HAND WASHING REFERENCES AND ABSTRACTS

Adams, D., Baggs, J., Limaye, M., Parsons, K., and Absi, E.G. 1992. A clinical evaluation of glove washing and re-use in dental practice. J. Hosp. Infect. 20: 153-162.
Study of durability of latex gloves used in dental practice. Studied glove washing and adherence of microorganisms to glove surfaces. Microorganisms were isolated from the glove surfaces 45% of the occasions after glove washing for 1 minutes in Hibiscrub. Glove washing was not recommended due to danger of cross-infection between patients. Suggest use of heavier type surgical gloves. Multiple use of any type of glove should be discouraged.

Altemeier, W. A. 1983. Surgical antiseptics. Disinfection, Sterilization, and Preservation. S. S. Block. Philadelphia, PA. Lea & Febiger.

Aly, R., and Maibach, H.I. 1979. Comparative study on the antimicrobial effect of 0.5% chlorhexidine gluconate and 70% isopropyl alcohol on the normal flora of hands. Appl. Environ. Microbiol. 37(3): 610-613.
Study compared the effect of chlorhexidine gluconate alcohol emollient hand wash (HIBISTAT) with that of 70% isopropyl alcohol on the normal flora of hands designed to mimic conditions used for surgical preparation. The chlorhexidine significantly reduced the normal microflora on hands. There was a slightly greater reduction when this product was used in comparison to the alcohol. After the chlorhexidine treatment, there was no significant growth of bacteria over a period of 6 h when compared with the base line bacterial counts.

Aly, R., and Maibach, H.I. 1980. A comparison of the antimicrobial effect of 0.5% chlorhexidine (Hibistat) and 70% isopropyl alcohol on hands contaminated with Serratia marcescens. Clin. Exper. Dermatol. 5: 197-201.
Two antimicrobial preparations for hand washing were compared by the gloved hand wash method in 72 subjects. The test preparation was 0.5% chlorhexidine gluconate alcoholic-emollient hand wash (Hibistat); the reference agent was 70% isopropyl alcohol. The hands were contaminated with Serratia marcescens and disinfected with each antiseptic 25 times over an 8-hour day. Bacterial counts were obtained for each hand after initial contamination, and after 5, 10, 15, 20, and 25 contamination/treatment procedures.

There was a statistically significant reduction in recovery of Serratia marcescens after chlorhexidine treatment compared to alcohol (P<0.01). When recovery of organisms was plotted against the number of hand washes, there was a significant linear reduction in transient flora for chlorhexidine treated hands (P<0.01) but not for alcohol treated hands (P<0.20)

Ansari, S., Sattar, E.A., Springthorpe, S., Wells, G.A., and Tostowaryk, W. 1988. Rotavirus survival on human hands and transfer of infectious virus to animate and nonporous inanimate surfaces. J. Clin. Microbiol. 26(8): 1513-1518.
The survival of the Wa strain of human rotavirus was tested and the transfer of the virus between animate and inanimate (stainless steel flasks) surfaces was also studied. The virus was diluted in a 10% suspension of feces, and 10µl (1 x 103 to 4 x 104 PFU) was placed on each of the four fingerpads of the left hand. One milliliter of 20% tryptose phosphate broth in Earle balanced salt solution was used for virus elution from each fingerpad, and the hands were disinfected with 70% ethanol before they were washed with an antiseptic soap and water. At 20, 60, and 260 min. after inoculation approximately 57, 43, and 7%, respectively, of the input infectious virus could be recovered. For virus transfer, the inoculum (2x104 to 8 x 104 PFU) was allowed to dry, and the donor surface was kept in contact with the recipient surface for 10 sec. at a pressure of approximately 1 kg/cm2. At 20 and 60 min. after virus inoculation, 16.1 and 1.8%, respectively, of the input virus could be transferred from the contaminated hand to a clean disk; when a clean hand was pressed against a contaminated disk, virus transfer was 6.6 and 2.8% respectively of the input infectious virus. These findings indicate the potential vehicular role for human hands in the spread of rotaviral infections.

Ansari, S. A., Sattar, S.A., Springthorpe, V.S., Wells, G.A., and Tostowaryk, W. 1989. In vivo protocol for testing efficacy of hand washing agents against viruses and bacteria: Experiments with rotavirus and Escherichia coli. Appl. Environ. Microbiol. 55(12): 3113-3118.
Ten antiseptic formulations, an unmedicated liquid soap and tap water alone were compared for their capacities to eliminate human rotavirus from finger pads of adult volunteers; three of the antiseptics, the soap, and tap water alone were tested against Escherichia coli. Tap water alone and the soap reduced the virus titers by 83.6% and 72% and the bacterial titers 90 and 68.7%. Concluded that fingerpad method is a suitable model for testing the in vivo efficacy of hand-washing agents and emphasizes the need for using appropriate test viruses and bacteria.

Ansari, S. A., Springthorpe, V.S., Sattar, S.A., Tostowaryk, W., and Wells, G.A. 1991. Comparison of cloth, paper, and warm air drying in eliminating viruses and bacteria from washed hands. Am. J. Infect. Control.
Compared efficiency of paper, cloth and electric warm air drying in eliminating rotaviruses and E. coli on finger pads washed with 70% isopropanol, a medicated liquid soap and an unmedicated liquid soap. Irrespective of hand washing agent, electric drying produced the highest and cloth drying the lowest reduction in the numbers of both test organisms.

ASTM. 1987. Standard Test Method for Evaluation of Health Care Personnel Hand Wash Formulation. Philadelphia, PA, ASTM (American Society for Testing and Materials).
See pages 779-781.

Ayliffe, G. A., Babb, J.R., Bridges, K., Lilly, H.A., Lowbury, E.J.L., Varney, J., and Wilkins, M.D. 1975. Comparison of two methods for assessing the removal of total organisms and pathogens from the skin. J. Hyg., Camb. 75: 259-274.
Compared standard hand-wash sampling technique with a simple finger streak sampling method.

Ayliffe, G. A., Babb, J.R., and Quoraishi, A.H. 1978. A test for hygienic hand disinfection. J. Clin. Pathol. 31: 923-928.
A standardized test procedure is described in which fingertips are inoculated with broth cultures of organisms (S. aureus, S. saprophyticus, E. coli and Pseudomonas aeruginosa). Counts were made from washing of hands after disinfection with various antiseptic-detergents, alcoholic solutions or unmedicated soap. 70% alcohol, with or without chlorhexidine was the most effective preparation. The two antiseptic detergents showed variable results, but against Gram-negative bacilli neither was significantly more effective than plain soap. Some tests were also made on the death rate of organisms dried on skin without disinfection.

Bannan, E. A., and Judge, L.F. 1965. Bacteriological studies relating to hand washing. I. The inability of soap bars to transmit bacteria. Am. J. Public Health 55(6): 915-921.
Study reports that bar soaps, without antibacterial additives do not transfer bacteria from person to person, and do not support bacterial growth.

Becks, V. E., and Lorenzoni, N.M. 1995. Pseudomonas aeruginosa outbreak in a neonatal intensive care unit: A possible link to contaminated hand lotion. Am. J. Infect. Control 23(6): 396-398.
This article describes a prolonged outbreak of Pseudomonas aeruginosa. The attack rate of this outbreak was 8.5%, with no associated mortality. Hand lotion contaminated with P. aeruginosa was implicated in the transmission of organisms; removal of this hand lotion ended the outbreak. Contaminated hand lotion applied to clean hands of health care workers may have lead to direct inoculation of infants at high risk for infection.

Bibel, D. J. 1977. Ecological effects of a deodorant and a plain soap upon human skin bacteria. J. Hyg., Camb. 78: 1-10.
The effects of a commercial trichlorocarbamide-containing deodorant soap and a commercial plain soap upon the cutaneous flora of individuals were compared. Using a crossover design, 21 volunteers, (10 women and 11 men) washed their forearms at least once a day with one soap for 3 weeks and then switched soaps for another 4 weeks use. By analysis of variance, no significant differences in total colony counts were noted among individuals in their use of the two soaps. With the exception of individual variation, neither sequence of use, sex, nor any combination was influential. However, in 20 of 21 subjects an alteration in the composition of skin flora was observed. The deodorant soap, which in six cases increased total flora, tended to reduce or eliminate diptheroids in 12 of 17 carriers (71%). Fewer kinds of bacteria were also noted. More S. epidermidis was seen with plain soap, but washing with the deodorant soap seemed to favor Acinetobacter calcoaceticus and Micrococcus luteus. The impact of this alteration and the use of total counts to measure effectiveness of deodorant soaps were brought into question.

Black, R. E., Dykes, A.C., Anderson, K.E., Wells, J.G., Sinclair, S.P., Gary, G.W., Hatch, M.H., Gangarosa, E.J. 1981. Hand washing to prevent diarrhea in day-care centers. Am. J. Epidemiol. 113: 445-451.
Study demonstrated that hand washing will probably prevent at least some of the diarrhea in day-care centers. The incidence of diarrhea in two hand-washing day care centers was half that of two control centers for the entire 35-week study period.

Blackmore, M. 1987. Hand-drying methods. Nursing times(September 16): 71-74.
Continuous towels are unsuitable for clinical areas, but may be appropriate for toilets and non-clinical areas if properly maintained. Warm-air dryers are too slow to use in clinical areas and their hygienic efficiency is questionable; they are not recommended. In clinical areas, suitable paper towels provide an efficient means of hand drying and can also be used for other purposes, such as cleaning up spillages.

Borgatta, L., Fisher, M., and Robbins N. 1989. Hand protection and protection from hands: Hand-washing, germicides and gloves. Woman & Health 15(4): 77-92.
A variety of soaps, detergents, germicides and protective gloves are available for use by health care workers. Appropriate hand washing and glove use will reduce the possibility of spread of infectious organisms from patient to staff, from patient to patient and from staff to patient . Both hand washing and glove use can have adverse effects. Excessive hand-washing, mechanical irritation from scrubbing, use of germicides, and wearing of gloves can result in an increased risk of infection to both the worker and the patient.
Note: Has bibliography on contact dermatitis due to gloves.

Brodie, J. 1965. Hand hygiene. Scot. Med. J. 10(1115-125).
Need to find method that is likely to give reasonably reliable information regarding the bacterial cleanliness of the hands of whose fingers come into direct contact with food, especially those foods to be eaten without further cooking or processing.
Investigations concerning the bacterial flora of hands before and after washing with soap and water alone, or supplemented by antiseptic treatment on a short-term basis, show that with both, total bacterial counts are of little use in assessing the value of such procedures; Coliform bacteria are adequately controlled using a soap and water technique only, but staphylococci are not; and supplementation of the soap and water wash with antiseptic treatment does not produce the dramatic results one would be lead to expect from the test-tube efficacious of the antiseptics tested.

Casewell, M., and Philips, I. 1977. Hands as route of transmission of Klebsiella species. Brit. Med. J. 2: 1315-1317.
Seventeen percent of the staff of an intensive care ward were found to have Klebsiella spp. contaminating their hands, and these strains could be related to the serotypes infecting or colonizing patients in the ward on the same day. Some simple ward procedures were identified that resulted in contamination of nurses' hands with 100 to 1000 Klebsiella per hand. The Klebsiella survived on artificially inoculated hands for up to 150 minutes. Hand washing with chlorhexidine hand cleanser reliable gave 98 to 100% reduction in hand counts, and the introduction of routine hand washing was associated with a significant and sustained reduction in the number of patients colonized or infected with Klebsiella spp. Staff clothing was occasionally contaminated, but ward air and dust rarely contained klebsiellae.

