact with visibly soiled hands or in low-water scenarios: Soap and water are essential when alcohol sanitizers fail against certain spores like Clostridium difficile.
In resource-limited environments, prioritization focuses on high-risk contacts, as WHO data show hand washing facilities correlate with lower child mortality from preventable diseases. Compliance varies, with observational studies reporting only 20-40% adherence in non-healthcare settings despite proven efficacy.

Scientific Basis and Effectiveness

Mechanisms of Pathogen Removal

Hand washing primarily achieves removal through mechanical generated by rubbing the hands together under running , which dislodges transient microorganisms, , and adhering to the skin surface. This physical action, combined with the flow of , rinses away the loosened contaminants, reducing microbial load without relying on inherent properties of alone. Studies demonstrate that even brief washing durations, such as 15 seconds with plain , can achieve partial bacterial reduction, though efficacy increases substantially with added and . The incorporation of enhances mechanical removal by acting as a that lowers , emulsifies and oils that trap , and suspends microbes for easier rinsing. Plain (non-antimicrobial) soaps exhibit minimal direct killing activity but facilitate the detachment of loosely adherent transient , with peer-reviewed evaluations showing hand washing with soap and water yielding a bacterial log10 reduction exceeding 2 (95% CI 1.91–2.33). For enveloped viruses, such as certain coronaviruses, soap's amphipathic molecules can insert into membranes, disrupting envelope integrity and inactivating the prior to mechanical removal. This dual action contrasts with water-only washing, which relies solely on dilution and flow but leaves more residues. Pathogen-specific outcomes vary: bacterial counts on hands drop by 77–92% with and compared to 56% with alone, while non-enveloped viruses and resilient spores demand thorough technique for effective clearance, as mechanical shear alone may not suffice against embedded contaminants. Overall log reductions of 0.6–1.1 for 15–30 seconds of washing underscore the dose-response relationship between duration, vigor of , and microbial elimination, with inadequate rubbing preserving higher . These mechanisms underpin hand washing's role in interrupting fecal-oral transmission and contact spread, though they do not eradicate resident .

Evidence from Clinical and Public Health Studies

Clinical trials and meta-analyses have demonstrated that hand washing with and water significantly reduces microbial load on hands, typically achieving greater than 2 log reductions in bacterial counts. In healthcare settings, interventions promoting hand , including soap-and-water washing, have been associated with reductions in healthcare-associated infections (HAIs) by 40-60%, with compliance rates around 60% correlating to lower HAI incidence. Public health studies in community settings show that promoting hand washing with soap prevents approximately 30% of diarrhea-related illnesses and 20% of respiratory infections. A systematic review of randomized controlled trials found that such interventions reduce the risk of diarrheal disease by 47% (95% CI 24-63%). For acute respiratory infections, meta-analyses confirm consistent reductions, with hand washing before and after food preparation, after defecation, and after cleaning dishes lowering odds of diarrhea and respiratory illness by over 70% in observational cohorts. In low-compliance environments, such as during outbreaks, hand washing protocols have proven effective against specific pathogens; for instance, trials during the reinforced reductions in transmission through frequent soap-based washing, though alcohol rubs often outperform soap for rapid bacterial (83% vs. 58% median reduction). These findings underscore causal links between mechanical removal via soap friction and surfactant action and decreased , independent of confounding factors like status in controlled studies.

Limitations, Myths, and Criticisms

Hand washing with soap and water mechanically removes many transient pathogens from the skin but fails to eliminate certain resilient , such as those of (C. difficile), which require specific friction and rinsing to dislodge effectively; alcohol-based alternatives are even less potent against these . Studies demonstrate that while soap and water reduce C. difficile counts on hands more than alcohol rubs, incomplete removal persists without vigorous technique, contributing to ongoing transmission in healthcare settings where environmental amplifies risks. Proper execution is essential, as suboptimal duration or coverage leaves up to 50% of intact, underscoring that hand washing alone cannot fully interrupt chains involving fomites or airborne routes. Frequent hand washing can induce dermatological issues, including dryness, irritation, and , particularly with harsh soaps or in high-compliance environments like hospitals, where adherence rates hover below 50% partly due to these discomforts. In resource-limited community settings, barriers such as inadequate water access or infrastructure hinder efficacy, with promotion programs showing inconsistent reductions in diarrheal or respiratory infections despite targeted interventions. Common myths include the belief that hot water enhances germ removal or kills microorganisms compared to cold; however, hot water at 40–50 °C does not effectively kill microorganisms, requiring sustained exposure above 60 °C for significant lethality, and only temporarily slows their growth during brief exposure. Controlled trials indicate no significant bacterial reduction difference between water at 15–38°C (59–100°F), with warmer temperatures risking greater skin irritation without added hygienic benefit. For handwashing, soap's mechanical removal and emulsification via are primary, with temperature playing a negligible role beyond comfort and lather facilitation. Another misconception is that inherently kills microbes rather than primarily detaching them via and mechanical action, as evidenced by equivalent efficacy of plain versus against most transient . Assertions that gloves obviate hand washing ignore risks during donning/doffing, where breaches allow transfer unless protocols are layered. Criticisms of hand hygiene frameworks, such as the "Five Moments for Hand Hygiene," highlight their incompleteness in addressing non-direct patient transmissions from distant contaminated surfaces, which harbor pathogens evading moment-based protocols. Public health campaigns often prioritize promotion over systemic fixes like or workload relief, yielding suboptimal adherence—e.g., nurses citing time constraints during peaks like —while overlooking that hand washing's impact diminishes against viruses with low hand-mediated spread. Overemphasis may foster complacency, as isolated hand hygiene without concurrent environmental or ventilation controls proves insufficient for sustained control, per analyses of multifaceted outbreaks.

Agents and Methods

Soap and Water Variants

Plain , consisting of derived from fats or oils, effectively removes from hands through mechanical disruption of microbial to and emulsification of and debris, allowing rinsing with to carry away contaminants. This process reduces bacterial counts by 1-3 log10 units, depending on washing duration and technique, outperforming water alone by factors of 10 to 100 in microbial reduction. Health authorities such as the CDC and WHO endorse plain soap in various forms—bar, liquid, leaf, or powder—for routine hand washing, as these variants achieve comparable pathogen removal without requiring additives. Antibacterial soaps, incorporating agents like or , were marketed for enhanced germ-killing but lack evidence of superior efficacy over plain in preventing community-acquired infections. The FDA's 2016 final rule, reaffirmed in subsequent reviews, concluded that over-the-counter antibacterial washes provide no added benefit against or viruses compared to plain and , citing insufficient data from controlled trials. Real-world studies, including those simulating household conditions, found no significant difference in bacterial contamination reduction between plain and triclosan-containing soaps (0.3% concentration). Potential drawbacks include promotion of and environmental persistence of active ingredients, leading to voluntary phase-outs of in many formulations by 2019. In contrast, isolated tests reported 70-80% greater bacterial log reductions with antibacterial soaps, but these overlook real-life variables like dilution in rinse and viral inefficacy. Bar and liquid soaps demonstrate equivalent microbial reduction , with both forms leveraging properties to suspend and rinse away transient . soaps are often preferred in shared settings to minimize cross-contamination risks from bar soap residue, though hygienic storage (e.g., drained racks) mitigates this for bars. Despite the inclusion of additives intended to improve mildness, such as glycerin (a humectant) and cocamide DEA (a foam booster and surfactant), liquid hand soaps can still cause skin dryness. Surfactants, including cocamide DEA, strip natural skin oils during cleansing, disrupting the skin barrier and potentially leading to irritation in some individuals. Glycerin attracts moisture but provides limited lasting benefit in rinse-off products, as it is largely washed away without substantial deposition. Additional factors such as insufficient emollient concentration, high surfactant strength, or residual surfactant on the skin may exacerbate dryness. Foaming variants, diluted soaps dispensed with air, yield similar bacterial removal to standard liquids but may underperform against certain viruses like MS2 due to lower concentration. Overall, variant selection should prioritize availability and proper use over formulation differences, as mechanical friction and thorough rinsing remain the primary determinants of .

