Hygiene is the practices we adopt in our homes and everyday lives to protect ourselves, our families and our friends and colleague from infectious diseases.
IFH is unique because it looks at hygiene “holistically” from the point of view of the family, at home and in their everyday lives and the range of actions they need to undertake (food and water hygiene, handwashing, using the toilet, coughing and sneezing, care of pets, safe disposal of waste) in order to protect from infectious disease. It also includes caring for family members who are infected, or who are at greater risk of infection e.g patients discharged from hospital or undergoing outpatient treatment, babies, pregnant mums etc.
In line with this, IFH is committed to promoting hygiene education and developing community-based projects that will empower communities and individuals to take responsibility for their health in terms of hygiene in the home and its environment.
In 2018 IFH published a consensus report which sets out why hygiene in home and everyday life is such an important part of public health, and what needs to be done to change hygiene understanding and hygiene behaviour as a means to tackle some of the key present day health issues such as reducing antibiotic resistance and reducing pressure on our health systems.
In the 1960s, there was a feeling that, with vaccination and antibiotics freely available, conquest of infectious disease would soon follow. The last five decades have shown this optimism was totally misplaced.
Infectious disease continues to exert a heavy burden on health and prosperity. Although the majority of deaths occur in the developing world, infectious disease still causes around 4% of deaths in developed countries and is a significant cause of morbidity. Social, demographic and other changes mean that the importance of hygiene in home and everyday life is increasing rather than decreasing.
Food, waterborne and non-food-related infectious intestinal diseases remain at unacceptable levels. Despite people’s general belief that foodborne infections occur outside the home, data collected from 18 European countries, suggests that about 31% of foodborne outbreaks occur in private homes. Norovirus, mainly spread from person-to-person, is the most significant cause of intestinal infections in the developed world, including 3 million cases per year in the UK, whilst rotavirus is the leading cause of gastroenteritis in children under 5.
On average, adults get 4 to 6 colds per year, while children get 6 to 8. Respiratory hygiene can limit spread of respiratory infections, particularly colds, but also influenza. Since respiratory and intestinal viral infections are not treatable by antibiotics, prevention through hygiene is key.
Governments, under pressure to fund the level of healthcare that people expect, are looking at prevention as a means to reduce health spending. Increased homecare is one approach to reducing health spending, but gains are likely to be undermined by inadequate infection prevention and control at home. Healthcare workers now accept that reducing the burden of infection in healthcare settings cannot be achieved without also reducing the circulation of pathogens such as norovirus and MRSA in the community.
Societal changes mean that people with greater susceptibility to infectious disease make up an increasing proportion of the population, up to 20% or more. The largest proportion comprises the elderly who have reduced immunity, often exacerbated by other illnesses. It also includes the very young, and family members with invasive devices such as catheters and people whose immuno-competence is impaired as a result of chronic and degenerative illness (including HIV/AIDS), or drug therapies such as cancer chemotherapy.
Emerging pathogens and new strains are a significant concern. It is remarkable that norovirus, Campylobacter and Legionella were largely unknown as human pathogens before the 1970s, with others such as E.coli O157 and O104 emerging in subsequent decades. Agencies worldwide recognise that, for threats such as new influenza strains, SARS and Ebola, hygiene is a first line of defence during the early critical period before mass measures such as vaccination become available. The low infectious dose observed for several of the emerging pathogens, such as E.coli O157:H7 and norovirus, is an additional concern that emphasises the role that hygiene can play in prevention.
Antibiotic resistance is now a global priority. Hygiene addresses this problem by reducing the need for antibiotic prescribing and reducing “silent” spread of antibiotic resistant strains in the community and hospitals. As persistent nasal or bowel carriage of these strains spreads in the healthy population, this increases the risk of infection from resistant strains in both hospitals and the community.
The 2019 UK National Action plan on AMR says “Health & social care providers can only do so much to prevent infections; when it comes to infections in the community (which requires exposure to antimicrobials), the public have a huge part to play”.
Infections can act as co-factors in diseases, such as cancer and chronic degenerative diseases. Syndromes such as Guillain-Barré and triggering of allergy by viral infections add to the burden of hygiene-related infection.