Coates, D., Hutchinson, D.N., and Bolton, F.J. 1987. Survival of thermophilic campylobacter on fingertips and their elimination by washing and disinfection. Epidem. Inf. 99: 265-274.
A simple impression-plate technique was used to investigate the survival of four thermophilic campylobacter strains applied to the fingertips. Campylobacters suspended in 0.1% peptone water and dried on the fingertips survived for different periods of time ranging from < 1 min. to 4 min or more. However, campylobacters suspended in chicken liquid or blood survived for much longer periods of time. One strain suspended in horse blood survived for an hour.
Suspensions containing 106 to 107 organisms prepared in 50% blood and dried on to fingertips were removed by thorough hand washing with either soap and water or water alone followed by drying on paper towels, but persisted on wet hands. The organisms were also eliminated by wiping the hands with a tissue saturated with 70% isopropyl alcohol for 15 seconds.

Collins, C. H., Allwood, M.C., Bloomfield, S.F., and Fox, A. (Ed) 1981. Disinfectants: Their use and evaluation of effectiveness. London, Academic Press, Inc.

Crisley, F. D., and Foter, M.J. 1965. The use of antimicrobial soaps and detergents for hand washing in food service establishments. J. Milk Food Technol. 28: 278-284.
Very good review of hand microflora, hand washing agents (antibacterial soaps, iodine preparations, quats). Final recommendation seems to be: have a conveniently located hand wash area in work area; frequent use of soap and water hand wash; foodservice workers are not necessarily benefited by use of antibacterial soaps.

Cruickshank J.G. and Humphrey, T. J. 1987. The carrier food-handler and non-typhoid salmonellosis. Epidem. Inf. 98: 223-230.
There is no justification for recommending routine stool testing for food handlers. The concern of those in the food industry over employees carrying organisms capable of causing food poisoning is understandable and is clearly reflected in the overcautious policies adopted by some organizations. Rational consideration of available evidence fails to implicate asymptomatic food handlers with formed stools as sources of outbreaks of salmonella food poisoning. Unnecessarily harsh attitudes may be counter-productive by encouraging staff to conceal illnesses, thereby creating real hazards.

Dalgleish, A.G., and Malkovsky, M. 1988. Surgical gloves as a mechanical barrier against human immunodeficiency viruses. Brit. J. Surg. 75(2): 171-172.
Seven different types of surgical gloves were investigated for the ability to prevent transmission of the human immunodeficiency virus (HIV). Six types of gloves withstood severe compression tests and also exhibited direct antiviral properties. No penetration of HIV through the intact gloves was detected.

Dankert, J., and Schut, I.K. 1976. The antibacterial activity of chloroxylenol in combination with ethylenediaminetetra-acetic acid. J. Hyg. (Camb.) 76: 11-22.
The bactericidal activity of RBA 777 has been found to vary with both the cultural and environmental test conditions against Pseudomonas aeruginosa and to a lesser extent against Staphylococcus aureus. These variations may explain certain anomalies in earlier work regarding the activity of chloroxylenon-based products. The addition of EDTA to RBA 777 has brought about an improvement in the performance against P. aeruginosa and this activity is confirmed in vivo. Previous reports have already illustrated this potential and the evaluations of the new antibacterial agent DA 136 confirms and extends these results to its performance under adverse conditions, often associated with the hospital environment.

DeGroot-Kosolcharien, J., and Jones, J.M. 1989. Permeability of latex and vinyl gloves to water and blood. Am. J. Infect. Control 17(4): 196-201.
2400 medical gloves were evaluated for leakage. Types of gloves examined (number of brands) included: sterile latex (7). sterile vinyl (4), nonsterile latex (6), and nonsterile vinyl (7). Sampling was done from one box of each brand. Fifty gloves from each box were filled with 300 ml water (the standard test used by the American Society for Testing and Materials). An additional 25 cm pressure was applied to water filled gloves. Another 50 gloves of each box were donned and dipped into a basin that contained heparinized human blood. Only 4 brands of sterile latex surgeon's gloves proved nonpermeable to water or blood. Other brands showed leakage that ranged from 1% to 52%. Analysis of proportions of pairs of gloves permeable to water or blood indicated a strong statistical associated of nonsterile packaging or packaging in suction kits with increased leakage rates. These findings affirm that gloves can be regarded only as a means of reducing the gross soil from blood or body fluids. Quality control standards are needed to ensure more uniform glove quality.

deWit, J. C., and Kampelmacher, E. H. 1984. Some aspects of bacterial contamination of hands of workers in foodservice establishments. J. of Bacteriol. Hyg. 186(1): 9-12.

Doebbeling, B. N., Pfaller, M.A., Houstan, A.K. and Wenzel, R.P. 1988. Removal of nosocomial pathogens from the contaminated glove: Implications for glove reuse and hand washing. Annal. Int. Med. 109: 394-398.
Effectiveness of three different types of hand cleansing agents in decontaminating gloved hands that were inoculated with a series of four nosocomial pathogens were placed on the gloved hands that were inoculated with a series of four nosocomial pathogens.
A standard concentration of one of four representative nosocomial pathogens was placed on the gloved hand, spread, and allowed to dry. One of three different hand-cleansing agents - a nonmedicated, a 60% isopropyl alcohol preparation, or 4% chlohexidine gluconate - was used to cleanse the gloves, which were cultured using a broth bag technique. The gloves were then removed and the hands were cultured in a similar manner.
Results: The hand washing agents reduced the media to log10 counts of organisms to 2.1 to 3.9 after an inoculation of 107 colony forming units. The proportion of positive glove cultures for S. aureus ranged from 8% to 100%; Serratia marcescens, 16 to 100%; and Candida albicans, 4 to 60%; varied greatly after the use of hand cleansers and varied considerably for Pseudomonas aeruginosa, 20 to 48%. After the gloves were removed, the differences among the observed proportions of hands contaminated with the test organisms varied from 5% to 50%, depending on the hand cleansing agent used.
It was concluded that it may not be prudent to wash and reuse gloves between patients. Further hand washing is strongly encouraged after removal of gloves.

Duncan, W. C., Dodge, B.G., Knox, J.M. 1969. Prevention of superficial pyogenic skin infections. Arch. Derm. 99: 465-468.
Four populations comprising 2,550 men were studied over nine months to determine the efficacy of an antibacterial bar soap in preventing superficial pyogenic skin infections. A double-blind study with crossover was used. Statistically significant differences between the rates of infect while using the active and the placebo soaps were found. In the two largest populations, regression analysis indicated there is a significant trend for the rate of infection to decline during the period of antibacterial soap usage. No instance of allergic photocontact dermatitis was observed.

Ehrenkranz, N. J. 1992. Bland soap hand wash or hand antisepsis? The pressing need for clarity. Infect. Control Hosp. Epidemiol. 13(5): 299-301.
Discussion of hand washing with regular soaps and hand antisepsis. Hand washing with bland soap reduces transient bacterial numbers by approximately 2 to 3 log10. In contrast hand antisepsis is able to reduce these number by 1 to 2 log10 more. Workers in clinical settings should use products that produce antisepsis. This article also discusses the false sense of security that exists when health care workers use gloves. Improperly donned gloves, failure to wash hands, and failure to change gloves leads to transmission of bacteria from patient to patient.

Emery, H. C. 1990. Changing poor hand washing habits - A continuing challenge for Sanitarians. Dairy Food Environ. Sanitation 10(1): 8-9.
Review article. "Studies indicate that personnel in both the health care and food service industries have poor hand washing habits. (60% of food service personnel in one study were reported to not wash their hands after using the toilet.) Need for training and education of food service personnel.

Emerson, R. ? Bacterial control problems in faucet aerators. no journal cited.
No abstract given.

Faoagali, J., Fong, J., George, N., Mahoney, P., and O'Rourke, V. 1995. Comparison of the immediate, residual, and cumulative antibacterial effects of Novaderm R, Novascrub, Betadine Surgical Scrub, Hibiclens, and liquid soap. Am. J. Infect. Control 23(6): 337-343.
Background: Triclosan (Irgasan) an antibacterial active against staphylococci and coliform bacteria, has been formulated for use as a hand wash. There has been only one previous report of the use of the glove juice test to determine the immediate, residual, and cumulative effects of a 1% triclosan-based hand wash product. There have been no previous studies on the use of 1% triclosan combined with povidone-iodine (PI) in a hand wash product.
Methods: The glove juice technique was used to document and compare the immediate 3-hour residual, and 5-day cumulative effects on the mean log10 bacterial counts of 1% triclosan-based hand wash product and 1% triclosan with 5% PI. A standardized surgical hand washing technique was used before sample collection. These results and the identity and type of the aerobic bacteria cultured from the samples were compared with the results of the standardized washing and glove juice sampling with 4% weight/volume chlorhexidine gluconate (CHG), 7.5% PI< and a nonantimicrobial liquid soap.
Results: All five tested products showed significant log10 reduction on day 1, hour 0 (p<0.05). There was no significant difference between the mean log10 bacterial count when 7.5% PI, 4% CHG; and 1% trichosan with 5% PI were compared with each other immediately after washing (p>0.05). There was a significant difference between 1% triclosan and the liquid soap when they were each compared with 4% CHG and 7.5%PI, and 1% triclosan with 5% PI. There was no statistically significant difference between the 1% triclosan product and the liquid soap (p>0.20). All products were effective at reducing the immediate bacterial count from the baseline level. All formulations except the liquid soap showed significant cumulative effect (p< 0.05) after multiple washes, with no significant difference between the cumulative effects of liquid soap and 1% triclosan (p > 0.05). Both products differed significantly (p<0.05) from the CHG, PI, and triclosan with PI. CHG, PI, and triclosan with PI showed effect significantly different from each other (p < 0.05).

Favero, M. S. 1985. Sterilization, disinfection and antisepsis in the hospital. American Society for Microbiology Sterilization, Disinfection and Antisepsis in the Hospital. E. H. Lennette. Washington D.C., American Society for Microbiology: 129-137.
The effective use of antiseptics, disinfectants, and sterilization procedures is important in the prevention of nosocomial infection. Physical agents, such as moist or dry heat play the major role in sterilization, and chemical germicides are used primarily for disinfection and antisepsis. In recent years, there has been an explosion in the number of germicidal products available to hospitals in the U.S. In 1973, the American Society for Microbiology Ad Hoc Committee on Microbiological Standards of Disinfection in Hospitals surveyed 16 hospitals with a combined bed capacity of more than 9,000. The survey showed that the average number of different formulations per hospital was 14.5 with a range of 8 to 22. A total of 224 products were used in the 16 hospitals, and 125 of the products were proprietary products.
The choice of agents and procedures to be used for hospital environmental sanitation and antisepsis depends on a variety of factors, and no single agent or procedure is adequate for all purposes. Factors to be considered in the selection of procedures included the degree of microbial killing , the nature of the items to be treated, and the cost and ease of using the available agents. This chapter discusses each of these factors and practical methods for evaluating the effectiveness of the various agents and procedures.