Alcohol-Based Sanitizers and Antiseptics

Alcohol-based hand sanitizers, also known as alcohol hand rubs or rubs, primarily consist of ethanol (ethyl alcohol) or isopropanol (isopropyl alcohol) at concentrations of 60% to 95% by volume, often combined with emollients like glycerol to reduce skin irritation and hydrogen peroxide to inactivate bacterial spores. The World Health Organization (WHO) endorses specific formulations, such as one with 80% ethanol or 75% isopropanol, plus 1.45% glycerol and 0.125% hydrogen peroxide, for local production in resource-limited settings to ensure broad antimicrobial activity. These agents function by denaturing microbial proteins, disrupting cell membranes, and dissolving lipid envelopes, achieving rapid bactericidal and virucidal effects within 10-30 seconds of application. Systematic reviews confirm that alcohol-based sanitizers effectively reduce transient flora and inactivate enveloped viruses, including coronaviruses, , and many bacteria such as and , with log reductions often exceeding 4-5 logs and on skin surfaces. For instance, sanitizers with 60-80% demonstrate superior against lipid-enveloped pathogens compared to lower concentrations, outperforming non-alcohol alternatives in most clinical scenarios where hands are not soiled. However, efficacy diminishes against non-enveloped viruses like or , fungal spores, and certain , where mechanical removal via and water remains preferable. The Centers for Disease Control and Prevention (CDC) recommends alcohol-based sanitizers containing at least 60% alcohol as an alternative to handwashing when and are unavailable and hands are not visibly dirty, advising application of sufficient volume to cover all surfaces and rubbing until dry (approximately 20 seconds). In healthcare settings, WHO guidelines specify 20-30 seconds of rubbing for standard antisepsis, extending to 3 minutes for surgical preparation with higher-concentration formulations. Compliance studies indicate these methods reduce healthcare-associated infections by 16-41% when integrated into protocols, though real-world effectiveness depends on proper volume (at least 2-3 mL) and technique. Limitations include ineffectiveness on soiled hands, where neutralizes alcohol; potential for dryness, , or with frequent use (affecting up to 10-20% of users in high-exposure groups); and risks like flammability, accidental ingestion leading to poisoning (particularly in children, with cases of reported), and reduced activity in low temperatures. Peer-reviewed analyses emphasize that while sanitizers excel in convenience and speed, they do not replace soap-and-water for removing or certain resilient pathogens, and overuse may select for alcohol-tolerant microbes, though evidence for widespread resistance remains limited.

Low-Resource Alternatives

In settings lacking access to and running , such as many rural or low-income communities, improvised hand cleaning methods including , , and have been utilized to mechanically remove dirt and pathogens from hands. These approaches leverage physical and abrasion to dislodge microbes, with ash potentially offering additional effects due to its alkaline , which can inactivate certain and viruses. However, their efficacy is generally inferior to and , achieving lower log reductions in microbial load, and they carry risks of incomplete or recontamination from faecally polluted materials. Wood ash, derived from burnt plant materials, has shown promise in and field tests for reducing bacterial . A study in rural found that rubbing hands with followed by water rinsing significantly lowered faecal coliform concentrations compared to rinsing with water alone, achieving greater than 90% reduction in viable organisms. Similarly, ash rubbing has demonstrated viral surrogate reductions of approximately 1-2 log10 in controlled experiments, though less effectively than , which typically exceeds 3 log10. The has acknowledged ash as a potential interim measure in water-scarce environments but emphasizes it as a supplement rather than a replacement for standard when resources permit. Sand or fine soil rubbing provides abrasive mechanical action to scrape away transient microbes and organic matter, particularly useful in arid regions. Research indicates sand can yield log10 reductions of up to 3.7 in bacterial counts, outperforming water alone but trailing soap in consistency and breadth of pathogen removal. A synthesis of methods in low- and middle-income countries notes that dry sand friction dislodges surface contaminants effectively before any available rinsing, though efficacy diminishes without subsequent water to wash away loosened particles. Mud or clay, as tested in Bangladesh, surpassed water-only washing by enhancing particulate removal through adsorption, yet introduces variability based on local soil quality. Despite these benefits over no intervention, systematic reviews highlight low-certainty for prevention outcomes, with most data from surrogate microbe studies rather than direct transmission trials. Cochrane analyses conclude uncertainty regarding ash's superiority to for reducing viral or bacterial spread, citing small sample sizes and heterogeneous protocols. risks persist, as soil or from unsanitary sources may harbor pathogens, underscoring the need for clean materials and combining methods with and rinsing where possible. In extreme scarcity, these alternatives align with causal principles of physical disruption over chemical inaction, but scalable improvements in access remain prioritized for impact.

Applications in Practice

Healthcare Settings

Hand hygiene practices in healthcare settings serve as a primary intervention to prevent healthcare-associated infections (HAIs), which affect millions of annually and contribute to significant morbidity and mortality. Empirical evidence indicates that adherence to hand hygiene protocols can reduce HAI rates by up to 50%, with meta-analyses showing that compliance rates around 60% correlate with substantial decreases in infection incidence. The (WHO) outlines five key moments for hand hygiene: before touching a , before clean/aseptic procedures, after body fluid exposure risk, after touching a , and after touching patient surroundings. Similarly, the Centers for Disease Control and Prevention (CDC) recommends hand hygiene before and after patient contact, after glove removal, and in other high-risk scenarios, emphasizing alcohol-based hand rubs (ABHR) when hands are not visibly soiled due to their superior efficacy against most pathogens compared to and . Clinical studies and systematic reviews confirm the causal link between improved hand hygiene and reduced HAIs, including bloodstream infections and . For instance, interventions enhancing compliance have demonstrated HAI reductions of 20-40% in intensive care units, with ABHR outperforming traditional washing in microbial load reduction for enveloped viruses and , though remains essential for removing spores like those of difficile. Despite this evidence, global compliance rates hover between 40% and 60%, with lower figures in low-resource settings (around 9% in critical care) and variability by profession—nurses often exceeding physicians. Barriers include workload, skin irritation, and accessibility issues, though multifaceted interventions like education, reminders, and performance feedback have boosted rates to over 80% in some facilities. In surgical and procedural contexts, preoperative hand antisepsis with agents is standard, reducing surgical site infections through sustained antimicrobial activity. Monitoring compliance via direct or electronic systems reveals persistent gaps, underscoring the need for ongoing quality improvement; for example, a 2024 study reported baseline rates of 38% improving to 63% post-ABHR . While academic sources may underemphasize in non-compliance—favoring structural excuses— points to individual and as key levers for sustained efficacy. Overall, hand hygiene's role in causal chains of transmission remains empirically robust, with non-adherence directly attributable to preventable outbreaks in peer-reviewed outbreak investigations.

