Contents
1. News from IFH
2. Fighting antibiotic resistance is everyone’s responsibility
3. Do consumers understand the difference between “clean” and “hygienic”?
4. Hand hygiene – new insights
5. Update on laundry
6. Cleaning up on the hygiene hypothesis
1. News from IFH
Home Hygiene Development Group Meeting - March 2017
On 21/22 March 2017 IFH hosted the third meeting of this informal group at the Royal Societry of Public Health, London. There were 22 delegates from 6 European countries and the US, representing all aspects of home and everyday life hygiene including home healthcare, domestic food hygiene, hygiene in schools, hygiene in combatting antibiotic resistance, and public understanding of hygiene etc. Using scientific knowledge to develop more effective home hygiene was also discussed. The meeting was very interactive and gave delegates the opportunity to learn about approaches in different sectors – and how approaches and priorities vary between countries. The topline issues which emerged from our very constructive discussions were as follows:
- Delegates agreed that the extent of the disease burden associated with poor hygiene in home and everydaylife is not well appreciated, because the various issues - foodborne infection, home healthcare, reducing antibiotic resistance, school education are usually dealt with separately, by different government agencies. Only when viewed together, can the importance of this issue be asessed. As a result strategies to reduce healthcare- associated infections, to combat antibiotic resistance by prevention spread of infection, etc. focus mainly on healthcare settings, with limited appreciation of the need to “close the cycle of infection” across all settings.
- There was much discussion about the significant shift in attitudes to our microbial world (both our internal and external microbiome) and its relationship with human health and disease. This issue is likely to have profound effects on public health and hygiene policies in the future, and means we will need to find ways to ensure protection against infection whilst re-establishing whilst also sustaining vital exposures to essential microbes.
- A recurrent theme throughout the meeting was the extent to which consumers do not understand hygiene, and how this is adversely affecting our ability to change consumer hygiene behaviour and attitudes. A pilot study asking consumers what they understand by terms “clean” and “hygienic” highlighted the current lack of understanding (see below). It means that consumer-facing strategies developed by Gvt and regulatory agencies must be based on sound science and not on current misconceptions and prejudices, and must include strategies to improve consumer understanding of our relationship to our microbial world
The group agreed to prepare a white paper summarizing the issues which currently dictate attitudes, policies and actions in promoting home and everyday life hygiene. The paper will aim to show how, given appropriate support and investment, and a more integrated approach, an evidence-based strategy is available (targeted hygiene), which allow us to maximise protection against infection whilst also addressing other competing issues.
IFH Activity review 2017 celebrates 20 years since IFH was established.
The new 2017 IFH Activity Review entitled “Hygiene in the home and in everyday life – promoting sustainable health” is available to download. The report illustrates the breadth and depth of what IFH has achieved, the specific issues we are currently addressing, and what we are working towards. It illustrates the extent to which IFH has now become a respected global player and influencer, and our very real contribution to the ongoing efforts to reduce the global burden of infectious diseases and tackle the problem of antibiotic resistance.
2. Fighting antibiotic resistance is everyone’s responsibility
Although there is recognition that hygiene is a key strategy to reduce antibiotic resistance by reducing the need for antibiotic prescribing and mitigating spread of resistant strains, in setting policies, the focus of attention by international and national agencies is on infection hospital and other healthcare settings, hygiene in home and everyday life is being largely ignored. Two recent developments suggest that this may be changing:
NICE Guidance endorses e-bug for hygiene education of children and young people
In the UK, the importance of hygiene education in schools has recently been recognised by NICE in their guidance document: “Antimicrobial stewardship: changing risk-related behaviours in the general population”, published in January 2017. NICE is the UK National Institute for Health and Care Excellence which has responsibility for using best available evidence to provide national guidance and advice to improve health and social care.
The endorsement of e-Bug by NICE, is a great step forward in highlighting the important issue of everyday hygiene and in particular teaching our future generations these important messages at a young age. The next step would be to see these messages included as part of the UK National Curriculum for schools.