Ferguson, R. L. 1971. Personal Hygiene. Hygiene and Food Production. E. J. Fox. Edinburgh and London, Churchill Livingstone.
Short discussion of personal hygiene by employees. Not very detailed.

Filho, P. P. G., Stumpf, M., and Cardoso. 1985. Survival of gram-negative and gram-positive bacteria artificially applied on the hands. J. Clin. Microbiol. 21(4): 552-653.
Pseudomonas aeruginosa, Klebsiella pneumoniae, Serratia marcescens, Escherichia coli, and Staphylococcus aureus, derived from either hospitalized patients or culture collections, on the fingertips of human volunteers. Over 99% of the bacteria died within 2 min. of application, and about 105 cells remained on the fingers for up to 90 min.

Gardner, A. D., and Seddon, H.J. 1946. Rapid chemical disinfection of clean unwashed skin. Lancet (May 11): 683-686.
In spite of seventy years of investigation it is still very difficult to give a clear account of the chemicals and their concentrations that will disinfect the skin under any particular set of practical conditions.
"The skin is a complex tissue of considerable thickness and can not be chemically sterilized without destroying it. The transient bacteria (Price, 1938) on the surface, can be destroyed by chemicals. However, after a period of time, resident bacteria emerge from below the surface of the skin. Resident bacteria are harmless and give no trouble when taken deeper into the skin , e.g. on a hypodermic needle. Pathogenic bacteria on the skin are generally transient, though some species, especially S. aureus and Strep. pyogenes occasionally become temporary residents, and their removal by chemicals may not be practical.
The main object of the research effort was to find a simple, reproducible and roughly quantitative method to determine what solutions will "virtually disinfect" an unwashed artificially contaminated simple flat skin surface in a short time (15 sec. - 5 min.) Virtual disinfection means to destroy at least 99.9% of the organisms on the surface of the skin, excluding spores. Virtual disinfection was achieved in 15-20 sec. with a single application of 2% iodine in 70% alcohol.

Garner, J. S., and Favero, M.S. 1985. Guidelines for hand washing and hospital environmental control. Springfield, VA., NTIS. United States Department of Commerce.
Government publication for hospital infection control. Discusses Hand washing; Cleaning and disinfecting; Infective Waste; Housekeeping; and Laundry.
Hand washing with plain soaps or detergents (in bar, granule, leaflet, or liquid from) suspends millions of microorganisms and allows them to be rinsed off; this process is often referred to as mechanical removal of microorganisms. This process removes transient microorganisms. Hand washing with antimicrobial-containing products kills or inhibits the growth of microorganisms; this process is often referred to as the chemical removal of microorganisms (both transient and some resident microorganisms).
Hand washing with plain soap for 15 seconds or less appears to be sufficient for most routine activities. For invasive procedures within hospitals or health care settings antimicrobial products may be used.
When gloves are used, hand washing is recommended because gloves may become perforated during use and because bacterial can multiply rapidly on gloved hands.

Garner, J. S., and Favero, M.S. 1986. CDC guidelines for the prevention and control of nosocomial infections. Guideline for hand washing and hospital environmental control. Am. J. Infect. Control 14(3): 110-115.
Hand washing with plain soaps or detergent (in bar, granule, leaflet, or liquid form) suspends microorganisms and allows them to be rinsed off. (This process is often referred to as mechanical removal of microorganisms. Hand washing with antimicrobial containing products kills or inhibits the growth of microorganisms. (This process is often known as the chemical removal of microorganisms.)
When gloves are worn, hand washing is also recommended because gloves may become perforated during use and because bacteria can multiply rapidly on gloved hands. Also recommended is convenient placement of sinks, hand washing products and paper towels

Gerberding, J. L., Littell, C., Tarkington, A., Brown, A., and Schecter, W.P. 1990. Risk of exposure of surgical personnel to patients. blood during surgery at San Francisco General Hospital,. New Eng. J. Med. 322(25): 1788-1793.
An observational study of 1307 consecutive surgical procedures at San Francisco General Hospital. Description of intraoperative exposures to blood and other body fluids were recorded in order to determine the factors predictive of these exposures, and identify interventions that might reduce their frequency.
Accidental exposure to blood occurred during 84 procedures (6.4%) . Parenteral exposure occurred in 1.7%. The risk of exposure was highest when the procedures lasted more than three hours, when blood loss exceeded 300 ml., and when major vascular and intraabdominal gynecologic surgery was involved. Neither knowledge of diagnosed human immunodeficiency virus (HIV) infection nor awareness of a patient's high-risk status for such infection influenced the rate of exposure. Double gloving prevented perforations of the inner glove and cutaneous exposure of the hands. It was concluded that all surgical personnel are at risk for intraoperative exposure to blood.

Green, S. 1974. Hand hygiene in practice. Food Manufacture 63: 19-20.
Discussion of hand washing practices for food hygiene in the United Kingdom. Discusses uses of soap, detergents and bactericides. Bactericides containing iodine, phenol and cresylic derivatives can cause extreme irritation to the skin surface.
In healthy skin, there is a horny layer, and a thin film of a water repellent substance is secreted by the sebaceous glands. This keeps the skin supple and helps prevent the ingress of water and dirt. When this layer is removed by irritants, the skin becomes inflamed. If this layer is replaced by an artificial layer of lanolin or similar water repellent grease, irritation can be avoided. Such products (barrier creams) should be specially formulated for the food industry. They should be non-perfumed, and not excessively greasy.

Guzewich, J. J. 1995. The anatomy of a "Glove Rule". E.N.D. LXI(2): 4-13.
New York State prohibits bare hand contact with ready-to-eat foods. This was the first such statewide policy in the U.S. and the forerunner of the no-hands requirement in the FDA Food Code. In a presentation at the 1995 annual meeting of IAMFES, New York's food protection chief, Jack Guzewich, described the state's rationale for what many in both government and industry consider to be a radical policy.
Article points out that it is not easy to monitor hand washing. However, it is easy for managers, co-workers, and customer to monitor glove use, because gloves can be seen.

Hall, R. 1980. Degerming the hands of surgeons and nurses. Problems in the Control of Hospital Infection. S. W. B. a. C. Newsoms, A.D.S. London, Academic Press.
Pre-operative procedures for preparing hands of surgeons and nurses is reviewed and current methods for evaluating the efficiency of degerming agents such as chlorhexidine are compared. The method used involves a 3 min. hand treatment with chlorhexidine and showed that there was both immediate and persistent effectiveness and that the traditional 10 min scrubbing procedure added nothing in the way of extra degerming. Both an alcoholic and an aqueous solution of chlorhexidine were found to be effective against S. aureus and Pseudomonas aeruginosa.

Hammer, K. A., Carson, C.F., and Riley, T.V. 1996. Am. J. Infect. Control 24(3): 186-189.
Tea tree oil, or melaleuca oil, is the essential oil produced by steam distillation of the leaves of the Australian native plant Melaleuca alternifolia or tea tree. Tea tree oil is known to possess antibacterial and antifungal activity.
The purpose of this study was to determine the susceptibility of a range of transient and commensal skin flora to the essential oil of Melaleuca alternifolia or tea tree.
Results: S. aureus and most of the gram-negative bacteria tested were more susceptible to tea tree oil than the coagulase-negative staphylococci and micrococci. these results suggest that tea tree oil may be useful in removing transient skin flora while suppressing by maintaining resident flora.

Heinze, J. E., and Yackovich, F.Y. 1988. Washing with contaminated bar soap is unlikely to transfer bacteria. Epidem. Inf.(101): 135-142.
Reported research that demonstrated there is little hazard in routine hand washing with previously used soap bars. Supports the frequent use of soap and water for hand washing to prevent the spread of disease.

Hobbs, B.C.a.G., R.J. 1982. Food Poisoning and Food Hygiene. London, Edward Arnold.
Book on foodborne illnesses, cleaning and sanitation, and personal hygiene.

Horn, W. A., Larson, E.L., McGinley, K.J., and Leyden, J.J. 1988. Microbial flora on the hands of health care personnel: Differences in composition and antibacterial resistance. Infect. Control Hosp. Epidemiol. 9(5): 189-193.
The composition and antibiotic sensitivity pattern of bacteria recovered from the hands of nurses and physicians in two service units of a major teaching hospital were compared with those found in a control population. Significant differences in the composition of bacteria were found in dermatology and oncology unit personnel. S. aureus was recovered from 31% of dermatology nurses and 37% if dermatology physicians, and 17% of controls. Oncology personnel had a significantly higher carriage of gram-negative bacteria, yeast, and multiple antibiotic-resistant, aerobic coryneforms (group JK bacteria). Both dermatology and oncology nursing personnel were colonized by organisms resistant to multiple antibiotics. Methicillin resistance was found in 26% and 66% of the staphylococci recovered from dermatology and oncology nurses respectively. Flora from physician on the two units has sensitivity patterns similar to controls.

Horwood, M. P., and Minch, V.A. 1951. The numbers and types of bacteria found on the hands of food handlers. Food Res. 16: 133-136.
The study dealt with the collection and bacteriological examination of hand washed samples derived from the hands of food handlers selected at random from 22 eating establishments in the Boston and Cambridge, MA. area.
The large numbers of bacteria isolated from the hands of food handlers in this investigation and the frequency with which E. coli, hemolytic streptococci and staphylococci and aerobic spore formers were isolated indicates the magnitude of the problem of hand hygiene among food handlers and the need for a greatly accentuated campaign of health education for this large and important group of workers.
While it is recognized that many of the organisms isolated in this study were derived from the foods being handled or processed, observation of food handlers has indicated that the hands are frequently soiled with the discharges from nose and mouth and in other ways. Frequently, food handlers bring the hands in contact with food when the use of an implement is indicated. This investigation discloses the bacterial conditions of the hands of food handlers as found. No attempt was made to discover how they got there. The data justify the conclusion that the hands of food handlers should be kept clean and that they should avoid contact with food whenever possible.
Suggested preliminary instruction for food handlers followed by examination prior to licensing. Management must assume the responsibility for daily education and supervision,

Jacobson, G., Thiele, J.E., McCune, J.H., and Farrell, L.D. 1985. Hand washing: Ring-wearing and number of microorganisms. Nursing Res. 34(3): 186-188.
A statistically significant difference was found between the bacterial count before scrubbing while wearing and the counts obtained when not wearing rings. However, after scrubbing the hands thoroughly, the difference in bacterial counts was not statistically significant.
Thorough hand washing substantially lowers the number of microorganisms present on the hands. While wearing rings increased the number of microorganisms on the hands, thorough hand washing reduced this number to a count similar to that obtained when rings were not worn.
In this study, a timed standardized hand washing procedure was used. Shortening this procedure or not thoroughly washing the hands may result in greater numbers of microorganisms on the hands of person who wear ring in patient contact areas.
In this study, the researchers observed that wearing hand lotion increased the bacterial count. Only bacterial counts were obtained in this study; no attempt was made to identify the organisms. This study was conducted in a laboratory setting.

Kaul, A. F., and Jewett, J.F. 1981. Agents and techniques for disinfection of the skin. Surgery 152: 677-685.
Discusses use of hexachlorophene, iodophor, benzalkonium, and chlorhexidine preparations for disinfection of skin. "From mass of conflicting data, it is thus apparent that neither the ideal agent nor protocol for surgical scrubbing and skin preparation has yet been devised."

