This is the time of the year the kids bring back home contagious illnesses they caught who knows where and from. Soon the siblings get sick as well, and we have to take time off from work. Schools and classmates are the usual suspects, but chances are hand hygiene negligence played the most part. To reduce the incidence of pathogens we are stocking antimicrobial products in our home cabinets, a behavior that is not without incidence on health, safety and the environment. In a three part series, I intent to address the issues surrounding this controversial topic, starting with revisiting the roots of poor hand hygiene, then sorting out some “staggering” evidence and finally offering some sound solutions that everyone – including schools and your work place – can easily adopt while keeping toxic products at bay and lowering our carbon footprint.

Part 2 – Our immune system is up against a steep hill.

Proof that we are all concerned with contagious illnesses, I have not met (1) someone who did not have an opinion on the topic. Whether or not they are reasonable or well founded, they are often the representation of a distorted reality. Adding to the distortion, a lot of information available to professionals and the general public are, in the format in which they are published, often misleading. I have to admit that despite having worked in this field for a number of years, I have been fooled by some “staggering evidence” – I’ll tell you more about them in this post. Suffice it to say that we are still learning about the consequences of our behavior in regards to germs.

“The greatest enemy of knowledge is not ignorance, it is the illusion of knowledge”

Does getting sick boost your immune system?
No need to smile, Doc, if you were more convincing, this popular belief would not have so much ground. No, it does not. Worse, it can make you so weak that you are more susceptible of catching another disease if it is not the same. Sometimes, we get confused with “being immune” to a particular strain of a virus, either because we have been vaccinated or because our immune system naturally produces antibodies when we are healthy (but I would not count on that too much). According to the CDC (center for Disease Control and Prevention) adults get on average 2-4 colds a year, while children get a cold 6-10 times. Gastroenteritis due to bacteria such as salmonella and e-coli or the highly aggressive norovirus can affect the same person more than once over the course of a year. There are too many nasty bugs to take a chance, don’t you think?

Do antimicrobial products build up resistance in microorganisms causing illnesses?
This is a controversial issue that needs further studies. To the best of our scientific knowledge, the answer is no. What were only speculations became a scientific controversy when Dr. Stuart Levy published the result of a study (8/6/1998, Nature) suggesting Triclosan (2), a molecule manufactured by Novartis (3) and of which mechanism of action is supposed to be similar to the one of an antibiotic, could be a factor in building up resistance strain in some bacteria. Since then at least seven studies (including one by the same Dr. Levy) have demonstrated Triclosan is not significantly associated with bacterial resistance. The question of bacteria – such as Escherichia coli and Salmonella enterica – building some kind of a defense mechanism in presence of Triclosan is still unanswered. What might appear to be a health issue is tolerance. In other words, these bugs fight Triclosan even harder every time making them less susceptible to antimicrobial products (also called cross-resistance). They will eventually die, but it seems to take longer (read more on Triclosan by Dr. Weiss). Triclosan deserves a post of its own, which I’ll write later, so forgive me to be a be short on this specific topic. Other antimicrobial products do not seem to have this problem.

Do gel/ liquid hand sanitizers can replace hand washing?
No, and the occurrences of gastrointestinal illness outbreaks on cruise ships should teach us a lesson. Cruiseline companies are at the forefront of the fight against Norovirus. They spend a considerable amount of resources observing guests behavior, testing delivery devices and antimicrobial products. Dr. Steve Williams, Director of Medical Operations for Carnival said that a popular brand of alcohol-based hand sanitizer was tested on volunteers after a known amount of Norovirus was applied on their fingers. The product resulted in an average removal of only 46%: plenty enough left to make you sick. There have been occurrences of outbreaks in settings fully equipped with liquid/ gel hand sanitizers. “They lull passengers into a false sense of security” says Dr. Steve Williams. The truth and the matter is that these products do not remove the organic matter off your hands (food, dirt, oil, …), which remain an environment to favor bad germs growth. Now, I am not saying hand sanitizers are useless, they just do not replace hand washing. The only hand sanitizer that can remove germs as well as water and soap is in the form of a wipe. I mean a real, thick and wide enough wipe. The friction of the wipe against the skin will do the job.

