Of Religious Tomes and Tippy Taps

Personal hygiene is the practice of keeping your body clean, including your hands. Hygiene has aesthetic and moral (purity) dimensions in addition to health dimensions.¹ Dating back to biblical times and beyond, societies have emphasized the importance of cleanliness of both people and the environment. Dirt was negatively construed, moving hygiene into the realm of morality.² These hygiene practices came in the form of rules and laws in religious books,³ for example, for washing bodies, food preparation, and burial practices.^4,5 A version of soap (a mixture of tallow and ash) was in use as early as 2300 BC.⁶ The 19th century heralded the use of disinfectants and antiseptics.⁷

As early as Roman times, hygiene became a social and cultural event,⁸ with hot and cold communal baths. The 1850s marked the start of a sanitation revolution in Great Britain, catalyzed by the “Great Stink”—the smell of a sewage-ridden Thames River flowing past the Houses of Parliament.⁹ In the mid- to late-19th century, mortality rates fell as Western European and American societies transitioned to higher standards of social development. Improved hygiene is one of the key innovations behind this transition, with baths and laundry facilities being made widely available and frequently utilized. Personal cleanliness was linked to both health and morals. Inroads made were a result of a combination of technical, scientific, public health, social, and political advances.¹⁰

Personal hygiene has now become a multi-million dollar industry, with soaps for bodies, hair, clothes, dishes, pets, and homes. It is synonymous with “good health, good manners, good rearing, good housekeeping, and civilization itself.”¹¹ It is estimated that there may be as many as 8,000 personal hygiene products sold in Europe alone.¹² Around the world, these soaps and other personal care products are being flushed out into sewers and surface waters. Wastewater treatment processes are not necessarily sufficient to remove these pollutants from the effluent prior to its discharge back into receiving waters, facilitating bioaccumulation in some aquatic animals, and in some crops irrigated with recycled wastewater.¹³ Another potential adverse health effect is summarized by the “hygiene hypothesis,” which suggests that, over time, decreased exposure to certain pathogens has had negative impacts on our immune responses, presumably increasing susceptibility to some pathogens. However, this is not so much a case of “too much hygiene,” as it is an emphasis on the importance of “good hygiene practice.”¹⁴ On the other hand, given the widespread development of antimicrobial resistance in pathogens (evolving resistance to antibiotics used to treat infections), there is a very real concern that excessive use of antibacterial products in healthy households may contribute to the development of resistant strains.¹⁵

However, over time, and with the drastic decreases in mortality rates associated with infectious diseases experienced in high income countries, complacency has led to the importance of hygiene for health being forgotten by many. The fact that historical rules and laws were likely borne out the negative consequences of not taking these actions on people’s health, such as pneumonia, scabies, and skin and eye infections, is no longer front of mind.¹⁶ Attention was drawn back to hygiene practices in 2010, when hygiene was referred to as one of the forgotten pillars of public health,¹⁷ answering a call for “renewal of the holistic approach of hygiene and public health [as] both urgent and necessary.”¹⁸ This is true both in the context of low and middle income countries, where infant and child mortality rates are still excessively high, with a large proportion due to preventable infectious diseases, and more globally, where drivers of environmental change are resulting in the emergence and re-emergence of infectious diseases regardless of the level of national development.

Today, hygiene, and hand hygiene in particular, is still not practiced to the extent necessary, and at times, critically necessary, in order to protect health. Hand hygiene is defined here as a preventive action and barrier to waterborne and foodborne infectious diseases – breaking the fecal-oral transmission cycle, as well as the broader pathogen transmission cycle. Hand hygiene is critical for infection control in the home, in schools, and in health care facilities. Handwashing with soap has been linked to significant reductions in diarrhea incidence rates.^19,20 Its role in acute infection control has been underscored in recent years by influenza epidemics and the Ebola pandemic, as well as its role in food contamination.