Community and Household Use

In household settings, hand washing with and water is recommended before preparing , eating, and after using the , changing diapers, or handling animals to prevent transmission of gastrointestinal and respiratory pathogens. Systematic reviews indicate that promoting hand washing with reduces acute respiratory infections by 11-21% in and household contexts, with stronger effects against diarrheal diseases, potentially averting up to 25% of episodes.00021-1/fulltext) Higher hand washing frequency correlates with lower illness incidence, particularly for gastrointestinal infections, though evidence for respiratory benefits is more variable. Community guidelines emphasize hand washing with plain and running for at least 20 seconds in homes, schools, and spaces, using single-use towels for drying to minimize recontamination. In schools and early care settings, hand interventions significantly decrease from gastrointestinal and respiratory illnesses, with access to and facilities improving compliance and rates. spaces often face barriers like shortages, which hinder effective practices despite evidence that hand washing removes germs more thoroughly than sanitizers when hands are soiled. Educational campaigns in households and communities reinforce proper technique—wetting hands, applying , scrubbing for 20 seconds including thumbs and nails, rinsing, and drying—to maximize removal. Studies in non-healthcare settings confirm hand hygiene reduces respiratory infection transmission by 16-21%, though sustained adherence remains challenging without infrastructural support like accessible sinks. In shared community environments, such as public restrooms or transit, visible reminders and supplies encourage compliance, aligning with causal mechanisms where mechanical action and disrupt microbial biofilms on .

Developing Regions and Global Disparities

In 2023, only 43% of the world's population had access to basic handwashing facilities with soap and water at home (representing about 3.5 billion people without such access) according to the WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply, Sanitation and Hygiene. Globally, there is no single unified statistic for the rate of handwashing with soap after using the toilet due to limited consistent measurement of behavior worldwide. However, access to handwashing facilities is the most reliable global indicator and serves as a prerequisite for the practice. Coverage varies sharply by income level, with high-income countries achieving near-universal access, while low- and middle-income countries, particularly in sub-Saharan Africa and South Asia, report significantly lower rates. For instance, in sub-Saharan Africa, over 50% of the population lacked such facilities as of 2019, exacerbating vulnerability to infectious diseases amid limited water resources and sanitation systems. In low-income countries, access drops to around 25% or less. Studies in low- and middle-income countries show that actual handwashing with soap after defecation is often much lower than self-reported rates, typically ranging from 5-30% depending on the region and setting, with observed rates frequently below 20%. Developing regions face compounded challenges due to poverty, rural isolation, and inadequate infrastructure, where handwashing prevalence remains low despite evidence of its efficacy in reducing disease transmission. A 2022 analysis of Demographic and Health Surveys indicated that 71.64% of households in low-income countries had limited handwashing facilities, correlating with higher incidences of diarrheal diseases and acute respiratory infections among children under five. In these areas, open defecation and water scarcity further undermine hygiene practices, with unsafe water, sanitation, and hygiene (WASH) practices attributable to an estimated 1.4 million deaths annually worldwide, disproportionately affecting low-income populations. Global progress has been uneven, with basic hygiene coverage rising from 66% in 2015 to 80% by 2024, yet an 18-fold acceleration is needed in low-income countries to meet Sustainable Development Goal targets by 2030. Inadequate handwashing contributes to 13% of the disease burden from acute respiratory infections in children, equating to substantial disability-adjusted life years lost, particularly in regions where soap availability and behavioral norms lag due to economic constraints rather than lack of awareness. These disparities not only perpetuate cycles of illness and poverty but also amplify risks during outbreaks, as seen in heightened COVID-19 transmission in areas without basic facilities.

Technological and Design Innovations

Drying Methods and Their Efficacy

After hand washing, proper drying is essential because wet facilitates greater bacterial transfer to surfaces compared to dry , with studies indicating up to 1,000 times more microbial transfer from wet hands. Common methods include disposable paper towels, reusable cloth towels, warm air dryers, and high-velocity jet air dryers. Paper towels achieve drying times of 10-15 seconds through mechanical friction, which aids in physical removal of residual microbes, while electric dryers rely on or high-speed air, often requiring 20-45 seconds or more. Peer-reviewed comparisons demonstrate that paper towels generally outperform traditional warm air dryers in reducing bacterial counts on hands post-washing. A randomized trial found that paper towel drying yielded greater log reductions in on palms and fingers (e.g., 1.4-2.0 log10) compared to stationary warm air (0.4-1.0 log10), attributing this to friction-enhanced removal rather than alone. Jet air dryers, which use high-speed (up to 600 km/h), can match or exceed paper towels in microbial reduction when times are under 12-15 seconds, with one study reporting superior elimination of hand versus paper towels or warm air. However, prolonged rubbing during warm air can reintroduce accrued during washing, negating gains. Environmental contamination risks differ markedly: warm and jet air dryers aerosolize into the air and onto nearby surfaces at higher rates than towels, with one analysis detecting up to 27 times more airborne microbes from jet dryers. towels minimize this by containing contaminants in disposable material, reducing transfer to users' clothing or adjacent areas by 77% or more in controlled tests. Cloth towels, while absorbent, pose recontamination risks from shared use unless laundered frequently, and are inferior to paper towels in bacterial removal per systematic reviews.
MethodAvg. Drying TimeBacterial Reduction on HandsEnvironmental Contamination RiskKey Study Evidence
Paper Towels10-15 sHigh (up to 77% removal via friction)Low (contaminants contained)Greater log10 reductions vs. air; less surface transfer
Warm Air Dryers30-45 sModerate (evaporation-limited)High (aerosolization)Lower efficacy if rubbing; increases airborne microbes
Jet Air Dryers10-20 sHigh (if rapid; comparable to PT)Moderate to High (velocity spreads particles)Best for hand bacteria in short cycles, but disperses to surroundings
Overall, from multiple trials favors paper towels for balanced in microbial removal and minimal secondary spread, though ultra-rapid jet dryers (<30 seconds) may offer hygienic equivalence in high-throughput settings without excessive . Variations in study outcomes stem from factors like airflow velocity, hand-washing thoroughness, and baseline microbial load, underscoring the need for method-specific validation in context.

