First published in the NASGP Newsletter in June 2019
A century after Semmelweis published his paper on reducing the spread of infection in maternity wards, his advice reached the Department of Health.
In post-war Italy TB was still rife and notices in buses commanded “No Spitting”. In Britain in 1946 the message “Coughs and sneezes spread diseases” promoted the use of handkerchiefs to catch the germ-laden droplets. Presumably a reasonably successful public health campaign, although if you are trapped like a sardine in a rush-hour tube train, you may have no alternative but to sneeze into the shoulder of the person jammed in front of you.
Reducing droplet spread is a great step forward, but rhinoviruses are also transferred from noses to hands and so to any surface we touch. They survive there for several hours for the next person grabbing the handrail or turning on the tap to pick up. So do more dangerous infective agents from other sources. Hence the slogan I recall from my childhood “Now wash your hands”. So, a century after Semmelweis published his paper on reducing the spread of infection in maternity wards, his advice had reached the Department of Health. If followed today, it could cut gastrointestinal upsets by a third, reduce sickness absence from school and work, and save the UK economy more than £1 billion every year. But the E coli counts on peanuts set out for grabs on pub bars demonstrate that the general public still isn’t heeding the message. A surgical scrub isn’t necessary, but the more thorough the wash, the better. The NHS recommends washing with soap (antibacterial not helpful) for as long as it takes to sing ‘Happy Birthday to You’. Twice. Though as most of the pathogens are on the fingertips, even waving the fingers under a dribbling tap may be better than nothing.
Wet hands still pass on a lot of pathogens, but effective drying removes almost all the bugs. Dryers in public toilets are a relatively recent introduction – the researchers of the 1965 Good Loo Guide found that less than five percent of public toilets had hot air dryers, though they probably had roller towels. Paper towels came later. Jet dryers (OK, Dyson Airblades ®) are a 21st century invention.
Which works best? Cloth towels are quick and effective, though try finding a clean area on a jammed roller towel. Studies comparing the effectiveness of paper and jet dryers are limited, and the results tend to support the product of the industry which sponsored them.
It does seem clear that jet dryers are more economical than paper towels, which have to be sourced, delivered, stocked, cleared away, and disposed of in landfill. Add in the cost of calling the plumber to unblock the loos and the fire service to put out fires in waste baskets. But on the road to reduction of infection, cost isn’t even a surrogate end point, it’s just a station on a by-line for institutions that are counting the pennies, not the pathogens.
The paper industry claims that jet dryers blast bugs into the air. The jet dryer industry claims more effectiveness and less mess. The only independent study, a literature search by the Mayo clinic in 2012, found (in a 2009 survey) that most members of the US public preferred paper towels, and recommended that single-use paper towels be used in health care settings.
The bottom line is, do people use whatever drying method is provided? And do they use it effectively?
Time is one hurdle. Traditional hot air dryers are too slow. Jet dryers are quick, but not that quick, and if there is a queue and the curtain is about to go up on the final act, you probably shake your hands and rush to your seat.
“People will wash thoroughly if they find their hands contaminated by something that disgusts them, like dog-shit, but they don’t make the same connection with illness after a visit to a toilet.”
Paper towels are quicker. But paper towels dissolving to pulp on a wet floor don’t encourage users to spend time doing even a cursory wash.
Poorly maintained facilities may make users feel they need to clean themselves of the grot, but probably make it more difficult to do so. Fastidious users don’t like the idea of contaminating themselves with other people’s germs, and it does seem illogical to turn on a tap with dirty hands and then re-contaminate them when you turn it off. No-touch facilities reduce cross-contamination and taps which turn themselves off must save water – as long as the system works.
Ultimately, it’s a matter of culture. People will wash thoroughly if they find their hands contaminated by something that disgusts them, like dog-shit, but they don’t make the same connection with illness after a visit to a toilet. Pete Hesgeth, the Fox News presenter, says he doesn’t wash his hands – he can’t see the pathogens so they aren’t there. A majority of Britons seem to share his view, at least unconsciously. Accurate statistics on the public’s hand-washing habits are hard to obtain, but apparently more than 60% of people don’t bother.
Behaviour change is difficult when the threat is invisible. Establishing a hand-washing ritual early in life is a challenge. Health visitors and Sure Start – where it still functions – can explain to mothers that leaving children’s hands unwashed is equivalent to feeding them faeces – sorry, poo – and teach them how to get their children into the habit. Schools have a responsibility to provide adequate facilities and to ensure they are used.
In the consulting room, hand-washing means more than just removing infective agents. It’s a brief time out. It’s a demonstration to the patient. Water or alcohol? Some GPs like the feeling that they are washing those germs down the basin. Others prefer an alcohol rub. It’s quick and it’s effective.
Some facilities are a pleasure to use. Upmarket gastro-pub loos are tastefully decorated with scent sticks and an orchid, maybe a real one. You take a pleasingly coloured fluffy towel square from the pile, enjoy getting your hands really dry and drop it into a wicker basket. But even there I bet you won’t time yourself by singing Happy Birthday – twice.