Obstetrician Ignatz Philipp Semmelweis (1818–1865) was the first person to demonstrate by experiment that handwashing can prevent infections. In May 1847, he instigated a chlorine-based handwashing regime in the labour ward of the Vienna Maternity Hospital, where monthly maternal mortality rates from puerperal fever – caused by group A beta-haemolytic Streptococcus – sometimes approached 20%. By June 1847, the labour ward maternal mortality rate was 1.2% (MacDonald et al, 2004).
Almost 180 years later, the hand-drying facilities in public toilets serve as reservoirs of drug-resistant bacteria (Suen et al, 2019) and it is doubly unfortunate that the handwashing standards of some health professionals remains poor. For example, when Gülsen et al (2022) assessed the surgical handwashing practices of 66 operating room staff (surgeons and nurses), 51.5% failed to follow the correct procedure of surgical handwashing ‘and 47% incorrectly performed the procedure of rinsing hands and arms while keeping the hands above the elbows under running water and passing arms through the water in one direction during this process.’
When Baye et al (2021) investigated how 304 pharmacy professionals in public hospitals of Addis Ababa during the COVID-19 pandemic used alcohol-based hand rub (ABHR), 58.9% had sufficient knowledge on its use for COVID-19 prevention ‘but only 35.9% of the study participants had good ABHR utilisation practice.’
What is being done to try to address what appears to be a perennial challenge? One approach has tapped into the cultural zeitgeist and, as the title of a study by Garnier et al (2023) confirms, deployed ‘Game-based training to promote handwashing, handrub and gloving for hospital pharmacy operators.’ Acknowledging that handwashing, hand disinfection and hand gloving are fundamental skills central to working in a hospital pharmacy cleanroom, Garnier et al (2023) concede that these skills are seldom addressed in Good Manufacturing Practices training.
In this Swiss study, a so-called ‘Handtastic Box’ module uses video screens, wooden hands, fluorescein and an ultraviolet lightbox that enables two players to learn optimum handwashing techniques through game playing. Garnier et al (2023) found that, among the 14 pharmacy operators who participated, there was ‘a high rate of satisfaction and a significant increase in operators' knowledge, it proved to be a highly effective training method.’
In terms of the quality of handwashing, Pluta et al (2023) investigated the practical aspects of handwashing that determine successful outcomes. Their recommendations for handwashing practices in pharma and related healthcare organisations stem from an insistence that hand hygiene practices must be appropriate for work situations based on risk and consequences of contamination. For example, Pluta et al (2023) note that fluorescence testing is an effective method to visually demonstrate handwashing efficacy and identify problem handwashing areas, and recommend that this should be included in site training sessions.
They explain that, depending on the backgrounds of personnel being trained and tested, ‘performance of a hand microbiome test to demonstrate the natural presence of microbes on the skin should also be available’; and emphasise that handwashing should be individualised, each person's hands are different, problem areas that require additional effort in washing should be identified, and sufficient force and friction during handwashing is critical.
Given the surge in the use of alcohol gels to promote hand hygiene that arrived with the advent of COVID-19, Lopez-Gigosos et al (2023) investigated the effect of continued use of alcohol-based gel hand sanitiser on biofilm formation by the Staphylococcus epidermidis resident strain isolated from the hands of health science students in a non-clinical setting. Although they found a high number of biofilm-producing isolates displaying biofilm induction by alcohol, they emphasise the need for further studies ‘in hospital settings where liquid alcoholic rub-in hand disinfectant is routinely used’ (Lopez-Gigosos et al, 2023). Since the mid-19th century investigations of Semmelweis demonstrated the value of handwashing as one of the most effective – and simple – infection control measures devised, it is concerning that health professionals, while apparently aware of the benefits conferred on both the patient and their carer, fail to consistently implement this basic procedure.
Research continues apace into the finer points of handwashing, but the extent to which a health professional's sense of responsibility to their patients, their colleagues and to themselves can influence their behaviour remains to be determined. This issue is perhaps more to do with morality than with medical science.