Automated and AI-Enhanced Systems

Automated and AI-enhanced hand washing systems integrate sensors, wearables, and technologies to track compliance, validate technique, and deliver real-time feedback, targeting healthcare environments to curb healthcare-associated infections. These systems typically link electronic dispensers with RFID badges or wristbands to record individual usage tied to room entries and exits, generating objective data without . AI components employ algorithms, such as convolutional neural networks, to detect dispenser activation from video feeds or assess washing via depth sensors capturing three-dimensional user silhouettes. Notable implementations include Vitalacy's platform, which uses wearable sensors for proximity-based monitoring and analytics, guaranteeing a 25% reduction in HAIs through compliance improvements. SureWash, an AI system introduced around 2013, projects instructional guides onto hands while cameras evaluate coverage and duration against WHO standards, demonstrating efficacy in technique training during evaluations. In April 2025, deployed the Artificially Intelligent Monitoring System (AIMS), Canada's first such initiative, to analyze and enhance hand practices via automated insights. IoT-based variants incorporate ultrasonic sensors for duration measurement and pressure sensors for agent application, enabling precise event logging in intensive care units. Peer-reviewed supports : a 2023 meta-analysis of intelligent technologies reported significant hand rate increases in hospitals, with standardized mean differences indicating robust intervention effects. Validation studies show automated systems achieving 92% accuracy in event detection compared to human observation, mitigating underreporting from direct audits. Real-time reminders in monitored rooms have sustained compliance gains over three years, with activated feedback in 20% of areas yielding facility-wide improvements. However, adoption debates highlight risks from continuous and potential over-reliance on technology without behavioral reinforcement.

Accessibility and Ergonomic Considerations

in hand washing facilities requires designs that accommodate individuals with disabilities, older adults, and children to prevent dependency and ensure independent use. Inaccessible , such as high-mounted sinks or twist faucets, poses barriers for those with mobility impairments or limited dexterity, leading to reduced compliance. Guidelines from organizations like emphasize modifying existing sinks with lever-arm taps for hands-free operation and ensuring clear floor space for approach, typically at least 30 inches by 48 inches. standards mandate that handwashing facilities be readily accessible to employees, including provisions for reaching soap dispensers and controls without excessive effort. Ergonomic considerations focus on minimizing physical strain during the 20-40 second handwashing process to promote sustained compliance, particularly in high-frequency settings like healthcare. Sinks positioned at 34-36 inches high for standing users reduce back bending, while adjustable or knee-operated models accommodate varying heights and prevent repetitive stress injuries. Sensor-activated faucets and dispensers eliminate manual twisting, lowering musculoskeletal risks and cross-contamination, as evidenced by designs that require minimal force—under 5 pounds per American with Disabilities Act principles adapted for hygiene stations. Non-slip flooring and elbow-height placement further enhance , with studies showing ergonomic stations increase handwashing frequency by facilitating natural postures. Universal design principles integrate these elements for broad applicability, ensuring facilities are intuitive and low-effort for all users, including those with visual or cognitive impairments through tactile indicators and simple sequences. In low-resource contexts, portable stations with foot pedals address reach barriers for disabled users, though maintenance challenges can undermine long-term accessibility. Empirical data from disability-inclusive WASH programs indicate that such adaptations reduce infection risks by enabling consistent hygiene without assistance.

Historical Development

Ancient and Pre-Scientific Practices

In , around 1500 BCE, the , one of the oldest medical texts, emphasized washing hands before eating and after as part of routines to maintain health. Egyptian priests bathed up to four times daily, with hand washing integrated into rituals for purity, reflecting an early empirical recognition of cleanliness's role in preventing ailments, though without knowledge of microbial causes. Aristocratic homes by this era featured for hot and cold water, facilitating frequent ablutions including hand cleansing. Across the and Mediterranean, hand washing before meals was commonplace, serving both practical and ceremonial purposes in civilizations like those of and , where soap-like substances emerged around 2800 BCE for personal . In , cuneiform records indicate and cleansing rituals, with hand washing implied in daily norms derived from codes. Greek and Roman practices extended this to facilities, though emphasis remained on ritualistic purity rather than control, predating scientific validation. Religious traditions institutionalized hand washing long before germ theory. In Judaism, netilat yadayim—pouring water over hands before meals and prayers—dates to biblical injunctions in Exodus (circa 13th century BCE), motivated by spiritual impurity removal rather than hygiene alone, yet aligning with observed benefits of cleanliness. Islam's ablution, prescribed in the (7th century CE), requires washing hands thrice before prayers, embedding the practice in daily life for ritual purity across Muslim societies. Hinduism, via texts like the (circa 200 BCE–200 CE), mandated hand washing before meals, after use, and prior to , tying it to (non-harm) and empirical health preservation. These pre-scientific customs, spanning millennia, relied on cultural and observational —linking visible dirt to illness—without microscopic evidence, yet reduced contamination risks coincidentally. Medieval figures like (1138–1204 CE) advocated hand washing in medical contexts for , as detailed in his treatise on , recognizing its prophylactic value empirically amid plague eras, though still framed in humoral theory. Such practices persisted into the primarily through religious and customary enforcement, with sporadic endorsements in non-Western traditions like ancient Indian Ayurvedic texts urging hand cleansing to balance doshas and avert disease. Overall, these rituals demonstrated causal awareness of transmission via unclean hands, grounded in first-hand experience rather than theory, contrasting later scientific paradigms.

19th-Century Breakthroughs and Resistance

In the mid-1840s, Hungarian physician observed stark disparities in maternal mortality from puerperal fever at General Hospital's maternity clinics: the doctor-attended First Clinic reported rates averaging 9.92% in 1846, compared to 3.88% in the midwife-attended Second Clinic. attributed this to doctors transferring cadaveric matter from autopsies to patients via unwashed hands, a hypothesis solidified after a colleague's death in 1847 from a wound during an autopsy, mirroring puerperal fever symptoms. Lacking knowledge of germ theory, he posited an invisible, preventable contagion rather than miasma or inevitable fate. On May 15, 1847, Semmelweis mandated hand disinfection with a 1% chlorinated lime solution for all staff transitioning from autopsies or ward duties to patient examinations, targeting the removal of decomposing . This intervention yielded immediate results: maternal mortality in the plummeted from 18.27% in March 1847 to 1.27% in June, and averaged 1-2% thereafter during consistent enforcement, aligning closely with the 's rates and providing empirical evidence of hand 's causal role in interrupting transmission. Semmelweis extended these protocols to general practices, further reducing infections, though compliance waned without strict oversight. Semmelweis detailed his findings in the 1861 treatise Etiology, Concept and Prophylaxis of Childbed Fever, advocating chlorine-based hand washing as prophylaxis against iatrogenic infections, supported by statistical data from and later Budapest clinics where similar reductions occurred. Concurrently, figures like reinforced hygiene's importance during the (1853-1856), implementing hand washing and in British military hospitals, which halved mortality rates from 42% to 2% through cleanliness protocols amid overcrowding and poor ventilation. Despite empirical successes, Semmelweis encountered vehement resistance from the medical establishment, who rejected his claims as unsubstantiated without a microscopic or theoretical basis—prefiguring germ theory's acceptance in the —and viewed the implication of physician culpability as a personal affront to professional honor. Critics, including influential Viennese professors, dismissed his data as coincidental or methodologically flawed, prioritizing humoral or atmospheric theories over interventionist evidence; this led to his dismissal from in 1849 and marginalization in , where opposition from academic gatekeepers stifled broader adoption. Such resistance exemplified systemic inertia against paradigm-shifting practices lacking alignment with prevailing doctrines, delaying hand washing's institutionalization until antisepsis advancements later in the century.