Kerr, K. G., Birkenhead, D., Seale, K., Major, J., and Hawkey. 1993. Prevalence of Listeria spp. on the hands of food workers. J. Food Protect. 56(6): 525-527.
The prevalence of carriage on Listeria spp. on the hands of food workers was investigated using a whole-hand impression plate technique. Ninety-nine workers engaged in food production and retailing were studied, with 75 clerical workers acting as control. Twelve (12%) of food workers carried Listeria spp., and 7 (7%) carried Listeria monocytogenes. None of the control group was positive for Listeria spp. Where the level of carriage was low (< 20 CFU) hand washing eliminated the organisms, but hand washing was not successful if larger numbers of bacteria were present. In two instances hand washing appeared to have caused contamination on subjects' hands. Food workers are significantly more likely to carry Listeria spp. than clerical workers (P<0.015 Fisher's extract test) and frequent hand washing represents an important element of hygiene which may interrupt transmission of these organisms. Of the 87 food workers found not to carry Listeria spp. on their hands, 54 (62%) were considered to have used adequate hand washing. Of cause for concern in this study was the observation that of the 12 people carrying Listeria spp. on their hands, only one was deemed to have washed their hands adequately. Authors emphasize importance of good hand washing technique for food workers, particularly in establishments where raw food, potentially contaminated with L. monocytogenes, and cooked/ready-to-eat products are handled.

Khan, M. U. 1982. Interruption of shigellosis by hand washing. Trans. Royal Soc. Trop. Med. & Hygiene. 76(2): 164-168.
Shigella is associated with poor hygiene. The effectiveness of the simple intervention of hand washing with soap and water was investigated, in preventing the spread of the disease.
The study population was comprised of confirmed cases of shigellosis. These and matched controls were followed up for 10 days. Several pieces of soap and earthenware pitchers for storing water were provided to the study families and they were advised to wash their hands with soap and water after defecation and before meals. Compliance was monitored daily by observing the sized of the soap and residual water. Rectal swabs of contact of both of the groups were obtained daily for culture.
The secondary infection rate was 10.1% in the study group and 32.4% in the control group. The secondary case (symptomatic) rate was 2.2% in the study group and 14.2% in the control group. These results suggest that hand washing has a positive interrupting effect, even in insanitary environments.

Kjolen, H., and Andersent, B.M. 1992. Hand washing and disinfection of heavily contaminated hands -- effective or ineffective? J. Hosp. Infect. 21: 61-71.
Hands are among the principal vehicles for transfer of nosocomial pathogens in hospitals. Often, outbreaks of infection are thought to be caused by a lack of compliance with hand washing guidelines, rather than due to the inadequacy of the hand washing agents used. In this study the effectiveness of proper hand washing and use of three different hand disinfectants (ethanol, 70% (E), isopropanol, 40% (I), and alcoholic chlorhexidine, 70% (AC) was compared using three volunteers whole fingertips were heavily contaminated with a succession of bacteria including: Enterococcus faecalis, S. aureus, E. coli, and Enterobacter cloacae. After each contamination, thorough hand washing and application of one disinfectant on the hands were performed three times. Fingerprint-samples were taken before and 1 min. after application of the disinfectants. Thorough hand washing with ordinary liquid soap (Sterisol) did not reduce the confluent growth of bacteria on fingertips for any of the species used (197 examinations). Only AC had a significant effect on fingers heavily contaminated with S. aureus, but did not completely eradicate the bacteria. After contamination with Enterobacter cloacae, none of the three agents were particularly effective but AC and E seemed to be some what more effective. When successive contamination was performed using all bacterial species, AC was the most effective decontaminant. However, Enterobacter cloacae, was still present on the fingertips after 15 repeated courses of hand washing and applications of disinfectants. Bathing hands in AC for 20 sec. completely eradiated all bacteria from the hands. This study demonstrated that, when heavily contaminated, an ordinary hand washing followed by disinfectants is not enough to eradicate potentially pathogenic bacteria from the hands.

Knights, B., Evans, C., Barrass, S., and McHardy, B. 1993. Hand drying - A survey of efficiency and hygiene. London, UK., The Applied Ecology Research Group, University of Westminster.
Observations of peoples' hand washing and drying habits under natural conditions have been carried out. The results show that disposable paper towels and cotton cabinet towels were a mush quicker and more efficient means of drying the hands than hot air driest. People rarely us hot air dryers long enough to insure more than 55-65% dryness and often complete drying by wiping hands on clothes, etc. Many women also use make-up and combs while hands are still damp. These activities can spread any bacteria left on the hands.
Microbiological studies revealed that using paper towels were slightly more efficient than cotton, both with respect to cleaning the finger tips and in between the fingers.
In contrast, hot air drying increased bacterial counts on the hands and in the local environment. Bacterially contaminated air was emitted whenever a machine was running, even when not being used for hand drying.

Korniewicz, D. M., Laughton, B.E., Butz, A., and Larson, E. 1989. Integrity of vinyl and latex procedure gloves. Nursing Res. 39(3): 144-146.
In a series of experiments, the integrity of vinyl and latex procedure gloves were tested under in-use conditions. Both types of gloves were tested by three methods: watertight (645 samples), bacterial penetration (50), and dye exclusion (90). Results of the water tight test demonstrated visible defects in 4.1% of vinyl and 2.7% in latex gloves. Twenty percent of latex gloves and 34% of vinyl gloves that had passed the water tight test allowed penetration of Serratia marcescens when worn by volunteers. A series of manipulations designed to simulate approximately 15 minutes of clinical activity in an intensive are unit resulted in failure rates as high as 66%. Using the dye penetration test, there was a statistically significant difference between vinyl and latex procedure gloves with full manipulations, with failure rates of 53% and 3%, respectively. Both types of gloves provided some barrier protection. However, latex gloves performed better when stressed.

Korniewicz, D. M., Laughon, B.E., Cyr, W.H., Lytle, C.D., and Larson, E. 1990. Leakage of virus through used vinyl and latex examination gloves. J. Clin. Microbiol. 28(4): 787-788.
A total of 490 examination gloves (240 vinyl and 240 latex) were stressed by using manipulations designed to mimic patient care. At the highest use level, 38 (63%) of 60 vinyl gloves leaked bacteriophage__X174 compared with 4 (7%) of 60 latex gloves. At lower use level, there was not statistically significant difference in leakage.

Korniewicz, D. M. 1996. In vitro versus in-use considerations for testing the permeability of gloves. Am. J. Inf. Control 24(3): 158-159.
Proper gloving practices include taking into account: 1) material of the glove (vinyl, latex, nitrile); 2) task to be performed (clinical, mechanical); 3) length of time the glove is used (1 min. to 1 hour); 4) exposure of the glove to chemicals, blood, or body fluids; and 5) quality of the glove.
In vitro testing is the most ideal because a variety of extraneous variable can be controlled such as 1) contamination (viral, bacterial, chemical), 2) glove (type, size, quality), 3) environment (temperature, materials used, control of substances that would compromise the glove barrier), 4) amount of time for exposure to substances, 5) data collection methods (computer, specifically trained personnel), 6) type of test to be performed (prescribed method can be adhered to in a laboratory setting), and 7) decreased risk of human error as a result of a more controlled environment and more accurate test methods.

Kotilainen, H. R., Brinker, J.P., Avato, J.L., and Gants, N.M. 1989. Latex and vinyl examination gloves: quality control procedures and implications for health care workers. Arch. Intern. Med. 149: 2749-2753.
In December 1987, we investigated an increased number of cases of herpetic whitlow in medical intensive care unit nurses who routine gloved for secretion contact. One particular brand of vinyl examination gloves had been used in the medical intensive care unit. Restriction endonuclease mapping established the similarity of employee isolates with one patient isolate of herpes simplex virus type 1. When initial viral assay demonstrated 2.5% to 10% penetration of herpes simplex virus type 1 across unused gloves and evaluation of glove quality was undertaken. In a 300-m. water-tightness test, seven brands of vinyl gloves failed 4% to 28% (average, 11.1%; 132/1200), while seven brands of latex gloves failed 0% to 2.6% (average 1.4%; 24/ 1750). The brands of vinyl Jove that have been in used in the medical intensive care unit failed 28% of the time. Water tight gloves were then tested for permeability to herpes simplex virus type 1. None of the latex gloved failed (n-1726), while only 10 of the vinyl gloves failed (n-1068, (0.95%). Extreme variability in glove quality was observed. However, gloves made from intact vinyl may provide similar protectiveness as those made from intact latex. As the demand for gloves increases, emphasis should be placed on the production of plentiful, better quality latex and vinyl gloves.

Kotilainen, H. R., Avato, J.L., and Gantz, N.M. 1990. Latex and vinyl nonsterile examination gloves: status report on laboratory evaluation of defects by physical and biological methods. Appl. Environ. Microbiol 56(6): 1627-1630.
Vinyl gloves (5 brands, 2500) and latex gloves (4 brands, 2000 ) were evaluated by the 300-ml. and the newly proposed 1000-ml. water tests for permeability to herpes simplex virus type 1, and polio virus type 1, respectively. While all 300-ml. watertight gloves were unlikely to leak herpes simplex virus type 1 (1.3% vinyl, 1% latex), polio virus was recovered mush more frequently (8.9% vinyl, 6.1% latex). In all gloves that passed 1000-ml test, herpes simplex was not recovered. Poliovirus was recovered infrequently (1.4% vinyl, 1.5% latex). Preliminary analysis suggest that the1,000 ml water test has significantly increased sensitivity over the 300 ml. water test in the detection of small holes in both vinyl and latex gloves that may allow the passage of viral particles. Gloves that pass a 1000 ml. water challenge are unlikely to allow the passage of a small virus such as poliovirus. Given that HIV, hepatitis B virus, and herpes simplex virus type 1 are larger particles than poliovirus, gloves that pass the 1000 ml. water test provide better protection.

La Rocca, M. A. K., and La Rocca, P.T. 1982. An evaluation of antimicrobial effect of a hand sponge-brush impregnated with 4% chlorhexidine gluconate (Hibiclens). Dev. Ind. Microbiol. 23(Chapter 51): 543-546.
Reports study of effective use of a sponge brush containing chorhexidine gluconate for washing and scrubbing hands. There were significant decreases of the numbers of bacteria on the hands. Significant reestablishment of the normal flora was prevented for over 6 hours. (Glove juice test was used for the assessment of bacterial population on the hands.)

Larson, E. 1984. Current hand washing issues. Infect. Control 5(1): 15-17.
This article is an update on the status of current issues regarding hand washing. Points out known issues: 5 min. surgical scrub is adequate; hands cannot be sterilized; flora of skin can cause nosocomial infections; hand washing is efficacious for preventing spread of infection. Points out areas that need more study : bacteriology of the hands; gram-negative as well as gram-positive cocci are present on the hands, even after "social" hand washing; there is tremendous individual variations in bacterial counts on skin, unexplained by current knowledge; methods to increase compliance with adequate hand washing.

Larson, E., and Lusk, E. 1985. Evaluating hand washing technique. J. Adv. Nursing 10: 547- 552.
Though standards for hand washing have been defined, little effort has been made to assess the quality of hand washing in clinical settings. This paper describes tests of reliability and validity of tools to evaluate two aspects of hand washing - appropriateness and technique. Based on these test, methods to evaluate hand washing are recommended.