A major problem is that, for the most part, both at national and international level, these various issues are handled by different health agencies. It is only when viewed together that the true size of the hygiene-related disease burden is apparent.
Since the 1980s, IFH has been developing a risk-management approach for hygiene in the home and everyday life - known as ‘targeted hygiene’. Targeted hygiene means focusing our hygiene practices in places and at times when harmful microbes are most likely to be spreading in order to break the chain of infection:
The chain of infection
This contrasts with historical approaches equating hygiene with eradicating dirt – incorrectly regarded as the main source of harmful microbes. An analysis of UK and US media coverage suggests that we still largely see hygiene as synonymous with cleanliness, and the terms ‘cleaning’ and ‘hygiene’ are often used interchangeably causing confusion about what hygiene really means.
Targeted hygiene means recognising that the main sources of harmful microbes are not places which are ‘dirty’ but contaminated food and water, domestic animals (pets), and people who are infected or are healthy carriers of potentially harmful microbes (e.g Staphylococcus aureus or its resistant form, MRSA). Since the presence of these potential sources of infection in the home is inevitable, this means that the only way to protect ourselves from infection is by preventing the spread of harmful microbes from these sources.
A pilot study of 117 people carried out by IFH indicated that about
assume that if a surface is visibly clean that means that microbial contamination has been reduced to a safe level i.e clean and hygienic mean the same thing.
Targeted hygiene also means recognising that the times or situations when harmful microbes are most likely to be spread i.e. the times when we need to practice hygiene are during food handling, using the toilet, coughing, sneezing, nose blowing, caring for domestic animals, handling and disposing of refuse, or where a family member is infectious and is shedding infectious microbes into the environment by vomiting or diarrhoea or by touching foods or hand contact surfaces. In short, getting people to adopt targeted hygiene means getting them to visualise the chain of infection, and understand that hygiene is about breaking it.
Targeted hygiene also means understanding which surfaces are likely to cause spread of infection in each of these situations.
There is no doubt that in the future we are going to have to view our microbial world very differently. Microbiome science now shows that the millions of microbes that live on and within us (the human microbiome) are as essential to our health as our liver and kidneys.
Lack of exposure to the diverse microbes in our human, animal and natural environments, the key to sustaining a healthy and diverse microbiome, is now being associated with rising levels of a whole range of diseases including autoimmune diseases, inflammatory bowel disease, type 1 diabetes and other diseases.
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Avoiding our microbial world is no longer the healthy option.
The realisation that microbial exposure is essential to health has fundamental consequences for hygiene because it poses the question “how can we develop lifestyles that sustain exposure to the right sort of microbes, whilst at the same time protecting against those that cause disease?
Key to addressing this challenge is understanding what the essential microbes are, and why we have lost contact with them. Current evidence shows the problem lies in lifestyle, medical and public health changes over the last 40-50 years, which, particularly in early life, deprive us of exposure to microbial “Old Friends”. These “Old Friends” are largely non-harmful species which inhabit the human gut and our natural environment. Lifestyle changes which are implicated in reduced exposure to Old Friends include C-section rather than vaginal childbirth, bottle rather than breast feeding, fewer siblings, urbanisation and less outdoor activity. Since communication between “Old Friends” and the immune system is mediated by the gut microbiome, excessive antibiotic use and altered diet can affect the microbiome in a way that increases inflammatory disease risks. We are still a long way from knowing which microbes might be used to reverse the adverse effects of reduced microbial exposure, and indications are that it is exposure to a diversity of microbes which is important.
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Key to tackling this problem is the need to understand that “being too clean or hygienic” is not the underlying problem as many people now think - if personal and environmental cleanliness is involved, its contribution is likely to be small relative to the cumulative effect of these other factors.