20th- and 21st-Century Adoption and Campaigns

Handwashing adoption accelerated in the as germ theory became entrenched in medical practice, though initial resistance persisted into the early decades. campaigns emerged to promote handwashing for disease prevention, particularly in educational and community settings; for instance, schoolchildren were routinely encouraged to wash hands before meals by the 1940s. Systematic guidelines formalized the practice in healthcare, with the first national hand hygiene protocols published in the 1980s across several countries, focusing on reducing nosocomial infections through standardized procedures. The late saw increased emphasis on hand compliance in hospitals, aided by research demonstrating its efficacy against , though adherence rates remained suboptimal without enforcement. In the , global institutions drove widespread campaigns to embed handwashing as a normative behavior. The World Health Organization's "SAVE LIVES: Clean Your Hands" initiative, launched in 2009, established annual World Hand Hygiene Day on May 5, targeting healthcare workers and achieving measurable improvements in compliance via multimodal strategies including education and monitoring. , initiated in 2008 and observed on October 15, promoted soap-based handwashing in households and schools, especially in developing regions, contributing to reduced diarrheal disease incidence where facilities were available. The from 2020 prompted unprecedented public campaigns, with agencies like the CDC and WHO urging frequent handwashing alongside masking and distancing, leading to temporary spikes in global self-reported hand hygiene adherence; in the United States, CDC surveys indicated significant increases in the percentage of adults who reported always or most of the time remembering to wash their hands in June 2020 compared with October 2019 for several situations, including after coughing, sneezing, or blowing the nose (71.2% vs. 53.3%), before eating at home (74.4% vs. 62.8%), and after using the bathroom at home (89.6% vs. 85.9%), while rates remained high and similar after using the bathroom in public (94.8% vs. 95.5%). Additionally, 85.2% reported frequent hand hygiene after contact with high-touch public surfaces, with 78.5% frequently using soap and water. However, self-reported rates remained below 75% in several everyday situations. For example, the CDC's later "Life is Better with " effort in reinforced home and community habits. UNICEF's "Hand Hygiene for All" initiative, launched in 2020, aimed for universal access by 2030, highlighting disparities in facilities. These efforts underscored handwashing's causal role in interrupting transmission chains, supported by empirical data from intervention studies showing 20-40% reductions in infections.

Societal, Economic, and Cultural Aspects

Behavioral and Compliance Factors

Hand hygiene compliance remains suboptimal across settings, with meta-analyses of healthcare environments reporting average rates of 32% to 52% among nurses and 45% among physicians, based on direct observations from studies post-2010. In community contexts, pooled prevalence estimates for hand washing before food handling or after toilet use hover around 55%, with significant variability due to self-reported data limitations. However, self-reported rates often overstate actual behavior due to social desirability bias. For instance, in the United States, self-reported handwashing habits during the COVID-19 pandemic showed elevated rates. According to CDC surveys, in June 2020, 94.8% of adults reported remembering to wash hands after using the bathroom in public (similar to 95.5% in October 2019), 89.6% after using the bathroom at home (up from 85.9%), 71.2% after coughing, sneezing, or blowing nose (up from 53.3%), and 74.4% before eating at home (up from 62.8%). Additionally, 85.2% reported frequent hand hygiene (always/often) after contact with high-touch public surfaces, with 78.5% frequently using soap and water. These rates were generally higher during the pandemic but remained below 75% in several everyday situations. No newer national CDC surveys on general population handwashing habits were conducted post-2020. In low- and middle-income countries, observed rates of handwashing with soap after defecation are significantly lower, typically ranging from 5% to 30%, and frequently below 20%. Additionally, global access to basic handwashing facilities with soap and water at home is limited, with only 43% of the world's population having such access according to the WHO/UNICEF Joint Monitoring Programme 2023 report (representing about 3.5 billion people without access), dropping to around 25% or less in low-income countries. This lack of access serves as a major prerequisite barrier to the practice in community and household settings. These figures persist despite widespread awareness of microbial transmission risks, indicating that knowledge alone insufficiently drives behavior and highlighting the role of habitual inertia and perceived low immediate consequences. Behavioral determinants include individual factors such as overestimation of personal performance, where healthcare workers often self-assess compliance higher than observed rates, exacerbating non-adherence through cognitive biases like optimism bias. Physicians demonstrate consistently lower compliance than nurses, potentially due to role-specific pressures, higher workload, or differing risk perceptions, with rates dropping further before patient contact (around 21%) compared to after (47%). Environmental cues, such as visible soap dispensers or social norms under observation, temporarily boost adherence—compliance reaches up to 91% with combined overt and anonymous monitoring—but wanes without sustained prompts. Psychological barriers, including forgetfulness amid multitasking and aversion to skin dryness from frequent washing, compound these issues, particularly in high-stress units like ICUs. Interventions targeting behavior, such as performance feedback and multifaceted reminders aligned with WHO guidelines, yield moderate improvements, with feedback alone increasing compliance in low-certainty evidence from six studies across 21 centers. Nudges like strategic signage and boosts via education on causal pathogen links prove effective in hospital trials, outperforming single-component approaches by reinforcing habit formation over mere rule enforcement. In community settings, addressing enablers like accessible facilities and disgust-based messaging enhances uptake, though long-term compliance requires overcoming intertwined barriers such as resource scarcity and cultural norms prioritizing convenience. Overall, causal realism underscores that compliance hinges on aligning incentives with empirical infection risks rather than relying on voluntary intent, as evidenced by sustained gains only from integrated strategies reducing pathogen transmission by up to 50%.