Larson, E., and Garibaldi, R.A. 1986. HIBICLENS: Abstracts from the work literature. Auckland, Adis Press Limited.
Book contains abstracts from the literature concerning antiseptics.

Larson, E., McGinley, K.J., Grove, G.L., Leyden, J.J., and Talbot, G.H. 1986. Physiologic, microbiologic, and seasonal effects of hand washing on the skin of health care personnel. Am. J. Infect. Control 14(2): 51-59.
The hand washing practices of 22 personnel in an oncology unit in an urban medical center were studied for 2 months. During 891 person-hours of observation, 986 hand washes were observed. Subjects washed a mean of 1.1 times an hour for a mean of 13.2 seconds. A total of 558 isolates were recovered from 158 hand cultures. The mean log count was 4.88 with no significant difference between physicians and nurses. Coagulase negative staphylococci isolated from hands of physicians and nurses were significantly more resistant to antimicrobial agents than those of personnel with minimal patient contact. Subjects had more skin damage in winter than in summer, as indicated by increased shedding of skin squames. Concluded that hand washing practices vary significantly by profession and that reporting of hand washing practices by personnel is inaccurate.

Larson, E., Leyden, J.J, McGinley, K.J. Grovem G.L. and Talbot, G.H. 1986. Physiologic and microbiologic changes in skin related to frequent hand washing,. Infect. Control 7(2): 59-63.
Hand washing practices may be adversely influenced by the detrimental effect of hand washing on skin. Five agents were tested: water alone, nonmedicated bar soap, a chorhexidine-containing antiseptic, and two agents containing povidone-iodine Some damage to the outer membrane, the stratum corneum, occurred in all groups. Significantly less shedding occurred in subjects using water alone, bar soap, and the chlorhexidine formulation. Greater antimicrobial activity was not correlated with increased skin trauma.

Larson, E., and Talbot, G.H. 1986. An approach for selection of health care personnel hand washing agents. Infect. Control 7(8): 419-424.
Selection of an appropriate hand washing product must be based on four criteria: efficacy, safety, cost and acceptability. Study reports evaluation of para-chloro-meta-xylenol (PCMX) which is currently used by hospital personnel. Efficacy of this product is formula dependent.

Larson, E., Eke, P.I., Wilder, M.P., and Laughon, B.E. 1987. Quantity of soap as a variable in hand washing. Infection Control. 8(9): 371-375.
The purposes of this study were to assess the effect of two quantities ( 1 ml or 3 ml) of four different hand washing products on reductions in log colony forming units (CFU) from the hands and to determine the amount of liquid soap used for hand washing by personnel in one hospital. First, 40 subjects were assigned by block randomization to one of four hand washing products (4% chlorhexidine gluconate in a detergent base, two alcohol hand rinses, and a liquid nonantimicrobial soap} to be used in either 1 ml. or 3 ml. amounts per wash. Each subject washed his or her hands 15 times per day for 5 days. After one of 5 days of hand washing there were significant reductions over baseline in log CFU between hand washing products (P<0.001). Additionally, subjects using 3 ml. of antiseptic soap had significantly greater reductions in log CFU than those using 1 ml. (P<0.001). Among subjects using control liquid soap, there was no such dose response. Second, a survey of 47 members of a hospital nursing staff from 9 specialty areas and ten individuals in the general population was conducted to measure amounts of two liquid soaps used for hand washing. Amount of soap ranged from 0.4 to 9 ml. per hand wash. Personnel working in clinical areas where patients were at high risk for nosocomial infection used significantly more soap than did others (P<0.05). We conclude that quantity of soap used is one variable influencing the microbial counts on hands, and that the quantity of soap used by health care personnel varies considerably.

Larson, E., Mayur, K., and Laughon, B.A. 1988. Influence of two hand washing frequencies on the reduction in colonizing flora with three hand washing products used by health care personnel. Am. J. Infect. Control 17(2): 83-88.
Four hand washing products (containing either 2% chlorhexidine gluconate, 0.6% parachlorometaxylenol, 0.3% triclosan, or a non-antimicrobial control) at two hand washing frequencies (6 or 18 times a day). On the basis of the findings, an antimicrobial soap is recommended when hand washing frequency is high and a long-term reduction in colonizing flora is desirable. When hand washing frequency is low (6 time/day), there seems to be less advantage of one product over another, although the use of chlorhexidine gluconate resulted in greater reductions at both high and low hand washing frequencies.

Larson, E. 1989. Hand washing: Its essential -- even when you use gloves. Am. J. Nurs. 89: 934-939.
Review article. CDC recommends plain soap for most general patient care. When the sole purpose of hand washing is to remove soil and transient organisms from hands, plain soap is adequate. In critical care units, immunosuppressed units, day care centers and long-term care centers, antimicrobials are needed. Discusses use of alcohols, chlorhexidine gluconate, iodophors, para-chloro-meta-xylenol and triclosan (Irgasan). (Hexa chlorophene is no longer recommended because it acts primarily against gram-positive bacteria, and has little or not effect on other types of bacteria that cause infection. It has also been associated with a rare but serious neurological toxicity.)
Hand washing can interrupt the skin's normal protective mechanisms by damaging or cracking the skin, altering its pH, or changing its normal flora. Recommends using hand lotions containing antimicrobial ingredient in small bottles.
Gloving: Bacteria on hand multiply rapidly inside warm, moist environment of glove, even when no external contamination has occurred. Bacteria and viruses can leak through gloves. Gloving does not replace hand washing; hand washing is imperative after removing gloves.

Larson, E. 1995. APIC Guidelines for Infection Control Practice. - APIC guideline for hand washing and hand antisepsis in health care settings. Washington, D.C., APIC (Association for Professionals in Infection Control and Epidemiology, Inc.).
This guideline provides information of skin flora of hands, characteristics of selected antimicrobial agents used on hands, hand washing and surgical scrub techniques, and related aspects of hand care and protection. In addition recommendations are made regarding 1) health care personnel hand washing; 2} personnel hand preparation for operative procedures; 3})other aspects of hand care and protection.
Very good definition section. Good discussion of hand washing practices. Good bibliography.

Lilly, H. A., and Lowbury, E.J.L. 1978. Transient skin flora - Their removal by cleansing or disinfection in relation to their mode of deposition. J. Clin. Path. 31: 919-922.
A suspension of Staphylococcus aureus deposited on the skin was much more effectively removed by soap-and-water washing when it had been spread and allowed to dry (mean survival 2%) than when it had been rubbed onto the skin (mean survival 29.9%); when antiseptics (70% ethyl alcohol, Hibiscrub without added water) were used, there was no difference between their action against bacteria dried on and bacteria rubbed onto the skin: both of these methods, and especially alcohol, were more effective than soap and water. When a detergent-disinfectant method (washing with Hibiscrub and water) was used, there was a significantly greater effect against rubbed on than against dried-on bacteria; soap and water was slightly more effective that Hibiscrub and water against the latter. The need to reappraise methods of reducing transient skin flora in "hygienic" hand cleansing and tests for this purpose are discussed.

Lowbury, E. J. L., and Lilly, H.A. 1960. Disinfection of the hands of surgeons and nurses. Brit. Med J. 1(May 14): 1445-1450.
Describes experiments on the relative merits of several preoperative antiseptic applications to the surgeon's hands with particular reference to the numbers of bacteria emerging through holes in gloves. Describe a study on the routine use of hexachlorophene soap and some other methods by nurses working in accident and burn wards.

Lowbury, E. J. L., Lilly, H.A., and Bull, J.P. 1960. Disinfection of the skin of operation sites. Brit. Med. J. 2: 1039-1044.
Tested a number of antiseptics both against pathogens deposited on the surface and against the normal skin flora; in the latter study a hand-washing method of sampling was used, and the comparative value of the antiseptics was statistically assessed by the use of a Latin square design. This study included a quantitative comparison of selected modern antiseptics with alcohol and iodine, an assessment of the value of repeated disinfection, and tests of the degree of association between counts of total organisms and of Staphylococcus aureus in hand wash-sampling before and after disinfection.

Lowbury, E. J. L., Lilly, H.A., and Bull, J.P. 1963. Disinfection of hands: removal of resident bacteria. Brit. Med. J. 1(May 14): 1251-1256.
In three series of experiment... a Latin square design was used for the comparative study of 12 antiseptic preparations; this method of assessment takes into account possible interfering effects of personal variation and of day to day changes of condition. The effects of a single application and of repeated use of the antiseptic preparation have been separately assessed. In two additional experiments, the removal of staphylococci and the value of a more recently available preparation were examined.

Lowbury, E. J. L., Lilly, H.A., and Bull, J.P. 1964. Disinfection of hands: removal of transient organisms. Brit. Med. J. 2(July 25): 230-233.
In this paper we report a comparative study on alternative methods for the removal of transient flora; we also describe experiments on the survival of bacteria deposited on the skin after treatment with antibiotics.

Mahl, M. 1989. New method for determination of efficacy of health care personnel hand wash products. J. Clin. Microbiol. 27(10): 2295-2299.
A method of studying the effects of health care personnel hand wash products is described. The fingernail regions of the hands of volunteers are inoculated with a mixture of Escherichia coli and Serratia marcescens, and the areas are dried for a standard time. After routine hand washing, each fingernail region is individually scrubbed with an electric toothbrush which moves longitudinally to the handle in to collection fluid contained in a petri dish. The test bacteria in the fluid are then enumerated. (Bacillus subtilis spores may be included as tracers to show degree of physical removal of the procedure.) This method has several advantages over the frequently used glove juice technique. Experimental designs with large numbers of volunteers, multiple sampling sites, and many hand wash products may be performed. Ten sampling sites (fingers) are available versus the two gloved hands for testing products. (Efficiency is almost 100% in the recovery of spore traces placed on the fingernails.) Many commercial health care personnel hand wash products containing antimicrobial agents substantive to the skin do not rapidly reduce numbers of inoculated bacteria in fingernail regions to any greater extent than nonantimicrobial hand washes. Products containing isopropanol or ethanol are very effective in decreasing bacteria in areas around and under the fingernails.
Used ivory liquid hand soap. Good data.

Makulowich, G. S. 1991. FDA establishes standards for gloves. Aids Patient Care 5(3): 143-145.
FDA Acceptable Quality Levels (AQL) for Gloves :
Surgical gloves: batches of latex or vinyl with less than 25 defects per 1000 gloves.
Examining gloves: batches with less than 40 defects per 1000 gloves.

Marples, R. R., and Kligman, A.M. 1974. Methods for evaluating topical antibacterial agents on human skin. Antimicrobial Agen. Chemother. 5(3): 323-329.
Three procedures were presented for appraising the ability of antibacterial chemicals and formulations to suppress the growth of microorganisms on human skin. In each of these, the microflora was quantified after the skin had been occlusively covered for a day or more, a circumstance which, in the absence of a deterrent, led to an explosive overgrowth of microorganisms

Matthews, J. A., and Newsom, S.W.B. 1987. Hot air electric hand dryers compared with paper towels for potential spread of airborne bacteria. J. Hosp. Inf. 9: 85-88.
Hot air hand dryers are used both in public areas and hospitals. Four units were examined by comparing the bacterial aerosols released from hands during use by sets of twelve subjects with those released by paper towels. Tests on two units also included hand imprints of agar plates for detection of residual bacteria. No significant difference between aerosols released by towels and dryers were observed for two units, while two units had significantly fewer aerosols than towels. Impression plates revealed similar numbers of bacteria on the hands after drying by either method. Hot air hand dryers appear safe from a bacteriological viewpoint.