NICE guidance recommends that children and young people are taught in an age appropriate manner, and recommends that schools use the e-bug resources, developed by Public Health England. The recognition by NICE highlights the importance of educating young people in basic hygiene principles, and how this can contribute to tackling the growing issue of antimicrobial resistance. The aim of e-Bug is to instil an awareness of the appropriate use of antibiotics from a young age, and to reduce antibiotic prescribing in young people. Through educating on the spread of infection and hygiene principles such as hand washing, respiratory hygiene and food hygiene, e-Bug aims to reduce infections in young people and therefore reduce the demand for antibiotics.
Every infection prevented means fewer antibiotics used – public engagement toolkit
In 2016, Public Health England (PHE) carried out a number of workshops with public-facing organisations to explore methods which could be used by these groups to engage the public on antibiotic resistance and the important part which the public plays in tackling the problem of antibiotic resistance. From the findings of these workshops, PHE prepared a toolkit intended for use by such organisations in their work with community groups.
The aim of the toolkit is to provide PHE centres and voluntary organisations with a compilation of resources to improve public engagement on antimicrobial resistance
The toolkit contains:
- key messages on AMR, frequently asked questions (FAQs), resources and examples of AMR related public engagement activities.
- Resources include: posters, leaflets, quizzes and worksheets accessible via the internet.
- Guidance on use of resources: Exhibiting resources at public events; distributing via e-mail, bulletins, newsletters, promoting resources and key messages via social media, sending resources to relevant groups, distributing to GP Patient Participation Groups, displaying posters and leaflets in public libraries
Re-emergence of methicillin susceptibility in a resistant lineage of MRSA
This paper gives interesting insights into antibiotic resistance, showing that resistant strains of MRSA can regain antibiotic susceptibility. The objective of this study was to understand Staph. aureus methicillin resistance microevolution in vivo, by focusing on 231 isolates from a S. aureus strain that caused an epidemic in the UK. Results show that resistance to methicillin was gained on at least two separate occasions, one of which led to a clonal expansion around 1995 presumably caused by a selective advantage. Resistance was, however, subsequently lost in vivo by 9 strains isolated between 2008 and 2012. The re-emergence of methicillin susceptibility suggests a significant fitness cost of resistance and reduced selective advantage following the introduction in the mid-2000s of MRSA hospital control measures throughout the UK.
Ledda, A., Price, J. R., Cole, K., Llewelyn, M. J., Kearns, A. M., Crook, D. W. (2017). Re-emergence of methicillin susceptibility in a resistant lineage of Staphylococcus aureus. Journal of Antimicrobial Chemotherapy, 7, dkw570. http://doi.org/10.1093/jac/dkw570
3. Do consumers understand the difference between “clean” and “hygienic”?
To explore consumer perceptions, IFH carried out a pilot study of 117 people to find out what they understand by the terms “clean “ and “hygienic” and the difference between these terms. The study population included UK, Netherlands, Germany and US. Although participants were selected at random, and did not reflect a cross section of age and socioeconomic groups, the results give interesting insights into the fundamentally different ways in which these terms are understood – and suggests the need to understand more about consumer understanding if behaviour change strategies are to be successful.
On being asked “what do YOU understand by the terms “clean” and “hygienic”, responses broke down into roughly 3 groups:
- Group 1 - about half (53% of 117 respondents) thought that clean means absence of dirt whilst hygienic means a state where the of microbes has been reduced
- Group 2 - about one third (38.5%) thought that clean and hygienic both mean dirt and microbe reduction.
