ECJ EUROPEAN Cleaning Journal

In the fourth part of our special series looking back at the history of hygiene, ECJ focuses on hand hygiene. When did we as human beings realise the value of washing our hands, and how did we become aware that clean hands play such a vital role in stopping and preventing the spread of infection?

The awareness of hand hygiene goes much further back in history than we may imagine. Jewish philosopher and physician Moses ben Maimon – having read the works of Hippocrates and Galen – taught and practiced medicine in Egypt. In 1199 he wrote the Mishneh Torah, a code of Jewish religious law, which included a chapter devoted to the principles of hygiene. In that chapter ben Maimon said: “Never forget to wash your hands after having touched a sick person.”

Ben Maimon’s principles were then completely ignored for many centuries, and there was no real progress in hand hygiene until the 19th century. Records show that in 1825 a French pharmacist stated physicians and other persons attending patients with contagious diseases would benefit from moistening their hands with a liquid chloride solution.

During the 19th century women in childbirth were dying at alarming rates in Europe and the USA. In fact up to 25 per cent of women who delivered their babies in hospitals died from childbed fever (puerperal sepsis), later found to be caused by Streptococcus pyogenes bacteria.

In 1843 Dr Oliver Wendell Holmes, working in the US, advocated handwashing to prevent childbed fever. Holmes was horrified by the prevalence in American hospitals of the fever, which he believed to be an infectious disease passed to pregnant women by the hands of doctors. He recommended that a physician finding two cases of the disease in his practice within a short time should remove himself from obstetrical duty for a month. Holmes' ideas were greeted with disdain by many physicians of the time.

Meanwhile in 1846, the importance of hand hygiene in hospital settings was being recognised for the first time in Europe. While assisting on a maternity ward in Vienna Hungarian Dr Ignaz Semmelweis noticed expectant mothers in his care shared a terror of being looked after by medical students on the ward rather than by a midwife.

Their fear was justified: the death rate from childbed fever was three times higher among the women whose babies were delivered by the students.

Dr Semmelweis then realised something else. The medical students were coming into the maternity suite straight from the pathology unit where they had been dissecting bodies for their studies. And they were not washing their hands before delivering the babies.

It was a ‘eureka’ moment for Dr Semmelweis. He knew he had discovered something important, and immediately instigated a handwashing programme at the hospital. He was fairly sure that infections were being carried from the dead to the living via the hands of the medical staff, and he insisted that anyone examining a woman in labour should wash their hands with a chlorinated solution first.

Resistance among doctors

And the results spoke for themselves. The mortality rate in April 1847 was 18.3 per cent, hand washing was instituted mid-May, the rates in June were 2.2 per cent, July 1.2 per cent, August 1.9 per cent and, for the first time the death rate was zero in two months in the year following this discovery.

Semmelweis lectured publicly about his results in 1850, however, the reception by the medical community was cold, if not outright hostile. His observations went against the current scientific opinion of the time, which blamed diseases on an imbalance of the ‘basic humours’ in the body. It was also argued that even if his findings were correct, washing one's hands each time before treating a pregnant woman, as Semmelweis advised, would be too much work. Nor were doctors eager to admit that they had caused so many deaths!

Semmelweis spent 14 years developing his ideas and lobbying for their acceptance, culminating in a book he wrote in 1861. The book received poor reviews, and he continued fighting the establishment vehemently. In 1865 he suffered a nervous breakdown and was committed to an asylum where he soon died. Only after Dr Semmelweis' death was the germ theory of disease developed, and he is now recognised as a pioneer of antiseptic policy and prevention of nosocomial (hospital-acquired) disease.

Perhaps the whole concept of handwashing seemed odd at the time. The lack of indoor plumbing made it difficult to get water. In order to make the water comfortably warm, it would have to be heated over a fire. Besides, contact with water was associated with diseases such as malaria and typhoid fever. It is difficult for us to imagine doctors being so resistant to what we now consider common practice. But the resistance continued.

In the 1870's in France, one hospital was called the House of Crime because of the alarming number of new mothers dying of childbed fever within its confines. In 1879 at a seminar at the Academy of Medicine in Paris, a noted speaker stood at the podium and cast doubt on the spread of disease through the hands. An outraged member of the audience felt compelled to protest. He shouted at the speaker: "The thing that kills women with [childbirth fever]... is you doctors that carry deadly microbes from sick women to healthy ones."

That man was Louis Pasteur, who of course contributed to the germ theory of disease. He was a tireless advocate of hand hygiene but his efforts too were met with scepticism.

In 1910 American doctor Josephine Baker established a hand hygiene programme for childcare providers in New York. This resulted in the city’s mayor being lobbied by 30 doctors who protested that Dr Baker was ruining their livelihood by keeping babies well.

Eventually, however, the message about hand hygiene was taken seriously and in 1961 the US Public Health Service produced a training film that demonstrated handwashing techniques recommended for use by healthcare workers. At the time recommendations directed that staff wash their hands with soap and water for between one and two minutes before and after patient contact. Rinsing hands with an antiseptic agent was believed to be less effective than handwashing and was recommended only in emergencies or in areas where sinks were unavailable.

Necessary for all of us

The rest, as they say, is history. Hand hygiene is now universally acknowledged as a necessary practice for all of us – and for those in the healthcare and food industries it is absolutely vital. Handwashing is recognised as being the single most important means of preventing the spread of infection and foodborne illness.

In 2009 this was recognised by the World Health Organisation (WHO) when it launched its annual global campaign Clean Your Hands – an initiative aimed at supporting healthcare workers to improve hand hygiene in that sector. A key element was the Five Moments for Hand Hygiene guidance, which defines the key processes for healthcare workers cleaning their hands, in clear and uncomplicated language.

And yet recent studies and reports indicate that lack of improper handwashing still contributes significantly to disease transmission in all parts of our society. While we are all potentially at risk of contracting hand-transmitted illnesses, one-third of our population is especially vulnerable, including pregnant women, children, old people, and those with weakened immune systems.

It would be reasonable to assume that hospitals have come closest to addressing this issue and while the situation has no doubt improved in recent years, fundamental problems surrounding hand hygiene still exist. And it’s not just hospitals where handwashing is important. A recent study focusing on infectious diseases in children states that improper or infrequent handwashing continues to be a major factor in the spread of disease in daycare.

These shortfalls in hand hygiene are surprising. In Europe we nearly all now have hot running water and many different antimicrobial hand soaps to choose from. If all of us paid more attention to how we clean and sanitise our hands many lives could be saved, illnesses prevented and hundreds of millions of euros saved every year.