McGinley, K. J., Larson, E.L., and Laeyden, J.J. 1988. Composition and density of the microflora in the subungula space of the hand. J. Clin. Microbiol. 26(5): 950-953.
There were significant quantitative differences in the composition and density of microflora in different areas of the hands of 26 adult volunteers. The subungual spaces had an average log10 CFU of 5.39, compared with a range from 2.55 to 3.53 for other hand sites. In quantitative cultures from five subungual spaces in 26 subjects, coagulase-negative staphylococci were the dominant organisms with S. epidermidis, S. haemolyticus and S. hominis being the most frequently isolated species. Other bacteria recovered from subungual spaces included gram-negative bacilli in 42.3% of subjects with Pseudomonas species composing 31.3% of this group, and coryneforms making up 12.5%. Yeasts were isolated from 69.0% of subjects samples, with 51.3% of the yeasts identified as Candida parasilosis. The subungual coagulase-negative staphylococci were susceptible to most antibiotics, with resistance to penicillin, ampicillin, and erythromycin detected in 23 to 38% of isolates.

Meers, P. D., and Leong, K.Y. 1989. Hot-air hand dryers. J. Hosp. Infect. 14: 169-171.
(In letters to the Editor section.) Although hot air hand dryers may be criticized for being noisy or for taking too long to complete their task, our experiment leads us to agree with Matthews and Newsom (1987) that there is not bacteriological reason to exclude them from clinical areas.

Mendes, M. F., and Lynch, D.J. 1976. A bacteriological survey of washrooms and toilets. J. Hyg. Camb. 76.
A survey of the bacterial flora present at various positions in 130 male and female washrooms and toilets is reported. Several bacteria of fecal origin were found in large numbers: the areas likely to be the most important sources of cross-infection from fecal contamination are indicated. The results are used to assess priorities for disinfection.

Michaud, R. N., McGrath, M.B., and Goss, W.A. 1976. Application of a gloved-hand model for multiparameter measurements of skin-degerming activity. J. Clin. Microbiol. 3(4): 406-413.
The application of an established gloved-hand model to multiparameter measurements of skin-degerming activity is described. In particular, appropriate experimental designs are illustrated which allow characterization of the performance of topical skin-cleansing preparations in terms of rapid, sustained, cumulative, and persistent skin-degerming effects on the hand. Single-contact studies were used to define the degerming activity profiles of selected commercial surgical scrub preparations, and to establish the optimal post-treatment sampling interval for individual preparations. Rapid and sustained skin-degerming effects were measured and contrasted. Rapid skin degerming activity, namely, that occurring on the gloved hand during a post-contact interval, was shown and characterized for two hexachlorophene preparations. Multiple-contact studies with a 3% hexachlorophene preparation were used to illustrate cumulative and persistent skin-degerming effect. Cumulative skin-degerming activity was demonstrated in terms of progressive bacterial reductions after repeated contacts within a single day. Persistent skin-degerming activity was shown in terms of the profile of daily pretreatment bacterial counts after multiple contacts over successive days. Uniformity of treatment response was established for a broad range of pretreatment bacterial counts extending from approximately log 4 to log 7 per hand. The importance of the pretreatment bacterial count measurement and of adequate neutralization of hand extract samples is stressed. A randomized-hand experimental design is discussed relative to its versatility and amenability to statistical analysis.

Nicoletti, G., Boghossian, V., and Borland, R. 1990. Hygienic hand disinfection: a comparative study with chlorhexidine detergents and soap. J. Hosp. Infect. 15(323-337).
The efficacy of two chlorhexidine hand-wash detergents and liquid soap was compared in a laboratory trial using artificial contamination of fingers with Micrococcus and Serratia. Agents were assessed for both a rapid and sustained effect after a single contact, and for a cumulative persistent effect after multiple contact over four days. Disinfectant activities were compared by statistical analysis of log reduction factors and log count time gradients (decimal reduction times). The later analysis attempted accommodate significant subject variation in response to both agent and organism. All hand washing methods significantly reduced contamination levels. Both chlorhexidine formulations were significantly better than soap in their activity against Micrococcus but were not more effective than soap in removing contamination with Serratia. Both chlorhexidine preparations showed significant skin persistence and were generally acceptable to subjects after prolonged use. Some effect of the formulation of the hand-wash on chlorhexidine activity was demonstrated.

Noble, W. C. 1980. Carriage of micro-organisms on skin. Problems in the Control of Hospital Infection. B. Newsom, and Caldwell, A.D.S. London, Academic Press Inc.
Chapter discussion of skin structure and predominant flora: Staphylococcus, Micrococcus, Peptococcus, Corynebacteria, Brevibacterium, Proprionibacterium. Minority flora include: Streptococcus, Neisseria, Bacillus, Acinetobacter

Ojajarvi, J. 1976. An evaluation of antiseptics used for hand disinfection in wards. J. Hyg. (Camb.) 76: 75-82.
The antibacterial effectiveness of hand antiseptics commonly used in wards was studied by laboratory and in-use tests and their acceptability assessed by means of a questionnaire passed to hospital staff. To determine the immediate and long-term antibacterial effects of the preparations, the in-use tests were performed by groups of students. The greatest immediate reduction in bacterial counts on has was obtained by products containing chlorhexidine. The long term antibacterial effect was recorded with emulsions containing 3% hexachlorophene, 2% Irgasan CRF3R or 4% chlorhexidine when used constantly on several consecutive days. Considerable discrepancies were recorded in the antibacterial effectiveness of some preparations when comparing laboratory and in-use test results. Therefore it is suggested that antiseptics should be tested by in-use tests which more closely resemble practical conditions before their use, or further trial, in hospital.

Ojajarvi, J. 1980. Effectiveness of hand washing and disinfection methods in removing transient bacteria after patient nursing. J. Hyg. (Camb,) 85: 193-203.
The effectiveness of various hand washing and disinfection methods in removing transient skin bacteria was studied in hospital after dry or moist contamination of the hands when nursing burn patients. The results were compared with those of laboratory tests with volunteers. A fairly good correlation of the bacterial reductions existed between hospital and laboratory tests. All other methods removed S. aureus from the hands more effectively than liquid soap. Gram-negative bacilli were more easily removed than staphylococci, even with soap wash alone.
In hospital, none of the washing and disinfection methods always removed all patient-borne bacteria from the hands. After dry or moist contamination and subsequent washing with soap only, colonies of S. aureus were after detected in finger-print samples. Staphylococci were more often completely removed by a 4% chlorhexidine detergent scrub and alcoholic solutions (either with or without previous soap wash) than by liquid soap, hexachlorophene or iodophor preparations. Gram-negative bacilli were more easily removed by all the washing and disinfection methods. After moist contamination, Gram-negative bacilli were more completely removed from the hands by ethanol than by other treatments.
The results of the present study emphasize the importance of always using gloves when nursing a profuse spreader of bacteria or one who must be protected from infection.

Ojajarvi, J. 1981. The importance of soap selection for routine hand hygiene in hospitals. J. Hyg. Camb.. 86: 275-283.
Five different types of liquid soap were studied in hospital wards, each during two month's use. Altogether 1306 finger print samples were taken from the hands of the staff by sampling twice a week and the acceptability of the soaps was measured by a questionnaire. During the use of different soaps, only slight differences were found in the numbers of total bacteria or in the occurrence of S. aureus and gram-negative bacilli on the hands. During the use of the emulsion-type product studied, several persons who had dermatological problems had lower mean bacterial counts of the fingers than during the use of the other soaps. This soap was favorably accepted by the staff. After over 1 year's use of pine oil soap and alcohol, the staff was satisfied with the method. However, several persons with skin problems admitted to using no soap or alcohol. The considerable differences found in the acceptability of soaps imply that for use in hospital the choice of a soap acceptable to the nursing staff is important in promoting proper hand hygiene.

Oldenburg, D. 1996. Wash up! Dirty hands can have tragic, deadly consequences. Washington Post. Washington D.C.
Article effectively describes the importance of hand washing in every day life, for medical personnel and for personnel in the food service industry.

Paulson, D. S. 1992. Evaluation of three hand wash modalities commonly employed in the food processing industry,. Dairy Food Environ. Sanit. 12(10): 615-618.
The study reported use of three methods: manual hand wash using Ivory bar soap; iodine dip using Zep-i-dine 20; automated hand wash system using 2% chlorhexidine. Serratia marcescens was used as test microorganism. The glove juice sampling method was also used. Results indicated that washing hands manually or by machine resulted in greater number of log reductions than with the iodine dip. No subject in the study complained of skin irritation from any of the three wash procedures, not was it noticed by laboratory personnel.

Paulson, D. S. 1992. Variability evaluation of two hand wash modalities employed in the food processing industry. Boseman, Mont., Bioscience Laboratories, Inc.
(No date is given on paper.) Compared standard manual hand wash procedure using ivory soap with manual cleansing system using 2% chlorhexidine. Glove juice testing procedure was used. Serratia marcescens was the test microorganism. Study found that automated hand washing provided more consistent results. There seems to be little difference in manual hand washing (if done correctly) and automated hand washing.

Paulson, D. S. 1993. Evaluation of three microorganism recovery procedures used to determine hand wash efficacy. Dairy Food Environ. Sc. 13(9): 520-523.
Compares glove juice test, swab method and finger press method for measuring hand contamination. Glove juice method is most accurate.

Paulson, D. S. 1994. A comparative evaluation of different hand cleansers. Dairy, Food and Environ. Sanit. 14(9): 524-528.
Most significant bacteria on hands of food processing personnel: Salmonella, Shigella, Escherichia, Yersinia, Klebsiella, Proteus, Clostridium, Citrobacter, Staphylococcus and Streptococcus. Discussion of hand sampling methods: "swab", "finger press", and "glove juice." Glove juice test is the only accurate method. Stresses that hand cleansing products must be effective in removing transient microorganisms, and must also be mild to the skin after many applications.
Degerming properties:
Non-antibacterial soaps assist in removal of transient microorganisms during a warm water hand wash.
ntimicrobial soaps have degerming effects during the hand wash due to removal of transient microorganisms and also due to the antimicrobial compound they contain. Some may also have a persistent effect.
Alcohol and alcohol gels (must exceed 50%) have the most pronounced immediate effect, but not residual effect. When these products are used without mechanical removal of microorganisms via hand washing there is a tendency for microbial build-up upon repeated exposure to contaminating microorganisms.
The study compared 6 common hand washing products: non-bacterial lotion soap; an antibacterial lotion soap [0.6% parachlorometaxylenol {PCMX)] ; E2 Sanitizing soap [0.2% PCMX], Alcohol gel sanitizer [62% ethanol]; non-bacterial lotion soap plus alcohol gel sanitizer; anti-bacterial lotion soap plus alcohol gel sanitizer.
Results: Non-bacterial lotion soap reduced microbial counts by about two logs (99.00%).
Antibacterial lotion soap [0.6% parachlorometaxylenol {PCMX)] reduced microbial counts by about 2.5 logs (99.68%).
E2 Sanitizing soap [0.2% PCMX] reduced microbial counts by 4 logs (99.99%) after 10 washings and demonstrated microbial effectiveness. However, it seemed to cause hand irritation negating its benefit.
Alcohol gel sanitizer [62% ethanol] reduced microbial counts by about 4 logs (99.99%) after the first inoculation/product cycle
on-bacterial lotion soap plus alcohol gel sanitizer reduced microbial counts 3.25 logs (99.94% to 99.97%)
Anti-bacterial lotion soap plus alcohol gel sanitizer gave same results as the non-bacterial soap plus alcohol gel.
Conclusion: The most effective product regimens, from an overall microorganism reduction profile as well as a skin irritation standpoint, were the combinations of alcohol gel with antimicrobial soap or plain lotion soap. Both of these configurations showed tremendous immediate transient organism reduction due to mechanical degerming by the soap hand wash couples with the alcohol's immediate antimicrobial properties. Both regimens also demonstrated persistent antimicrobial properties.