Cost-Benefit Analyses

Hand hygiene interventions in healthcare settings have demonstrated substantial cost savings by reducing healthcare-associated s (HAIs), with implementation costs often offset by decreased treatment expenses and stays. A review of economic evaluations indicates that multimodal hand programs can yield net savings, as the excess costs of HAIs—estimated at thousands of dollars per case—far exceed promotion expenses, such as staff training and alcohol-based hand rub provision. For instance, one analysis in intensive care units found that improving compliance from low levels to over 70% reduced HAI incidence, resulting in benefit-cost ratios exceeding 10:1 through averted antibiotic use and prolonged patient days. The reports average economic returns of 16 times the investment in hand hygiene policies, driven by empirical data from global audits linking compliance to rate drops of 40-50%. In community and household contexts, handwashing with proves highly -effective for preventing diarrheal and respiratory diseases, particularly in low-resource settings. Economic models estimate the of averting one (DALY) at approximately $3.35 through promotion, outperforming many other measures like campaigns in similar environments. Scaling universal access in requires an investment of $12.2–15.3 billion over 10 years for facilities and behavioral campaigns, yet this yields massive returns by reducing ; for example, promotion costs average $334 million annually across 46 such nations, representing just 4.7% of expenditures but preventing millions of cases. Recent evaluations confirm handwashing interventions as cost-saving or dominant (cheaper and more effective) compared to no intervention, with sensitivity analyses showing robustness even under conservative infection reduction assumptions of 20-30%. Costs of handwashing include direct expenses for , , and —estimated at $0.50-1.00 per person annually in household settings—plus indirect burdens like time (20-40 seconds per session) and potential irritation from frequent washing. However, these are minimal relative to benefits; a cost-utility in hospitals found automated monitoring systems for compliance to be cost-saving over manual methods, with incremental cost-effectiveness ratios below willingness-to-pay thresholds in most scenarios. In long-term care facilities, multifaceted strategies cost around €2,000-4,000 per site but generated savings from fewer , assuming sustained compliance. Empirical challenges, such as variable compliance rates (often 40-60% baseline), underscore that benefits hinge on behavioral adherence, yet first-principles causal links from microbial reduction to prevention affirm net positivity across contexts.
ContextKey Cost MetricBenefit MetricSource
Healthcare$10-50 per compliance improvement event16:1 ; HAI reduction 40-50%WHO audits
Household (LDCs)$1//year for facilitiesAverts 1 DALY for $3.35; prevents millions of diarrheal casesGlobal Handwashing Partnership
Long-term Care€2,000-4,000 per facility for strategyNet savings from reduced infectionsJAMDA study

Controversies Including Resistance Risks and Policy Debates

The use of antibacterial soaps containing agents like has sparked debate over their potential to foster , as laboratory studies indicate that exposure to triclosan can select for bacteria with reduced susceptibility to antibiotics, including cross-resistance mechanisms observed in and . In 2016, the U.S. (FDA) ruled that 19 antibacterial ingredients, including triclosan and , lacked sufficient evidence of superior efficacy over plain and water for preventing illness, while posing risks such as hormonal disruption and ecological harm from environmental persistence; this led to a ban on their use in over-the-counter consumer hand soaps and body washes effective September 2017. The Centers for Disease Control and Prevention (CDC) has echoed this, noting that antibacterial soaps may contribute to resistance without added benefits in non-healthcare settings, recommending plain soap for routine hand washing to mechanically remove pathogens rather than relying on chemical antimicrobials that could exert selective pressure. In healthcare settings, policy debates center on enforcing hand compliance amid persistent low adherence rates, with studies reporting averages below 60% in hospitals despite WHO guidelines mandating it before and after contact; factors include time constraints, irritation from frequent washing, and perceived low personal risk, leading to "defiance" among physicians who comply less when unobserved. Automated monitoring systems, such as electronic sensors, have been proposed to address biases in compliance audits, but debates persist over their invasiveness, accuracy, and whether they incentivize genuine behavior change or mere performative adherence, with some facilities tying to metrics via reviews. Critics argue that punitive mandates overlook systemic barriers like inadequate access in 25% of global healthcare facilities, advocating instead for multimodal interventions combining education, products, and cultural shifts to sustain improvements beyond short-term campaigns.