- The other 8 people - all from UK - thought that clean means it has been cleaned with e.g detergent, whilst hygienic means it has been treated with a disinfectant
If we dig more deeply:
- For Group 1, who said that clean is absence of dirt whilst hygiene is microbe reduction , they further reinforced this by talking about other discrimators - “hygienic” means protection of health, safety, sanitary conditions (only the US participants used the term sanitary)
- For Group 2 – of the 45 people in this group 19 (42%) saw a discriminator between hygienic and clean i.e. they saw hygienic as more rigorous cleaning i.e. “more clean, clean enough, safe for purpose, but that left 26 out of the 45 (58%) who did not make this distinction, This latter response suggests 2 possibilities:. Either a) they believe that provided something is clean it is also microbe safe or b) they see clean and hygienic as interchangeable terms. In Germany for example, it is acceptable to make a “hygiene” claim for products intended for cleaning.
Importantly, this suggests that, of 117 respondents, 26 (22%) (from group 2) assume that if a surface is visibly clean, it means there is sufficient microbe reduction to make it “safe”.
We then asked consumers in groups 1 and 2 “how do you judge whether a surface is clean or hygienic?”:
- Almost universally respondents agreed that “clean” was indicated by absence of visual dirt (and/or by touch or smell)
- Encouragingly – about half (47%) did recognize that there was no way of telling whether a surface was hygienic/“microbe safe” except by being confident that they themselves, or someone else had carried out the hygiene procedure correctly
However, in both groups 1 and 2, there were people (4/44 (9%) in group 1, 11/28(38%) in group 2) who said they would judge whether a surface is “hygienic “ solely by whether it looks and smells clean. Of the 12 responses, 5 were from Germany where it is allowable to label products intended for cleaning (removal of dirt) can be labeled as hygiene products. It is argued that the claim “hygiene” is justified because cleanliness has a positive impact on our feeling of well-being and therefore on our health.
Although further work is necessary to explore these concepts, this pilot studies suggest that if we want to improve consumer hygiene behaviour, we need an accepted term – such as hygienically clean - to be able to tell consumers when “visibly clean” is not enough and that you can only know if it is hygienically clean if you are confident it has been cleaned (and disinfected if necessary) in the right way.
As part of strategy to tackle antibiotic resistance through hygiene – and reduced antibiotic presecribing, IFH has produced a simple e-leaning resource to help consumers, healthcare workers etc. understand how infections spread and how targeted hygiene can break the chain of infection transmission4. Hand hygiene – new insights.
4. Hand hygiene - new insights
Insights into the controversy over the effectiveness of antimicrobial soap: future prospects
Kim, and Rhee review current controversy over antibacterial soaps and discuss possible reasons why some studies show significant difference between plain soap and antibacterial soap whilst others do not. In particular they discuss how differences in experimental design may be a significant factor. They also comment on the FDA rule on antibacterial soaps, which will come into effect from September 2017. FDA conclude that, based on the lack of evidence for the effectiveness of antibacterial soap, the risks (the negative effects of antiseptic active ingredients on human health and the environment, such as antibiotic resistance, acute/chronic toxicity, endocrine disruption, allergies, and bioaccumulation) outweigh its benefit. The ruling means that consumer antiseptic products containing one or more of 19 ingredients, including triclocarban, and triclosan, can no longer be marketed.
In general, Kim and Ree express agreement with the FDA decision, concluding that “consumers should be protected from advertisements exaggerating the positive effects of antimicrobial soap, especially as consumers are usually prepared to spend more money purchasing antimicrobial soap with the expectation that it will be more effective in preventing infectious disease than plain soap. Governments have the responsibility to educate the population continuously on the beneficial and adverse effects of antimicrobial soap”.
Finally they discuss the need for more research into the efficacy of antibacterial soaps containing a variety of antiseptic ingredients in order to develop safer and more effective ingredients. The say “Continuing research into antimicrobial soap will contribute towards establishing appropriate regulations and standards for use of antibacterial soap in personal care settings, and it is expected that this will further improve personal health". The paper can be found at: http://www.journalofhospitalinfection.com/article/S0195-6701(17)30144-5/abstract. or Journal of Hospital Infection (2017), doi: 10.1016/j.jhin.2017.03.013.