Paulson, D. 1996. Get a handle on hand contamination. Food Quality(April): 42-45.
In any successful hand wash program, two main parameters must be considered: the immediate and persistent antimicrobial effects. the immediate antimicrobial effects depend on two attributes: the mechanical removal of contaminating microorganisms and the topical antimicrobial compounds ability to skill microorganisms upon contact. The persistent antimicrobial effects (the ability of the hand wash to keep the microbial population at a low level after washing) are dependent upon the type of anti microbial product used.
Immediate antimicrobial effectiveness depends upon the type and amount of antimicrobial hand sanitizer used, the amount of time spent washing the hands, the mechanical pressure and friction exerted in the wash, and the temperature of the water.
Iodophor Iodine - good immediate and persistent effect. Remove both normal and contaminant organisms. Can irritate hands.
Chlorhexidine gluconate - good immediate and persistent effect against both normal and contaminant organisms. Residual effect - binds to skin and retards microbial regrowth on the hands. Tends to irritate skin if used at the 4% level. At levels of 2% or lower, there is generally no problem.
Triclosan - is effective against both resident and transient microorganisms, (not as effective as iodophors or chlorhexidine gluconate). Has both immediate and persistent antimicrobial effects as well as causing low level of skin irritation.
Parachlorometaxylenol (PCMX) - effectiveness comparable to Triclosan. Effective for use in the food industry. Low potential for causing skin irritation.
Alcohols - containing over 50% ethyl alcohol provide good immediate effect, but no persistent antimicrobial properties. Tend to irritate skin.
Sodium hypochlorite - Dilute sodium hypochlorite (bleach) is antimicrobial to both resident and transient skin microorganisms, as well as bacterial spores. Very irritating to hands.
Article describes the hand sampling procedures: swab, finger press, and glove juice method. Presents graphical evidence for the effectiveness of the glove juice method.

Paulson, D. 1996. Use of gloves by food handlers. (letter). Boseman, MT., Bioscience Laboratories.
Recent studies performed by Biocience Labs suggest that the increased margin thought to be derived from food workers wearing gloves to prevent transmission of disease from their contaminated hands may be grossly over-estimated.
Cites two studies. In one study, volunteer human subjects' hand were inoculated with contamination levels of Escherichia coli. The subjects then put on vinyl server gloves to prevent microbial transmission. Immediately the gloved hands were samples for a baseline or time zero (0) value. In the majority of cases, the gloved hands demonstrated significant bacterial counts on the outside glove surface, suggesting that Escherichia coli were easily transferred from the hands through "pre-existing" punctures on to the outer surfaces of the gloves.
In a separate study, 80% of randomly selected vinyl grade gloves were found to have pre-existing punctures and tears. Both food quality grade and hospital grade protective vinyl/latex gloves are know to be ripped, torn or punctured while personnel perform their duties. In many cases, the rips, tears or punctures remain unknown to the wearer.
When gloves are worn, the normal and contaminating microorganisms on the skin are provided a more favorable environment (increased moisture, nutrients, and warmth) to reproduce than is offered on bare hands. It was observed that without a prior hand wash, contaminant Escherichia coli increased their population numbers, when gloves were worn, but the hands were not washed prior to putting on the gloves. This occurred at 1 hour and 3 hour glove change times. However, if an effective hand wash was performed prior to gloving, no significant contaminant microbial growth was observed.
Recommendation: If gloves are worn to prevent microbial contamination of the food by food servers, the gloving should be preceded by an effective hand wash. The hand wash effectiveness, not the glove barrier appears to be the determining factor responsible for the cross contamination.

Peterson, A. F., Rosenberg, A., and Alatary, S.D. 1978. Comparative evaluation of surgical scrub preparation. Surgery, Gyn. Obstet. 146: 63-65.
The efficacy of 0.75% available povidone-iodine scrub solution, 4% chlorhexidine gluconate detergent solution and 3% hexachlorophene emulsion against resident and transient flora of the hand has been compared using two currently accepted study designs. Chlorhexidine gluconate produced the greatest initial reductions against resident flora, followed by povidone-iodine and hexachlorophene, respectively. In subsequent washings, all three treatments further reduced the flora, chlorhexidine giving the greatest reduction on any test day. On gloved hands, there was significant re-growth on gloved hands which had been washed with chlorhexidine gluconate or hexachlorophene.
Against transient flora, chlorhexidine gluconate gave the lowest over-all counts, followed by povidone-iodine and hexachlorophene respectively. The reduction in bacteria counts increased following the repetitive use of chlorhexidine; no such trend was noted with either povidone-iodine or hexachlorophene.

Pether, J. V. S., and Gilbert, R.J. 1971. The survival of salmonellas on finger-tips and transfer of the organisms to food. J. Hyg.(Camb.) 69(673-681).
Escherichia coli and several Salmonella serotypes were shown to survive on the fingertips for various period of time, for example S. anatum could be recovered 3 hr. after artificially contaminating them with between 500 and 2000 organisms. S. anatum could also be recovered from the finger tips after contaminating them with more than 6000 organisms followed by a 15 second hand wash, 10 minutes later. Similarly, the survivors from minimal inocula of less than 100 S. anatum/fingertips were, after 10 min still capable on infecting corned beef and ham. E. coli was isolated from the fingertips of 13 of 110 butchers soon after they had left the meat line at a meat products factory, but was not detected on the fingertips of 100 volunteer at the Central Public Health Laboratory.
The implications of the present findings to the spread of salmonellas from raw to cooked foods, and the relevance of this to outbreaks of Salmonella infection in the general population and in hospitals are discussed.

Post, F. J., and Balzer, J.L. 1963. Effect of a hexachlorophene detergent on the microbial population of the hands of food handlers. J. Milk Food Technol. 26: 142-147.
A hand washing study was conducted to determine whether a 3% hexachlorophene hand detergent could materially reduce the normal bacterial population on the hands of food handlers. Total count, staphylococcus count, and total gram negative bacteria count showed significant reductions when the hexachlorophene detergent was used. No decline occurred when three other hand detergents were used. It was suggested that the gram negative bacteria count may be a better indicator of transient organisms on the hands than the total count which includes a greater proportion of resident bacteria.

Price, P. B. 1938. The bacteriology of normal skin: a new quantitative test applied to a study of the bacterial flora and the disinfection action of mechanical cleansing. J. Infect. Dis. 63(301-306).
Skin bacteria are of two sorts, "transients" and "residents". Transients, acquired mainly by contact, vary greatly in both number and kind. They may be abundant on exposed skin, under nails, etc., but are relatively scarce on clean, unexposed skin. Resident bacteria form a comparatively stable flora. Forces increasing (Chiefly multiplication insitu) and decreasing their number tend to reach an equilibrium. Protected skin has as a rule a somewhat larger resident flora than exposed skin.
After reduction (e.g., disinfection) reestablishment of the resident flora appears to proceed at a rate represented in general by a sigmoid curve, as is true of bacterial growths in cultures. Hands and arms thoroughly degermed may require a week or more for complete reestablishment of the usual flora.

Prince, H. N. 1983. Disinfectant activity against bacteria and viruses: A hospital guide. Fairfield, New Jersey, Gibraltar Biological Laboratories, Inc.
Discussion of disinfectants used in hospitals from view of EPA. Discusses test procedures and effectiveness of disinfectants.

Redway, K., Knights, B., Bozoky, Z., Theobald, A., and Hardcastle. 1994. Hand drying: A study of bacterial types associated with different hand drying methods and with hot air dryers. London, UK, Applied Ecology Research Group, University of Westminster.
In a previous study under natural conditions, towels were found to be more efficient in drying the hands that hot air dryers where many people completed drying on clothes etc. Microbiological studies revealed that using towels after washing reduced bacterial counts on the hands by an average of 42% (paper) and 10% (cotton). With hot air dryers, however, counts increased by more than 500%. Bacteria were blown out of dryers whenever they were running.
In the present study, standard techniques were used to identify and count the bacteria associated with hand washing and drying under natural conditions. Average bacterial counts were again reduced using towels - the most significant decrease being with paper towel. Hot air dryers produced significant increases in all bacteria -436% rise with some skin and gut bacteria. The presence of gut bacteria is indicative of fecal contamination of the hands.
In a further study, bacteria were isolated from swabs taken from the air flow nozzle and air inlet of 35 hot air dryers in nine types of locations (including hospitals, eating places, railway stations, public houses, colleges, shops and sports clubs.) Bacteria were relatively numerous in the airflows and on the inlets of 100% of dryers sampled and in 97% of the nozzles. Staphylococci and micrococci (probably from skin and hair) were blown out of all of the dryers sampled for these type of bacteria and 95% showed evidence of the potential pathogen Staphylococcus aureus. At least 6 species of gut bacteria (enterobacteria) were isolated from the air flows of 63% of the dryers, indicating fecal contamination.
It is concluded that hot air dryers have the potential for depositing pathogenic bacteria onto the hands and body. Bacteria could also be inhaled and are distributed into the general environment whenever dryers are running. It is suggested that the use of hot air dryers should be carefully considered on health grounds, especially in sensitive locations.

Reingold, A. L., Kane, M.A., and Hightower, A.W. 1988. Failure of gloves and other protective devices to prevent transmission of Hepatitis B virus to oral surgeons. JAMA. 259(17): 2558-2560.
A survey of 434 oral surgeons was conducted to examine risk factors for hepatitis B virus (HBV) infection. Overall, 112 (26%) of the participants demonstrated serologic evidence of past or current infection with HBV. Seropositivity was significantly associated with age, number of years in practice, and year of graduation from dental school but not with other variables examined, such as the number of patients seen annually or the number of patients seen who were at high risk of HBV infection. The strong correlation between years in practice and seropositivity was unaffected by reported use of gloves, face masks, or eye shields. The use of gloves and other protective devices does not appear to offer substantial protection against HBV exposure in oral surgeons, and all oral surgeons should receive HBV vaccine.