This misleading idea arose in 1989 when Dr David Strachan hypothesized that a cause of rising allergic diseases was lower incidence of infection in early childhood. He suggested an underlying cause could be “improved household amenities and higher standards of personal cleanliness”. By naming it the “Hygiene” hypothesis, the notion that we have become “too clean for our own good” has arisen and continues to be publicised alongside the unsupported idea that being less “hygienic” could reverse this trend. This is despite ongoing evidence since 1989 which now refutes the link to infection. Unfortunately, despite most experts accepting that the exposures we need are Old Friends microbes not infections, and that the underlying problem is lifestyle changes not hygiene, this relationship is still being referred to as the “hygiene” hypothesis, thereby perpetuating the concept that “too much cleanliness and hygiene” is the underlying cause - to the extent that it is now received wisdom. This is illustrated by a 2018 review of UK/US media coverage. In all 70% of 36 articles published from 1998 to 2017, including more recent articles, emphasize the role of home cleanliness as a causative factor in rising allergies, etc., referring to the home environment as being too clean, hygienic, sanitized, oversanitized or sterile.
Whilst targeted hygiene was originally developed by IFH as an effective approach to hygiene practice in the home and community, it also seeks, as far as possible, to sustain "normal" levels of exposure to the microbial flora of our environment to the extent that is important to build a balanced immune system.
Consumer responses to articles reviewed in the media survey suggest that the public fail to grasp the key concept. Many responses expressed a view that “dirt and germs” are important for building a strong immune system – otherwise children grow up “weak, sickly, prone to every ailment – and to allergies”.
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A telephone survey of 2000 people carried out by the RSPH in 2018 showed that
mistakenly assume that children need to be exposed to harmful germs to build their immune system.
By associating germs with dirt, people conclude that too much cleanliness means that children fail to build the strong immune system to not only ”fight” infections but also “allergies”. They need simple clear communication that allergic reactions occur when the immune system “fights” allergens rather than ignores them – which is what Old Friends exposure trains the immune system to do.
With the explosion of interest in the human microbiome, nutritionists and microbiomists are now encouraging us to reconnect with essential microbes by “getting out and getting dirty”. In interviews they were asked what advice they would give families to increase their exposure to a diversity of microbes. Recommendations included getting outdoors and getting dirty, stroking pets, and avoiding antibiotics where possible. Worryingly, in some cases, the advice also included letting pets lick your face, sucking a babies pacifier to clean it, washing dishes by hand instead of using a dishwasher and, most importantly, not washing hands”. Although data suggests that these actions may increase exposure to Old Friends microbes, they are also critical target surfaces and actions likely to increase the risk of exposure to infection. As yet there are no intervention studies demonstrating that lifestyle changes, such as those discussed above, actually impact on inflammatory disease rates, but significant evidence that abandoning hygiene measures such as handwashing are associated with increased rates of respiratory and gastrointestinal disease.
Getting people to adopt lifestyles which sustain exposure to necessary microbes, whilst protecting against pathogens requires a significant change in public understanding of our microbial world, and what hygiene means. Providing consumers with unambiguous messages, as our knowledge of the microbiome and its implications for health and hygiene expands, represents a considerable challenge.
One of the most contentious hygiene issues is consumer use of antibacterial products and the concerns that this may be contributing to the development of antibiotic resistance.
A number of expert reports have been commissioned in the last 10 years. These agree that laboratory evidence “does indicate” that use of certain types of microbiocidal products could contribute to reduced susceptibility to antibiotics, but they also conclude that there is no evidence, as yet, that disinfectant/antibacterial/hand sanitizer use has contributed to antibiotic resistance in clinical practice”. (a), (b) (c) Unfortunately the former statement is often quoted without reference to the latter, leading others to conclude that the problem has been identified under real life conditions. As a result the concept that disinfectants/ antibacterials used in the home cause development of antibiotic resistance has become received wisdom.
The 1990s saw an explosion in marketing of antibacterial cleaning products (and antimicrobial-impregnated materials e.g. chopping boards).This creates problems, because the widely publicised opposition to routine use of antibacterial soaps, cleaners and impregnated materials is preventing objective assessment of evidence indicating that, in specific risk situations, cloth wiping and detergent-based cleaning can increase the spread of pathogens via hands and surfaces thereby increasing infection risks, and that, in this situation, targeted use of a disinfectant antibacterial or sanitizer may be required. Data show that failure to use microbiocidal products in these situations can increase transmission and exposure to infectious microbes.
Expert bodies stress the hygiene importance of microbiocides, but also stress the need to use them prudently, and confine use to situations where there is identifiable risk of spread of harmful microbes. Taken together, these examples demonstrate the need to evaluate use of microbiocidal products on a case by case basis according to the type of agent involved, where it is to be used, and the risk of infection exposure if microbiocides are not used.