So, why aren’t people washing their hands? Even in high income country settings, hand hygiene adherence in acute-care hospitals has been demonstrated to average 30 percent.²¹ Globally, fundamental reasons for poor hand hygiene practices are inextricably linked to poor access to sufficient volumes of water of adequate quality, and to poor sanitation. Water, sanitation, and soap are essential partners to hand hygiene. While options other than soap and water exist, such as alcohol rubs, these have been demonstrated to be less effective than soap and water for some pathogens.²² While the Millennium Development Goals recognized the importance of drinking water and sanitation access in homes, institutions, such as schools and healthcare facilities, as well as hygiene practices, were not considered. These have been addressed in the Sustainable Development Goals, with a phased approach to universal access to water and sanitation that includes hygiene practices. However, barriers to sustained effective handwashing in healthcare facilities appear to be similar the world over. High patient loads often leave staff with insufficient time to practice adequate hand hygiene, staff are sometimes confused as to what constitutes proper hand hygiene, and even in high income countries, there are complaints of inadequate supplies for proper hand hygiene.^23,24

The lack of adequate facilities for practicing hand hygiene and proper sanitation in healthcare facilities is particularly concerning. Notwithstanding the lack of data on water and sanitation status in healthcare facilities, or the difficulties in assessing who is consistently practicing proper hand hygiene, several studies indicate the likely magnitude of the problem. Across 54 low and middle income countries, almost two in five healthcare facilities do not have adequate water supplies, one in five do not have adequate toilet facilities, and one third do not have soap and water for practicing hand hygiene.²⁵ Given that many people in healthcare facilities are already health-compromised, these data represent preventable risks for additional morbidity and mortality, including nosocomial (hospital-acquired) infections. Maternal and newborn health outcomes in particular are severely compromised by poor hygiene practices, especially in the case of caesarian sections.²⁶

At the household level, handwashing with soap is practiced by less than 50 percent of the population (based on data from 38 Sub Saharan Africa countries).²⁷ The burden of poor hygiene facilities falls on the immunocompromised (e.g., people living with HIV/AIDS), and on women and girls. Gastrointestinal illness contracted through poor hygiene practices is, quite literally, a death sentence for the immunocompromised individual. An inability to practice adequate menstrual hygiene can leave women and girls embarrassed and socially stigmatized and prevent girls from attending school each month.²⁸ As identified in a recent research initiative undertaken by the authors, in the case of pregnant women, an inability to clean themselves or their clothes can actually result in women missing prenatal appointments.

In summary, hygiene may be as old as the ancient civilizations, but it has not been given the attention it deserves. Hand hygiene is particularly essential to maintaining, improving, and preventing negative impacts of health in the most vulnerable. In order to realize the benefits of this historic solution, it is important to reinforce positive hygiene knowledge and attitudes, and to habituate good hygiene practices while ensuring the necessary physical elements (water and soap, or alternatives) are available. Campaigns such as Global Handwashing Day (October 15),  emotional drivers, and collective action support the former,²⁹ while handwashing equipment can be works of art, such as Victorian porcelain bowls and jugs, or a simple, “tippy tap” made out of a couple of pieces of wood, a plastic bottle, and some soap.