References

  1. https://pmc.ncbi.nlm.nih.gov/articles/PMC3249958/
  2. https://www.sciencedirect.com/science/article/pii/S1201971204001729
  3. https://www.ajicjournal.org/article/S0196-6553%2823%2900074-3/fulltext
  4. https://pmc.ncbi.nlm.nih.gov/articles/PMC7240806/
  5. https://gh.bmj.com/content/10/Suppl_7/e018925
  6. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2823%2900021-1/fulltext
  7. https://pubmed.ncbi.nlm.nih.gov/37121242/
  8. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-022-13667-y
  9. https://www.cdc.gov/clean-hands/about/index.html
  10. https://www.who.int/teams/integrated-health-services/infection-prevention-control/hand-hygiene
  11. https://www.cdc.gov/mmwr/volumes/69/wr/mm6940a2.htm
  12. https://www.cdc.gov/mmwr/volumes/69/wr/mm6941a3.htm
  13. https://aricjournal.biomedcentral.com/articles/10.1186/s13756-023-01293-1
  14. https://www.sciencedirect.com/science/article/pii/S0196655322000670
  15. https://www.ncbi.nlm.nih.gov/books/NBK470254/
  16. https://www.who.int/docs/default-source/patient-safety/how-to-handwash-poster.pdf
  17. https://www.cdc.gov/clean-hands/faq/index.html
  18. https://www.cdc.gov/clean-hands/data-research/facts-stats/index.html
  19. https://pmc.ncbi.nlm.nih.gov/articles/PMC10469426/
  20. https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html
  21. https://pmc.ncbi.nlm.nih.gov/articles/PMC8033386/
  22. https://www.cambridge.org/core/journals/epidemiology-and-infection/article/effect-of-hand-hygiene-frequency-on-reducing-acute-respiratory-infections-in-the-community-a-metaanalysis/FC28A0855864FBBB33A8AEFBFFF55FC4
  23. https://my.clevelandclinic.org/health/articles/17474-hand-washing
  24. https://www.dhs.wisconsin.gov/disease/handwashing.htm
  25. https://www.ncbi.nlm.nih.gov/books/NBK144035/
  26. https://pmc.ncbi.nlm.nih.gov/articles/PMC7094481/
  27. https://www.ncbi.nlm.nih.gov/books/NBK144041/
  28. https://pmc.ncbi.nlm.nih.gov/articles/PMC2094883/
  29. https://gh.bmj.com/content/10/Suppl_7/e018925.full.pdf
  30. https://www.mdpi.com/1660-4601/8/1/97
  31. https://www.medrxiv.org/content/10.1101/2025.03.12.25323775v1.full-text
  32. https://pubmed.ncbi.nlm.nih.gov/34582962/
  33. https://www.sciencedirect.com/science/article/abs/pii/S1473309903006066
  34. https://pmc.ncbi.nlm.nih.gov/articles/PMC8657428/
  35. https://clinicaltrials.gov/study/NCT01337856
  36. https://www.mcmasterforum.org/docs/default-source/product-documents/living-evidence-syntheses/living-evidence-synthesis-17-2---effectiveness-of-hand-hygiene-to-reduce-the-transmission-of-respiratory-infectious-diseases-in-the-community.pdf?sfvrsn=5e4edea0_1
  37. https://pmc.ncbi.nlm.nih.gov/articles/PMC9585124/
  38. https://pubmed.ncbi.nlm.nih.gov/20429659/
  39. https://www.infectioncontroltoday.com/view/importance-hand-hygiene-clostridioides-difficile-reduction
  40. https://www.ncbi.nlm.nih.gov/books/NBK144042/
  41. https://academic.oup.com/cid/article/46/Supplement_1/S43/457041
  42. https://wwwnc.cdc.gov/eid/article/7/2/70-0234_article
  43. https://pmc.ncbi.nlm.nih.gov/articles/PMC10115288/
  44. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-11815-4
  45. https://www.palomar.edu/ehs/wp-content/uploads/sites/298/2015/10/HandWashing.pdf
  46. https://pmc.ncbi.nlm.nih.gov/articles/PMC8394668/
  47. https://www.sciencedirect.com/science/article/pii/S0362028X22097459
  48. https://www.meritech.com/blog/5-handwashing-myths
  49. https://vitalacy.ai/gloves-vs-hand-hygiene-myths-facts-safety-tips/
  50. https://qualitysafety.bmj.com/content/31/4/322
  51. https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2022.968231/full
  52. https://gh.bmj.com/content/10/Suppl_7/e018928
  53. https://pmc.ncbi.nlm.nih.gov/articles/PMC3037063/
  54. https://www.health.harvard.edu/newsletter_article/The_handiwork_of_good_health
  55. https://www.fda.gov/consumers/consumer-updates/skip-antibacterial-soap-use-plain-soap-and-water
  56. https://newsnetwork.mayoclinic.org/discussion/antibacterial-soap-no-more-effective-at-killing-germs-than-is-soap/
  57. https://www.bmj.com/content/351/bmj.h4944
  58. https://www.sciencedirect.com/science/article/pii/S0362028X24000565
  59. https://www.mcgill.ca/oss/article/health/liquid-or-bar-soapy-tales
  60. https://news.uoregon.edu/content/no-bar-soap-isnt-gross-millennials-seem-believe
  61. https://www.health.state.mn.us/people/handhygiene/how/bestsoap.html
  62. https://pmc.ncbi.nlm.nih.gov/articles/PMC3088928/
  63. https://www.sciencedirect.com/science/article/abs/pii/S0956713516302225
  64. https://pmc.ncbi.nlm.nih.gov/articles/PMC8548033/
  65. https://www.ncbi.nlm.nih.gov/books/NBK144054/
  66. https://www.ajicjournal.org/article/S0196-6553%2820%2930562-9/abstract
  67. https://pubmed.ncbi.nlm.nih.gov/27296611/
  68. https://pdfs.semanticscholar.org/3f05/8df5be9cd21ef2cbf7696ed51200683840b6.pdf
  69. https://www.todaysrdh.com/hand-hygiene-how-effective-are-alcohol-based-hand-sanitizers-against-non-enveloped-viruses/
  70. https://www.sciencedirect.com/science/article/pii/S0362028X22080887
  71. https://www.cdc.gov/clean-hands/about/hand-sanitizer.html
  72. https://www.cdc.gov/clean-hands/data-research/facts-stats/hand-sanitizer-facts.html
  73. https://aricjournal.biomedcentral.com/articles/10.1186/s13756-021-01049-9
  74. https://pmc.ncbi.nlm.nih.gov/articles/PMC7550876/
  75. https://pmc.ncbi.nlm.nih.gov/articles/PMC10772474/
  76. https://www.ncbi.nlm.nih.gov/books/NBK513254/
  77. https://www.researchgate.net/publication/362803052_Advantages_and_Disadvantages_of_Alcohol-Based_Hand_Sanitizers_A_Systematic_Review
  78. https://pmc.ncbi.nlm.nih.gov/articles/PMC9896316/
  79. https://pmc.ncbi.nlm.nih.gov/articles/PMC7315655/
  80. https://www.engineeringforchange.org/news/places-without-soap-handwashing-ash-effective-prevent-covid-19/
  81. https://bmjopen.bmj.com/content/12/5/e056411
  82. https://www.who.int/publications-detail-redirect/WPR-DSE-2020-019
  83. https://ijic.info/article/view/21586/14662
  84. https://resources.hygienehub.info/en/articles/5798423-summary-report-promoting-handwashing-behaviour-in-low-resource-and-water-scarce-settings
  85. https://pubmed.ncbi.nlm.nih.gov/32343408/
  86. https://www.cochrane.org/evidence/CD013597_does-cleaning-hands-ash-stop-or-reduce-spread-viral-and-bacterial-infections-compared-soap-or-other
  87. https://www.who.int/campaigns/world-hand-hygiene-day/2021/key-facts-and-figures
  88. https://www.cdc.gov/infection-control/hcp/hand-hygiene/index.html
  89. https://pmc.ncbi.nlm.nih.gov/articles/PMC8409116/
  90. https://www.sciencedirect.com/science/article/pii/S2590088924000271
  91. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-024-19461-2
  92. https://link.springer.com/article/10.1186/s12982-025-00546-1
  93. https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-025-10924-4
  94. https://mjima.org/articles/hand-hygiene-compliance-rates-and-interventions-to-increase-hand-hygiene-compliance-among-healthcare-workers-in-a-tertiary-care-educational-hemato-oncology-hospital-a-prospective-observational-study/mjima.galenos.2025.25435.14
  95. https://pmc.ncbi.nlm.nih.gov/articles/PMC10937679/
  96. https://www.cdc.gov/clean-hands/prevention/about-handwashing-a-healthy-habit-in-the-kitchen.html
  97. https://www.cdc.gov/clean-hands/prevention/index.html
  98. https://www.mdpi.com/2673-947X/4/4/36
  99. https://pmc.ncbi.nlm.nih.gov/articles/PMC10314431/
  100. https://www.who.int/news/item/15-10-2025-new-guidelines-on-community-hand-hygiene-to-help-governments-reduce-the-spread-of-infectious-diseases