The survey of media coverage 1997 to 2017 shows the extent to which marketing of microbiocidal products is opposed by experts and the public, even in situations where there is data showing that they are needed to break the chain of infection. Their conviction that risks outweigh benefits partly reflects lack of understanding. Antibiotics are administered at low concentrations to avoid side effects, but declining drug levels between doses creates conditions favourable for emergence of resistant strains. By contrast microbiocides can be safely used at much higher concentrations, which rapidly kill microbes before they can enter the body thereby obviating the need for antibiotic prescribing. It is rarely considered that disinfectants, antibacterials or hand sanitizers, used as part of targeted hygiene (right place, right time, right product) could combat antibiotic resistance by reducing the need for antibiotic prescribing.
Whilst targeted hygiene was originally developed as an effective approach to hygiene practice in the home and community, it also provides a framework for minimising any risks of encouraging the development of antibiotic resistance through low level biocide exposure.
Whilst targeted hygiene was originally developed by IFH as an effective approach to hygiene practice in the home and community, it also provides an excellent framework for building sustainability into hygiene.
Through prudent and focussed use of hygiene products and processes, it intrinsically minimizes environmental impacts and minimizes any risks of encouraging the development of antibiotic resistance through low level microbiocide exposure. It also seeks, as far as possible, to sustain "normal" levels of exposure to the microbial flora of our environment to the extent that is important to build a balanced immune system.
Although infection prevention is more sustainable than treating infections, sustainability of hygiene procedures must also be considered. On one hand it is important that hygiene practices are effective in reducing contamination to safe levels, at the same time we need to avoid overuse of resources (water, detergents, soaps, heat, mechanical action, microbiocides) and manage possible risks (environmental, toxicity, resistance, etc.).
Unfortunately, in the current climate of concern about the environment, these risk issues tend to be addressed, with limited effort to counterbalance against the importance of mitigating infection through hygiene. Lack of an authoritative voice advocating for hygiene means that risk issues have been allowed to take precedence. Particularly in Northern Europe, concerns about environmental impacts are strongly voiced, with little attention to well-established evidence of the need for effective hygiene.
This is illustrated by reference to 2 specific examples.
Awareness that domestic laundering is a significant contributor to total energy consumption in the home, has prompted the householdcare industry to develop detergent which can produce visibly clean clothing when laundered at temperatures less than 30ºC. What has been overlooked however is that, although low temperature laundering can achieve visible cleanliness, it is less effective in reducing levels of microbial contamination on fabrics. Evidence shows that clothing in direct contact with the skin has the potential to spread potentially pathogen organisms including antibiotic resistant strains such as MRSA and suggest that this situation is not ideal. In an RSPH telephone survey 55% of people said that hygiene was more important than saving energy when laundering clothing, set against 12% who disagreed with this view.
A further concern relates to the use of disinfectants in the home and concerns that this may a contributory factor in development of antibiotic resistance. Although lab studies indicate that exposing bacterial populations to disinfectants/ antibacterials can lead to reduced susceptibility to antibiotics, there is no good evidence that domestic use of disinfectants is a cause of rise in antibiotic resistance in clinical practice - as yet. Opponents of the use of antibacterial products argue that “plenty of hot soapy water is all you need”? but this ignores evidence which demonstrating that soap & water can contribute to spread microbes via clothes and hands used for cleaning, and that in in some situations disinfectants needed.
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A study showed that soap and water cleaning of surfaces used to handle and prepare chicken contaminated with campylobacter spread campylobacter to hands and other surfaces, whilst another showed that wiping surfaces contaminated with norovirus spreads virus to hands, cloths & other surfaces.
People, rightly concerned about these issues are unsure how to balance this against the conflicting information which they they hear. Faced with this, there is a tendency to reject well tested effective hygiene practices in favour of “greener” alternatives, which could increase the risk of infection, and fuel greater demand for antibiotics. It could be argued that, although indiscriminate us of antibacterial products for routine cleaning is unacceptable, if targeted use of microbiocidal products contributes to reducing infection risks, they could actually decrease the need for antibiotics, which is a key part of tackling antibiotic resistance.