Study suggests handwashing compliance in child care facilities is insufficient
A new study suggests that child care personnel properly clean their hands less than a quarter of the times they are supposed to. This study used video cameras to record handwashing habits and compliance among child care workers at a childhood center in northwest Arkansas. Researchers found that personnel and parents at the facility followed proper handwashing procedures only 22% of the time before and/or after tasks such as wiping noses, emptying garbage cans, preparing food, changing diapers, or using cell phones. Caregivers washed 30% of the time it was called for, with paraprofessional aides at 11%, and parents at 4%. Handwashing can prevent about 30% of diarrhoea-related sicknesses and about 20% of respiratory infection in children, according to CDC. The study can be found at: Clark, J., Henk, J. K., Crandall, P. G., Crandall, M. A., O’Bryan, C. A., Bureau, U. S. C., … Pittet, D. (2016). An observational study of handwashing compliance in a child care facility. American Journal of Infection Control, 44(12), 1469–1474. http://doi.org/10.1016/j.ajic.2016.08.006.
Visit www.apic.org/infectionpreventionchildcare to access APIC’s new infographic and more information about preventing infections in child care facilities.
How much does poor hand hygiene cost?
A new study has found that annual net costs to India from not handwashing are estimated at US$23 billion and to China at US$12 billion. Expected net returns to national behaviour change handwashing programmes would be US$ 5.6 billion (3.4-8.6) for India at US$ 23 (16-35) per disability adjusted life year (DALY) avoided, which represents a 92-fold return to investment, and US$ 2.64 billion (2.08-5.57) for China at US$ 22 (14-31) per DALY avoided – a 35-fold return on investment. The authors conclude “Our results suggest large economic gains relating to decreases in diarrhoea and acute respiratory infection for both India and China from behaviour change programmes to increase handwashing with soap in households”. The study can be found at: Townsend, J., Greenland, K., & Curtis, V. (2016). Costs of diarrhoea and acute respiratory infection attributable to not handwashing: the cases of India and China. Tropical Medicine & International Health. http://doi.org/10.1111/tmi.12808
5. Update on laundry
Laundry – How to get more than clean – new review.
Although laundering should mainly remove stains and dirt from used and worn textiles, the
elimination of microbial contamination is also an important part of the laundry process. While industrial and institutional laundering employs standardized processes using high temperatures (i.e. 60°C and above) and bleaching agents to ensure a sufficient hygienic reconditioning of textiles, domestic laundering processes are less defined and not always led by purposeful aims. The strive to achieve greater energy efficiency of household appliances and increase sustainability of domestic laundering has resulted in a decrease in washing temperatures in Europe during the last decades. At the same time, a desire for convenience has led to an increased use of liquid detergents that do not contain bleach which in turn impacts the antimicrobial efficacy of domestic laundering.
This review considers the different factors that influence the input and removal of microorganisms in the laundering process and discusses the possible adverse effects of microbial contaminants in the washing machine and on the textiles as well as suitable counteractions. This review by Dirk P Bockmuhl is published online in the Journal of Applied Microbiology at doi: 10.1111/jam.13402
Low temperature laundering may not be effective in removing fungal contamination from socks
Athlete’s foot (Tinea pedis) is a common chronic skin disease. In early 2013, IFH carried out a review of studies of the hygiene effectiveness of laundering, but found that there were relatively few studies involving fungal contamination. In this study, samples from 81 socks worn by patients suffering from tinea pedis were laundered at 40°C or 60°C. Samples washed at 40°C revealed 29 (36%) positive fungal cultures, of which 14 came from the toe and 15 from the heel areas. Trichophyton rubrum was isolated in 4 specimens, and Aspergillus spp. were found in 20 (70%) specimens. Samples from the same socks washed at 60°C revealed 5 (6%) positive fungal cultures, of which 3 came from the toe and 2 from the heel area. Only Aspergillus spp. were detected. Yeasts were eradicated at 40°C. The authors concluded that, contravening current trends for energy saving and environmental protection, laundering at low temperatures is not effective in eradicating fungal pathogens, which requires high-temperature laundering at 60C. Boaz Amichai, Marcelo H. Grunwald, Batya Davidovici, Renata Farhi , Avner Shemer. The effect of domestic laundry processes on fungal contamination of socks. International Journal of Dermatology. 2013,Volume 52, Issue 11, pages 1392–1394. DOI: 10.1111/ijd.12167