  101. https://www.apha.org/policy-and-advocacy/public-health-policy-briefs/policy-database/2014/07/07/11/15/hand-hygiene-in-prek-to-12-schools-and-child-care-settings
  102. https://bmjgroup.com/lack-of-soap-most-reported-barrier-to-effective-hand-hygiene-in-shared-community-spaces/
  103. https://pmc.ncbi.nlm.nih.gov/articles/PMC5781206/
  104. https://www.who.int/teams/environment-climate-change-and-health/water-sanitation-and-health/monitoring-and-evidence/wash-monitoring
  105. https://washdata.org/
  106. https://ehp.niehs.nih.gov/doi/full/10.1289/EHP7200
  107. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-022-14390-4
  108. https://www.who.int/news/item/28-06-2023-improving-access-to-water--sanitation-and-hygiene-can-save-1.4-million-lives-per-year--says-new-who-report
  109. https://data.unicef.org/topic/water-and-sanitation/hygiene/
  110. https://pmc.ncbi.nlm.nih.gov/articles/PMC6593152/
  111. https://pmc.ncbi.nlm.nih.gov/articles/PMC7263456/
  112. https://pmc.ncbi.nlm.nih.gov/articles/PMC3538484/
  113. https://sfamjournals.onlinelibrary.wiley.com/doi/10.1111/jam.14796
  114. https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/efficiency-of-hand-drying-for-removing-bacteria-from-washed-hands-comparison-of-paper-towel-drying-with-warm-air-drying/0481B2A379ADDD0C616273050FE755BC
  115. https://www.nature.com/articles/s41598-019-50239-4
  116. https://shea-online.org/high-speed-air-hand-dryers-spread-contamination-more-than-paper-towels/
  117. https://www.kcprofessional.com/en-us/workplace-insights/health-and-safety/jet-dryers-vs-single-use-paper-towels
  118. https://pmc.ncbi.nlm.nih.gov/articles/PMC6437338/
  119. https://pmc.ncbi.nlm.nih.gov/articles/PMC11009559/
  120. https://vitalacy.ai/automated-hand-hygiene-monitoring-technology/
  121. https://pmc.ncbi.nlm.nih.gov/articles/PMC10040360/
  122. https://academic.oup.com/jamia/article/27/8/1316/5876566
  123. https://med.stanford.edu/cerc/publications/cerc-articles/improving-hospital-hand-hygiene.html
  124. https://onlinelibrary.wiley.com/doi/full/10.1002/hsr2.70288
  125. https://hospitalnews.com/using-ai-to-improve-hand-hygiene-and-patient-safety/
  126. https://onlinelibrary.wiley.com/doi/10.1002/gch2.202400124
  127. https://www.jmir.org/2023/1/e37249/
  128. https://pmc.ncbi.nlm.nih.gov/articles/PMC9801014/
  129. https://www.sciencedirect.com/science/article/abs/pii/S0195670121003005
  130. https://www.journalofhospitalinfection.com/article/S0195-6701%2824%2900107-5/fulltext
  131. https://thedocs.worldbank.org/en/doc/4e6d0e6641a7c391a23f0402c04628d5-0320012022/original/WBG-TECHNICAL-NOTE-PART-3-1.pdf
  132. https://www.unicef.org/media/126126/file/Wash-and-disability-guidance-note-final.pdf
  133. https://washmatters.wateraid.org/sites/g/files/jkxoof256/files/technical-guide-for-handwashing-facilities-in-public-places-and-buildings.pdf
  134. https://www.unicef.org/media/114921/file/WASH%2520Disability%2520Toolkit.pdf
  135. https://www.osha.gov/laws-regs/standardinterpretations/1992-04-09
  136. https://innerspacehealthcare.com/news/scrub-sink-environment/
  137. https://www.elpress.com/products/personal-hygiene/hand-cleaning/wash-basins
  138. https://www.aesfoodequipment.com/product/hygiene-equipment/personal-hygiene-equipment/hand-wash-sinks-chemical-dispensers/stainless-steel-sink-sensor/
  139. https://www.neo-metro.com/blog/universal-design-in-public-bathrooms
  140. https://stepnwash.com/blogs/news/universal-design-bathroom
  141. https://www.pmmag.com/articles/100485-universal-design-assures-accessibility-for-all-ages-abilities
  142. http://floodsroyalflush.com/best-ways-to-ensure-hand-washing-stations-are-accessible/
  143. https://sanixway.com/the-history-of-hand-washing-and-hygiene/
  144. https://africame.factsanddetails.com/article/entry-1126.html
  145. https://timelines.issarice.com/wiki/Timeline_of_hygiene
  146. https://gprosperity.org/index.php/journal/article/download/75/63
  147. http://www.perinijournal.it/Items/en-US/Articoli/PJL-38/A-dive-into-the-hygiene-of-ancient-Mediterranean-civilizations
  148. https://www.myjewishlearning.com/article/hand-washing/
  149. https://www.ncbi.nlm.nih.gov/books/NBK143998/
  150. https://sanixway.com/hand-hygiene-in-religious-and-cultural-practices/
  151. https://pmc.ncbi.nlm.nih.gov/articles/PMC9632745/
  152. https://www.ncbi.nlm.nih.gov/books/NBK144018/
  153. https://edgewashroomsolutions.com/blog/f/ancient-rituals-to-modern-sanitation-the-history-of-hand-hygiene
  154. https://pmc.ncbi.nlm.nih.gov/articles/PMC11568873/
  155. https://pmc.ncbi.nlm.nih.gov/articles/PMC6053623/
  156. https://www.cureus.com/articles/290450-dr-ignaz-phillip-semmelweis-the-unrecognized-pioneer-of-aseptic-practices
  157. https://pmc.ncbi.nlm.nih.gov/articles/PMC9209376/
  158. https://theconversation.com/florence-nightingale-a-pioneer-of-hand-washing-and-hygiene-for-health-134270
  159. https://www.cambridge.org/core/journals/british-journal-for-the-history-of-science/article/why-semmelweiss-doctrine-was-rejected-evidence-from-the-first-publication-of-his-results-by-friedrich-wieger-and-an-editorial-commenting-on-the-results/3EE64C106330A92B894CB6AC2CA17C52
  160. https://globalhandwashing.org/about-handwashing/history-of-handwashing/
  161. https://www.who.int/campaigns/world-hand-hygiene-day
  162. https://www.cdc.gov/clean-hands/globalhandwashingday/index.html
  163. https://www.cdc.gov/clean-hands/lifeisbetterwithcleanhands/index.html
  164. https://www.unicef.org/media/71776/file/Hand-hygiene-for-all-2020.pdf
  165. https://www.ajicjournal.org/article/S0196-6553%2821%2900687-8/fulltext
  166. https://pmc.ncbi.nlm.nih.gov/articles/PMC10213575/
  167. https://www.nature.com/articles/s41598-024-52444-2
  168. https://aricjournal.biomedcentral.com/articles/10.1186/s13756-022-01188-7
  169. https://www.sciencedirect.com/science/article/pii/S0195670123002414
  170. https://www.ajicjournal.org/article/S0196-6553%2821%2900792-6/fulltext
  171. https://pmc.ncbi.nlm.nih.gov/articles/PMC6483670/
  172. https://www.cambridge.org/core/journals/behavioural-public-policy/article/improving-hand-hygiene-in-hospitals-comparing-the-effect-of-a-nudge-and-a-boost-on-protocol-compliance/44EFD0FF5B87C54332342835337B7C17
  173. https://www.medrxiv.org/content/10.1101/2025.03.11.25323730v1
  174. https://www.ncbi.nlm.nih.gov/books/NBK143995/
  175. https://globalhandwashing.org/about-handwashing/why-handwashing/economic-impact/
  176. https://gh.bmj.com/content/6/12/e007361
  177. https://www.medrxiv.org/content/10.1101/2025.10.13.25337661v1.full.pdf
  178. https://pmc.ncbi.nlm.nih.gov/articles/PMC8679104/
  179. https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2023.1117680/full
  180. https://www.sciencedirect.com/science/article/pii/S1525861024005280
  181. https://pmc.ncbi.nlm.nih.gov/articles/PMC6204657/
  182. https://www.jamda.com/article/S1525-8610%2824%2900528-0/fulltext
  183. https://www.health.harvard.edu/blog/are-antibacterial-products-with-triclosan-fueling-bacterial-resistance-2019080617473
  184. https://pmc.ncbi.nlm.nih.gov/articles/PMC4144231/
  185. https://pmc.ncbi.nlm.nih.gov/articles/PMC3809478/
  186. https://abcnews.go.com/Health/doctors-hand-hygiene-plummets-watched-study-finds/story?id=39737505
  187. https://www.prnewswire.com/news-releases/us-hospitals-show-dramatic-improvements-in-hand-hygiene-according-to-new-leapfrog-report-302251282.html
  188. https://globalhandwashing.org/the-hospitals-where-doctors-cant-wash-their-hands/
  189. https://trustees.aha.org/articles/1107-hand-hygiene-still-a-challenge
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