References

1. Smith, V. Clean: a history of personal hygiene and purity (Oxford University Press, 2007).
2. Curtis, VA. Dirt, disgust and disease: a natural history of hygiene. Journal of Epidemiology and Community Health61(8): 660-664 (2007).
3. Chamberlain, GRLP. Troubled Waters: Religion, Ethics, and the Global Water Crisis (Rowman & Littlefield Publishers, New York, 2007).
4. Allegranzi, B & Pittet, D. Role of hand hygiene in healthcare-associated infection prevention. Journal of Hospital Infection 73(4): 305-315 (2009).
5. Curtis, VA, Danquah, LO & Aunger, RV. Planned, motivated and habitual hygiene behaviour: an eleven country review. Health Education Research 24(4): 655-673 (2009).
6. Myers, D. Surfactant Science and Technology (John Wiley & Sons, Hoboken, New Jersey, 2005).
7. Greene, VW. Personal hygiene and life expectancy improvements since 1850: Historic and epidemiologic associations. American Journal of Infection Control 29(4): 203-206 (2001).
8. Kosso, C & Scott, A (eds.).The Nature and Function of Water, Baths, Bathing, and Hygiene From Antiquity Through The Renaissance (Brill, Boston, 2009).
9. Benidickson, J. Why did people ever think it was ok to dump waste in water? In UNU-INWEH. 2010. Sanitation as a Key to Global Health: Voices from the Field. United Nations University Institute for Water, Environment and Health [online] (2009). http://inweh.unu.edu/wp-content/uploads/2013/05/2010_Sanitation_PolicyBrief.pdf.
10. Greene, VW. Personal hygiene and life expectancy improvements since 1850: Historic and epidemiologic associations. American Journal of Infection Control 29(4): 203-206 (2001).
11. Aiello, AE, Larson, EL & Sedlak, R. Hidden heroes of the health revolution Sanitation and personal hygiene.American Journal of Infection Control 36(10): S128-S151 (2008).
12. Ellis, JB. Pharmaceutical and personal care products (PPCPs) in urban receiving waters.Environmental Pollution 144(1): 184-189 (2006).
13. Wu, C, Spongberg, AL, Witter, JD, Fang, M & Czajkowski, KP. Uptake of pharmaceutical and personal care products by soybean plants from soils applied with biosolids and irrigated with contaminated water. Environmental Science & Technology44(16): 6157-6161 (2010).
14. Bloomfield, SF, Stanwell?Smith, R, Crevel, RWR & Pickup, J. Too clean, or not too clean: the hygiene hypothesis and home hygiene. Clinical & Experimental Allergy36(4): 402-425 (2006).
15. Levy, SB. Antibacterial household products: cause for concern. Emerging Infectious Diseases7(3): 512 (2001).
16. Johansson, EW, Wardlaw, T, Binkin, N, Brocklehurst, C & Dooley, T. Diarrhoea: Why children are still dying and what can be done. UNICEF (2009).
17. Bartram, J & Cairncross, S. Hygiene, sanitation, and water: forgotten foundations of health. PLoS Medicine 7(11): e1000367 (2010).
18. Exner, M, Hartemann, P & Kistemann, T. Hygiene and health—the need for a holistic approach. American Journal of Infection Control 29(4): 228-231 (2001).
19. Curtis, V & Cairncross, S. Effect of washing hands with soap on diarrhoea risk in the community: a systematic review.The Lancet Infectious Diseases 3(5): 275-281 (2003).
20. Luby, SP et al. Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: a randomized controlled trial.Jama 291(21): 2547-2554 (2004).
21. Mertz, D et al. Adherence to hand hygiene and risk factors for poor adherence in 13 Ontario acute care hospitals.American Journal of Infection Control 39(8): 693-696 (2011).
22. Oughton, MT, Loo, VG, Dendukuri, N, Fenn, S & Libman, MD. Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile.Infection Control & Hospital Epidemiology 30(10): 939-944 (2009).
23. Jang, TH et al. Focus group study of hand hygiene practice among healthcare workers in a teaching hospital in Toronto, Canada. Infection Control & Hospital Epidemiology 31(02): 144-150 (2010).
24. Holmen, IC et al. Improving Hand Hygiene Practices in a Rural Hospital in Sub-Saharan Africa.Infection Control and Hospital Epidemiology 1-6 (2016).
25. Water, Sanitation and Hygiene in Health Care Facilities: status in low- and middle-income countries and way forward. WHO and UNICEF [online] (2015). http://apps.who.int/iris/bitstream/10665/154588/1/9789241508476_eng.pdf?ua=1.
26. Schuster-Wallace, CJ & Watt, S. Women and the Water-Health Nexus. In: Women’s Health in the Majority World (eds. Chamberlain Froese, J & Elit, L) (Nova Sciences Publishers, Hauppauge, New York, 2015).
27. Progress on Sanitation and Drinking Water: 2015 Update and MDG Assessment. WHO and UNICEF [online] (2015). http://www.wssinfo.org/fileadmin/user_upload/resources/JMP-Update-report-2015_English.pdf.
28. Sommer, M & Sahin, M. Overcoming the taboo: advancing the global agenda for menstrual hygiene management for schoolgirls. American Journal of Public Health 103(9): 1556-1559 (2013).
29. McMichael, C & Robinson, P. Drivers of sustained hygiene behaviour change: A case study from mid-western Nepal. Social Science & Medicine (August 2016).