Targeted hygiene also allows us to focus the use of resources (heat, water, mechanical action, detergents, disinfectants) in a manner which minimises environmental and other impacts.
One of the barriers which must be addressed if we are to be successful in promoting hygiene behaviour change as part of tackling urgent public health issues is the fact that the public have become confused about hygiene - what it is and how it differs from cleanliness.
Significant confusion arises because we still hold to the idea that dirt is the main source of harmful germs, and that hygiene means cleanliness aimed at eradicating dirt. An analysis of UK and US media coverage suggests that we still largely see hygiene as synonymous with cleanliness and the terms ‘cleaning’ and ‘hygiene’ are often used interchangeably.
At the turn of the C19th, when Florence Nightingale introduced stringent hospital cleanliness and showed a dramatic decrease in mortality of wounded soldiers, she was unaware of the germ theory of disease. Whilst growing knowledge of how infectious bacteria and viruses spread and cause infection has led to dramatic changes in microbial quality assurance in manufacture of foods, etc., this is not so for home and everyday life hygiene.
Cleanliness achieved by routine (non-targeted) daily or weekly cleaning may contribute to preventing the spread of pathogens, but there is little data to suggest that its contribution is significant relative to hygienic cleaning at critical points at key times. The health benefit of keeping our home clean is the removal of soil etc which encourages infestation with rats, mice, cockroaches, dust mites, bed bugs etc. It also encourages the growth of mould which can have adverse health effects.
Common use of the term “germs” also causes confusion. Whereas, in the past it was used to indicate harmful microbes, we now talk about good and bad germs. The media frequently talk about “millions of germs” on household surfaces but rarely explain that the majority are likely to be harmless. This is reinforced by ongoing portrayal of “germs and dirt” in a sinister way to suggest that they are universally harmful.
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A telephone survey carried out by the RSPH in 2018 showed that whilst
saw “germs” as “sometimes good but sometimes harmful”,
saw them as “usually or always harmful”.
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Whilst some people develop extreme fear of invisible microbes, others are increasingly sceptical about the need for hygiene in our modern world, concluding “if there are so many dangerous microbes in our home, how come we have survived so long”.
A further issue is the hygiene hypothesis, first published in 1989, which proposed that children who had more infections were less likely to develop allergies, and that this could be due to “improved household amenities and higher standards of personal cleanliness”. Although this concept has now been refuted (i.e. research shows that the exposures we need are to beneficial rather than harmful bacteria), widespread publicity given to the “hygiene” hypothesis in the 1990s has led to a received wisdom that we have become “too clean for our own good”. The idea that we need exposure to harmful germs to build a strong immune system is still being constantly repeated.
These issues have caused the public to become mistrustful about hygiene; it may be helpful to encourage children to spend more time playing outdoors and getting dirty, but messages such as “we must stop washing our hands”, which involve a significant risk of increased exposure to infection, are unacceptable.
A survey of media coverage and consumer feedback shows that some believe the scaremongering about “germs” is a ploy to sell antibacterial products. Taken alongside media messaging about environmental and toxicity risks, and possible links between antibacterial use and antibiotic resistance, they are tending to reject established hygiene practices and look for organic, environmentally friendly alternatives to commercially tested and approved disinfectants, thereby increasing infection risks and demand for antibiotic prescribing.
The outdated concept of “dirt and germs” as the source of infection in home and everyday life needs to be replaced with understanding the “chain of infection” i.e. where harmful germs originate, how they survive in the environment, how they transmit and how hygiene can break the chain of infection.
It seems clear that, getting people to change hygiene behaviour depends not only on promoting hygiene practice but also changing public understanding and restoring their confidence in hygiene. We need the public to believe that infection doesn’t “happen by accident or misfortune” - it is preventable in many cases. If we believe we have no control over whether we get an infection, we will not take measures to control it. We also need to persuade people of the direct benefits of hygiene to them as individuals e.g. avoiding loss of income, costs of childcare, disruption of family leisure activities, etc.
Targeted hygiene based on the concept of breaking the chain or infection provides a simple visual basis for understanding and practising effective hygiene.