Do antimicrobial products kill the “good germs” as well?
That is a key issue in regards to hand hygiene. This belief refers to the flora of the skin. Actually, one would be amazed to learn that we harbor more bacterial cells than we have human cells … (learn more about human flora from Carbondale University here). One important notion to keep in mind is that bacteria, in any environment, are in perpetual competition for space, by doing so our normal skin flora maintains the amount of “bad” bacteria to level that do not endanger our health. Once our normal skin flora is removed, we become defenseless. Any pathogen can develop to proportions that can make us sick. What a trip! A jungle on our skin, invisible but in constant transformation. But I diverge. This is what happens after overusing chemical based hand sanitizers or antimicrobial soaps. For instance, if you use alcohol based hand sanitizer 3 times in let say 2 hours, you have “deforested” your hand. The most aggressive germs will take over momentarily until the jungle regains its balance. Let’s pause for a second and have a compassionate thought for health care workers that need to use these products 30 to 80 times a day! This is inferno to me. Let’s have a second compassionate thought for people with skin sensitivity that can’t use soap of which pH is too high (>10) or quaternary ammonium and alcohol because too harsh for the skin.

Even some professionals get it wrong: the 20 seconds rule.
That is a constant fear of mine: using scientific data while not understanding what they mean and telling people half of the story. Washing your hands properly, you have understood, is the surest way to remove germs from your hands. It entails to turn the water on until it reaches a warm temperature, to wet (or pre-wash) your hands, to apply the right amount of soap (better be more than not enough) as to cover the entire surface of your hands (if you are skilled enough and for the sake of water conservation – about a gallon/ 30 sec, use your elbow to turn the water off), rub your hands vigorously, everywhere from wrist to nails. Turn the water back on and rinse your hands long enough so you have removed the soap. The whole process is called “washing your hands”. Now how long, to be effective the whole process should last? According to this person working for this great company: 20 seconds. Wrong! But she is not the only one. If you look at the table 10 on the left, the author of this study is using the word “handwash” even though throughout the study he makes the distinction between handwash and scrubbing/ rubbing hands with soap, which is what should have been indicated. The rubbing, friction part is “recommended to last” 20 seconds. This is of utmost importance because 5 seconds or 15 seconds is not enough to remove germs as shown in this table. The last part of the process is drying your hands. If left wet, your hands will be “re-colonized” quicker. That means every part of your hands should be dried up with a clean dry towel.

165 million school days in k12 are lost due to contagious illnesses.
Wow. 165 million! This number is used by a lot of antimicrobial product manufacturers to market hand sanitizers and hand soaps to schools (yes, that included me as well). That one really fooled me. It seems so huge that I did not apply some common sense. What’s wrong with that number? Is it too much? Not enough? Well, if you put it in perspective with the following: 90% of students attend public schools, and 90% of these public schools depend on students attendance to get state money ($20 to $40/ day), that’s a lot of money! I had to remind myself that this is an estimate, and like every estimate, it has flaws. This one has a big one though. There are 55 million students attending k to 12 schools. That’s an average of 3 days per student per year. Not that big of a number after all. Three days seem pretty reasonable to me. But gee, it even sounds awfully low if I recall correctly. So I called a few school districts with an above than average academic record and asked them to share with me their ADA (average daily attendance): public domain, ah ah!!! Wow, 95% to 97% ADA. Very comforting. Then I took 96% and multiplied it by 180 days of schools. 7.2 days of absenteeism. What has happened to the remaining 4.2 days? Answer from the school districts: we do not track the cause of absenteeism. But it should be: absenteeism due to contagious illnesses is an important data that could help health professionals and school administrators take appropriate measure to fight illnesses and outbreaks more efficiently.