6. Cleaning up on the hygiene hypothesis - is it time to throw out the hygiene hypothesis?”
This new feature article by Megan Scudellari (open access) in Proceedings of the National Academy of Sciences is a well-researched review on the rise of allergy and autoimmune diseases, from which she concludes “it’s obviously due to much more than rampant cleanliness”. She reflects on whether it is possible to abandon the term hygiene hypothesis and thereby detach the concept from its association with “hygiene” as the public understands it.
Megan traces the issue from the 1989 “hygiene hypothesis” proposal – the idea that the surge in autoimmune and allergic disorders and simultaneous sharp decline in mumps, measles, tuberculosis, and other infectious diseases were connected in some way. Studies soon showed that this hypothesis did not hold up - infections like measles and many respiratory diseases proved not to be protective against allergic disease.
In 2003, Graham Rook proposed a revised explanation - that early exposure to “old friends” microorganisms present throughout human evolution train the immune system to react appropriately. Rook likens the immune system to a computer programme: It has software, but needs data—in the form of exposure to a diverse set of microbes—to train it to identify threats appropriately. It’s not about just learning what to attack, but learning what to tolerate. The problem comes when our immune system meets an allergen like pollen or peanuts and doesn’t know that is harmless.
Rook argues that hygiene in its broad sense - improvements in sanitation, food, and water in the late 20th century - were involved in reducing our exposure to old friends microbes, but simultaneous changes in other factors most likely had an even larger influence especially in early life. Caesarean sections have been linked to increased risk of allergy and asthma, whilst owning a pet or growing up on a farm is protective. Antibiotic use (which kills off both good and bad microbes) has been linked to asthma, cow’s milk allergy, IBD, and eczema.
Still, the catchy “hygiene” hypothesis is widely embraced by the public, the media, and even scientists. Meghan says “Use of the term in the scientific literature rose threefold over the past 10 years compared with the decade prior. However, as soon as you use the word ‘hygiene” hypothesis, it prejudges what the cause is. The public interpret “hygiene” as personal cleanliness: washing hands, keeping food clean, sanitizing the home. The term fails to incorporate the other factors now linked to immunoregulatory diseases, like antibiotic use and diet. Her research showed however that the call to abandon the original theory is falling on deaf ears when it comes to scientific experts, who may have little interest in the impact on public attitudes to hygiene and its importance. Several researchers interviewed for the article said the issue was semantics, and they didn’t care what name is used - they themselves as scientists understand that it now means the “Old Friends mechanism”. They are unconcerned that when using the term with less well informed media, journalists find it imperative to explain to their readers what “hygiene hypothesis” means – namely the 1989 version of the hypothesis and the link to infection and hygiene!
Looking to the future, Meghan concludes that although we have now moved beyond the “hygiene” hypothesis, there are very few credible studies testing interventions to reregulate the immune system. She quotes Wills-Karp as saying “Researchers hope that, at some point, they will identify which regulatory pathways train the immune system. By finding common pathways, we could adopt drugs or probiotics to activate them to condition the immune system properly in early life.”
This may seem exiting - but meanwhile the media will continue to persuade us that we have become too clean for our own good - and we need to stop washing our hands – despite the fact that this is probably the most cost effective means to reduce the global burden of infectious disease - and key to tackling the global problem of antibiotic resistance?
