We all know that making hand hygiene contagious is not easy, but if the wealth of questions and comments flooding this blog were any indication, we all seem to be striving towards a common goal of improving our knowledge and hopefully changing behaviors.
Here's a few highlights of some recent dialogue worth mentioning again. This is part of a new series, where we'll be featuring some of your hand hygiene and skin care questions, along with expert feedback regularly.
"I am wondering if a bar of soap harbors viruses. Can I "catch" something if I use a bar of soap I find, like at a public shower. If the person before me used the bar and rubbed it on themselves, is rinsing the bar good enough to provide effective washing for next person?," asked Blue in response to a recent article comparing hand washing effectiveness to hand sanitizer.
Barry Michaels commented, "Indeed bar soap can be grossly contaminated with bacteria, especially when they have sat in a puddle for any period of time. This undermines the hygienic nature of any hand or body wash taking place with one of these contaminated bars but unless immunocompromised or in a healthcare setting, it might not be a major health risk. Dry bars could be contaminated in a way that could make them infectious if someone had that as their intent. Bar soaps have gone by the wayside with respect to use in commercial venues, hospitals, dental clinics and public restrooms. The research has gone both ways, in that one of the major bar soap makers inoculated soap and showed soap bars are self cleaning but more recent studies of bars, in use show the same potentially dangerous bacteria found in contaminated refillable liquid soap reservoirs plus some Staphylococcal species.
I am not aware of virus data on bar soaps and whether anyone has done survival studies but survival for short to medium periods would certainly be possible. Human papillomaviruses (HPV) the virus group (30-40 types) causing a range of infections from planter warts to "high risk types" normally sexually transmitted could be an issue. HPVs survive for long periods outside of hosts and are typically transmitted in locker room locations and in gyms. There might be other infectious viruses that could be picked up from bar soap if conditions were just right, but hand and foot contact surfaces are a far greater risk in these locations. The idea of using a soap bar that is left from someone else's use starts falling into the category of communal use of hygiene implements like sharing towels, tooth and hair brushes etc. This where public health experts usually draw the line. Some self cleaning probably does occur, so while there is little risk, why take chances.
Of the same nature and of much greater concern in commercial and public locations are reservoir soap dispenser systems that are refilled. These have been studied and found to be heavily contaminated with some very potentially dangerous microorganisms if you were immuno-compromised (old, very young, cancer treatment, HIV etc.). Studies have shown that around 25% of these reservoir units contain around a million bacteria per mL with Klebsiella, Pseudomonas, Enterobacter and Serratia species dominating (potentially deadly in healthcare environments). Use of contaminated liquid soap can heavily contaminate hands and cause infections. This is why closed reservoir soap systems are considered the gold standard for maintenance of hygienic integrity."
In the same article Mark Minter commented, "It is my impression that when dealing with Norovirus, using hand sanitizers that even though may not be quite as effective as hand washing, can make up for this shortfall by increased frequency. This would be particularly significant if a food or healthcare worker could use hand sanitizers 60 times a day versus only 10 or 15 weak hand washing events. Do you care to comment?"
"Everything is a balancing act. On the one hand HCW cannot be troubled to wash hands even with knowledge of potential C. diff exposure, which points out the difficulty of even getting HCW to wash hands a few times during the day. At 12 to 15 hand washes for some people we may be reaching the limit of skin damage even with gentle soap especially if it is an aggressive scrub during hand wash. We only have around 15 layers of stratum corneum and when those are gone - ouch, hands begin to hurt. As pointed out earlier the switch was to hand sanitizers because HCW were not using sinks which I believe is partly true. There were probably over washers with sore hands and under users with filthy hands as well as a large group in the middle with rather poor compliance who still posed some risk to patients," comments Michaels.
"So hand sanitizers brought relief for hands with high frequency use even showing skin health improvement. Sanitizers with emollients really help skin, and it needs to be more than just IPA. And there are some good foams, liquids and gels that are highly efficacious. The problem here is getting frequency up to the magic number of around 60 hand sanitizer events a day. This level interrupted by hand washing would probably be ideal but I doubt that HCW or food workers reach that frequency because it is just not convenient. Portable rapid use hand sanitizers would probably make a major difference and result in reduced infection rates. There are some excellent portable units out there that have the potential to raise compliance significantly."
"With C. diff the differential between hand washing and alcohol hand sanitizer effectiveness is so great you would never make up the difference as there is at least a 1000 to 1 difference based on hand contamination studies. With the best hand sanitizer formulations, I have tabulated norovirus efficacy results on hands showing close to equivalency between sanitizer and hand washing. Total reliance on low cost hand sanitizer formulations, just won’t cut it though and there are major differences in efficacy between low budget and top of the line formulations."
"And in extended care/nursing homes studies, total reliance on hand sanitizers didn’t work very well and that has also been reported. Here I expect that they were using budget formulations. A much quieter success in fighting some norovirus outbreaks in cruise ships has come where frequency was seen to trump efficacy. But this is with high tech formulas, a lot of surface sanitizing and frequent hand washing. Of course airborne norovirus is another thing, and thats where I am going to close my mouth on that subject."
And when you think about it, in facilities with numerous hot spots as we saw in the recent article by Ginny Moore in the May 2013 issue of Infection Control and Hospital Epidemiology, surfaces near the patient were heavily contaminated. This means 3 things; 1) HCW need very frequent hand sanitizer use when touching anything within reach of the patient, 2) the patient also needs frequent hand hygiene and should be equipped with sanitizer that they can use single handed, 3) it is important to make the determination if C. diff might be an issue requiring gloves or hand washing. But again we need to engage our brains and not trade one false sense of security for another which we are so fond of doing," concluded Michaels.
We challenge you to keep posting your hand hygiene and skin care questions, so we can continue with this important dialogue and explore even more topics related to infection prevention in healthcare, cross-contamination prevention in the food industry, preventing occupational skin disease and infection prevention in the workplace and public facilities. We already have an expert panel of contributors and have a number of new thought leaders joining the conversation in the coming months. So please, ask away and let us know what topics you would like to hear more about.
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