A comprehensive hand hygiene program can reduce the incidence of contagious illnesses by 50%.
This one has bugged me since it came on my desk even though I gladly integrated it into my messaging to convince schools and businesses of the importance of hand hygiene. There have been 4 major intervention studies that have had that kind of outcome. The first by Dr. Susan Long who found that youngsters who washed their hands four times a day (before re-entering the classroom) had 24% fewer sick days due to respiratory illnesses and 51% fewer sick days because of stomach upset. A 45% reduction in total outpatient visits for respiratory illness was observed after implementation of a handwashing program amongst new military recruits at a training camp. It required each recruit to wash his/her hands at least 5 times a day. This was probably the best setting to conduct a study of this kind amongst young adults: military recruits do listen to orders. An interesting study was conducted in squatter settlements in Pakistan. Hand soap were giving to 300 low income households and researchers compared the incidence of such illnesses as acute respiratory infection, diarrhea (a major cause of death in children under 5 in poor countries), and impetigo, a bacterial skin infection. It revealed that youngsters that received plain soap and hand washing promotion (education) had respectively 50%, 53% and 34% fewer of the above mentioned illnesses than the ones who did not. A last group of studies undertaken on behalf of hand sanitizers manufacturers by physicians and scientist showed that a comprehensive hand hygiene program (both soap and hand sanitizers) could reduce the incidence of UI and GI by 50% in a student population. Here again, students were asked to wash their hands or/and use hand sanitizers at a specific moment of their daily routine (after breaks, before and after lunch and snacks, after using the restrooms, and so on).
All these studies have great value: they do show that by implementing a comprehensive hand hygiene program, we’ll reduce the incidence of contagious illnesses. The only issue I have with them is that they will fail delivering on their promises. Why? Because none offers an accurate picture of the reality. Any teacher will tell you it is impossible to implement these types of practices, it would require too much class time (1 minute per kid per hand wash, that’s 240 hours per year for a classroom of 20). Teenagers are not soldiers, every parent is well aware of this. Our homes have nothing comparable with a squatter settlement in which good hygiene is nearly impossible to achieve.
Another study allowing students more freedom (they were given a lecture on hand hygiene and provided access to hand sanitizer on top of already available hand soap) showed a reduction of contagious illnesses of 20%. That is more in line with what one can expect to reach with current products and solutions. The key factor, once you have chosen the right products is convenience, which I’ll touch on in a next post. In other word, how to make it simple and easy for everyone to keep their hands germ free.

Antimicrobial Soap Vs. Regular Soap: the winner? Regular soap of course.
Isn’t it comforting? Regular soap works! True enough, scientists say there is not a significance difference both in terms of germs removal from the hands and in illness reduction. Better, some intervention studies have shown a greater reduction in regular hand soap than in antimicrobial hand soap. I might be a little hard of the leaf here, but what are we, well they, trying to compare? If we washed our hands properly (especially the “20 seconds” scrubbing-rubbing our hands with soap) we, the consumers, would not need antimicrobial soap. Again it is not as simple as it sounds. Soap bars have shown to be a source of cross-contamination, the water splashing into a contaminated sink can lead to the spread of germs, some antimicrobial ingredients have little effect on specific pathogens. One comparison that would truly be helpful would be one that tests hand hygiene products in different settings (ones that are similar to our regular environment), highlighting the log reduction of the ten most common pathogens after 5, 10, 15, 20, 30 and 60 seconds of hand rubbing.

We are all a little bit confused when it comes to which product to use and when. A lot of us are choosing antimicrobial and chemical based hand sanitizers hoping we’ll beat the germs, if not by hand washing, at least by giving them a lethal dose of some antimicrobial ingredient. Still, we are not fixing the problem. In conclusion I’d like to share a moment: one person suggested that dry friction of the skin would remove germs. Now take your hands – do not apply anything on them – and rub them by way of friction, palm against palm, the back of your hands, now, in between fingers, don’t forget the wrist, and most importantly the nails. How, how do you do the nails … why not doing the same exercise with soap and water?

(1) Through professional research, group discussions, interviews, observations on site during product trial and personal experience.
(2) Triclosan is the most common antimicrobial molecule found in personal care products. The last market data I have found dates back to 2002: 70% of all liquid soap and 30% of bar soaps contained Triclosan (Dial Corporation). It is also present find in most plastics (from cutting boards and toys to car bumpers) and in toothpaste, mouthwash. It is also known marketed through the brand Microban.
(3) Novartis is a Swiss pharmaceutical company ranked 5th in the world. It operates through Ciba, Sandoz and Chinon. The company recently acquired Bristol Meyers Squibb over the counter (OTC) portfolio for 660 million USD.

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