Restaino, L., and Wind, C.E. 1990. Antimicrobial effectiveness of hand washing for food establishments. Dairy Food Environ. Sanit. 10(3): 136-141.
A complex etiological relationship exists among the factors: food; environment; and food handlers. Controlling all three factors so they or their interactions do not become a health hazard is of utmost importance. The primary goal is to define an adequate plane, which will control the resident and transient bacterial types. The overall aim of an hand sanitation program must implement hygienic measures to control and prevent contamination of the food products. Health Departments, Sanitary Regulations, and Good Manufacturing Practices stress the importance of frequent and thorough hand washing to prevent microbial contamination. Washing the hand with ordinary soap and water removes the transient bacteria and the use of an antiseptic or sanitizer in the hand soap would control the resident bacterial. The pH of these hand soaps should be acidic to prevent hand irritation and pH altering of the skin. Hospitals have shown that an alcohol rinse containing a humectant can be beneficial in controlling and removing both transient and resident bacteria without hand irritation.
Hand washing and hand treatment scheme for a food service establishment must: 1) kill a broad spectrum of microorganisms (both transient and resident) especially pathogenic bacteria. 2) maintain a residual effect where the bacterial load on the skin is controlled between applications by antimicrobial agents remaining on the skin. 3) be non irritating to the skin.

Rotter, M. L., and Koller, W. 1992. Test models for hygienic hand rub and hygienic hand wash: the effects of two different contamination and sampling techniques. J. Hosp. Infect. 20: 163-171.
Methods used to contaminate hands for hand washing effectiveness studies were described. The study concluded that contamination and sampling should be done by simple immersion and subsequent air-drying of the hands and by the classical fingertip technique.

Schuler, G. A., Christian, J.A., and Hurst, W.C. 1989. Food, Hands and Bacteria. Athens, Georgia, University of Georgia.
Good visuals of petri dish cultures of hands before and after washing; gloves, before and after washing

Seligmann, R., and Rosenbluth, S. 1975. Comparison of bacterial flora on hands of personnel engaged in non-food and food industries: A study of transient and resident bacteria. J. Milk Food Technol. 38.(11): 673-677.
Prevalence and level of coagulase negative and coagulase positive staphylococci, fecal coliforms and enterococci on the hands of employees in non-food industries were compared with findings from five occupational groups, varying in their degree of food contact. A correlation was noted between the flora on the hands and that of the food contacted. Further evidence for transmission of bacteria from food to the hands emerged from comparison of the results before and during work in meat industries. The prevalence and level of coagulase positive staphylococci were present at the same rate before and during work. The conclusion was drawn that this organism and to a limited extent, the other test bacteria had changed their status and had become permanent residents on the skin. The complex etiological relationship in food production was described as a permanent interaction between three factors: food, environment, and food handler. Bacteria were considered ubiquitous and the food handler, a small link in the multiphase process of food preparation. Strict implementation of hygienic measures in all stages of food preparation was urged to prevent bacteria from becoming a health hazard.

Sheena, A. Z., and Stiles, M.E. 1982. Efficacy of germicidal hand wash agents in hygienic hand disinfection. J. Food Protect. 45(8).
The efficacy of hygienic hand wash procedures for food handlers using germicidal soaps and hand dips was studied by measuring the changes in numbers of microorganisms released from hands before and after each of two successive 15 second treatments. Both hand rinse and fingertip imprint sampling techniques were used.
Of the hand dip agents, including sodium hypochlorite (50 ppm available chlorine), iodophor (25 ppm available iodine) and a quaternary ammonium compound (QAC) (930 ppm benzalkonium chloride), only the QAC gave a statistically significant decrease in the number of bacteria released when tested by the finger imprint technique. This experiment included a bar soap containing 1.0% trichlorocarbanilide, which gave results equivalent to an non-germicidal soap control. Of the hand wash agents, 4% chlorhexidine gluconate and iodophor (0.75% available iodine) resulted in significant decreases in numbers of bacteria released when tested by either sampling technique. Products containing Irgasan DP 300 (0.25% active ingredient at use concentration), tribromosalicyllanilide (0.5%) and para-chloro-meta-xylenol (0.325%) were no better than the non-germicidal soap control under conditions of this experiment. Identification of 3,591 aerobic isolates from finger imprint plates indicated that Staphylococcus epidemidis and Micrococcus spp. were the predominating organisms (85.3%) released from the hands.

Sheena, A. Z., and Stiles, M.E. 1983. Comparison of barrier creams and germicides for hand hygiene. J. Food Protect. 46(11): 943-946.
Germicidal hand wash agents and two barrier creams for use on hands were compared to determine their ability to reduce the number of microorganisms released from fingertips. Use of the barrier creams resulted in a significant decrease in the number of microorganisms released equivalent to the reduction achieved when effective germicidal agents were used, such as 4% chlorhexidine gluconate or iodophor containing 0.75% available iodine. The persistence of the effect of barrier creams on the skin was also studied and it was found that the initial increase in number of microorganisms released occurred after rinsing with water or washing with non-germicidal soap. Sequential rinsing of hands with tap water, after treatment with the barrier creams or with the effective germicidal agents gave similar results. Barrier creams can perform a useful adjunct role in hygienic hand disinfection. In this study, they were equivalent to effective hand germicides.

Sheena, A. Z., and Stiles, M.E. 1983. Efficacy of germicidal hand wash agents against transient bacteria inoculated onto hands. J. Food Protect. 48(8): 722-727.
The efficacy of germicidal hand wash agents against transient bacteria (Escherichia coli and Pseudomonas fluorescens) in ground beef rubbed onto hands was determined using a hand rinse sampling technique. The reduction in E. coli and P flouorescens counts on the selective growth media and the change in count of Baird-Parker medium were used to indicate action against transient and resident bacteria, respectively. Most of the agents tested, including 0.4% chlorhexidine gluconate, iodophor (0.75% available iodine), Irgasan DP 300, para-chloro-meta-xylenol (PCMX) as well as the non-germicidal soap gave marked reductions in E. coli and P fluorescens (>90% reduction), even after one 15 sec. wash. The hand dip treatments with iodophor (25 ppm available iodine), hypochlorite (50 ppm available chlorine) or QAC (930 ppm benzalkonium chloride) were generally less effective than hand wash treatments, especially against P flouorescens. Iodophor (25 ppm available iodine) and 4% chlorhexidine gluconate significantly reduced more E. coli on hands than other agents.

Sheena, A. Z., and Stiles, M.E. 1983. Immediate and residual (substantive) efficacy of germicidal hand wash agents. J. Food Protect. 46(7): 629-632.
A range of commercial hand wash agents was compared against 4% chlorhexidine gluconate (Habitant) for immediate and residual (substantive) germicidal effect in hygienic hand disinfection. Chlorhexidine gluconate (4%) liquid detergent gave an immediate and residual reduction in number of microorganisms released from finger tips after a short exposure (15 sec. ) hand wash. An iodophor product containing 0.75% available iodine gave comparable results for the immediate reduction in number of microorganisms released, but it did not give a residual effect. Other products, including those containing Irgansan DP 300, para-chloro-meta-xylenol (PCMX) or low concentration iodophor (0.005% available iodine) as the active ingredient, did not give an immediate or residual reduction in microorganisms released from finger tips.

Snelling, A. M., Kerr, K.G., and Heritage, J. 1991. The survival of Listeria monocytogenes on fingertips and factors affecting elimination of the organism by hand washing and disinfection. J. Food Protect. 54(5): 343-348.
The survival of Listeria monocytogenes applied to the fingertips was investigated using both an impression plate and an elution method. When suspended in saline, L. monocytogenes NCTC 9863 survived up to 60 min. on fingertips, but survival times were greatly extended when the inoculum was suspended in milk. Survival was time was apparently affected by skin lipids, the skin's normal flora, or the fat content of the milk. Different serotypes displayed similar results for the percentage persistence over a 2 hour period when suspended in milk except for an isolate of L. monocytogenes serotype 7 which had a greater percentage survival than other organisms tested. In contrast, Escherichia coli C600 failed to survive for one hour under the same conditions. Hand washing with either soap or a water-based chlorhexidine hand cleanse usually failed to decontaminate fingertips to which an inoculum of 104 /CFU per fingertip suspended in milk was applied, but a solution of chlorhexidine gluconate in methanol was found to be effective.

Sprunt, K., Redman, W. and Leidy, G. 1973. Antibacterial effectiveness of routine hand washing. Pediatrics 52(2): 264-271.
A broth rinse method was used to determine the indigenous bacteria of the hands of nursery personnel and to demonstrate its stability under test conditions. the efficacy of five wash agents in removing infant-acquired organisms from the hands was then explored. All agents were equally effective including water when followed by drying on a paper towel. The data show that the routine-type quick hand wash usually employed by busy aides and nurses is effective in removing patient-acquired organisms and provide additional emphasis on the importance of the hand wash procedures in prevention of spread of bacteria from patient to patient.

Standaert, S. M., Hutcheson, R.H., and Schaffner, W. 1994. Nosocomial transmission of salmonella gastroenteritis to laundry worker in a nursing home. Infect. Control Hosp. Epidemiol. 15(1): 22-26.
Background: Outbreaks of salmonella gastroenteritis in nursing homes are common. Person-to-person transmission to nursing home personnel occurs occasionally, but infection of laundry staff as a result of handling soiled linen rarely has been reported.
Objective: to examine the nosocomial transmission of infection to laundry staff during an outbreak of salmonellosis in a nursing home.
Setting: A 250-bed nursing home in a rural Tennessee county.
Methods: Residents and staff of the nursing home were interviewed and cultures of stool samples examined for enteric pathogens.
Results: Stool cultures from 32 residents and 8 employees were positive for Salmonella hadar. Infection among employees likely represented secondary transmission, as none of the employees ate food prepared in the kitchen and their onset of symptoms occurred seven to 10 days after that of the ill residents. Three laundry personnel who had no contact with residents were infected. Most of the ill residents (81%) were incontinent, which led to an increase in both the degree of fecal soiling and the amount of soiled linen received by the laundry during the outbreak. Laundry personnel regularly ate in the laundry room, did not wear protective clothing, and did not wear gloves consistently when handling items
Conclusions: This implication implicates linen soiled with feces as the source of nosocomial S. hadar infection in laundry worker and underscores the importance of using appropriate precautions when handling them.

Steere, A. C., and Mallison, G.F. 1975. Hand washing practices for the prevention of nosocomial infections. Annals Int. Med. 83(683-690).
Hand washing is generally considered the most important procedure in preventing nosocomial infections, because many types of these infections may be caused by organisms transmitted on the hands of personnel. Personnel should wash their hands before and after significant contact with any patient. The risk of personnel acquiring transient hand carriage of organisms is usually greatest after significant contact with any patient. The risk of personnel acquiring transient hand carriage of organisms is usually greatest after contact with excretions, secretions, or blood; patients at greatest risk are those undergoing surgery, those with catheters and newborn infants. Although hand washing with an antiseptic agent between patient contact is theoretically desirable, hand washing with soap, water, and mechanical friction are sufficient to remove most transiently acquired organisms. Antiseptic agents may produce excessively dry skin if used frequently, and any regimen of hand washing that leads to dermatitis negated the purpose of hand washing. We favor antiseptic for hand washing before surgery and other high-risk invasive procedures and in the care of newborn infants, but prefer soap and water for other hand washing.

Stiles, M. E., and Sheena, A.Z. 1978. Efficacy of germicidal hand wash agents in use in a meat processing plant. J. Food Protect. 50(4): 289-295.
The in-use efficacy of a selected range of germicidal hand wash agents was tested in a meat processing plant. The hand washes included non-germicidal soaps and germicidal agents containing chlorhexidine, iodophor and Irgasan DP 300 as active ingredients. A laboratory study was done under controlled conditions with standardized procedures for hand washing; in the meat plant, "normal" (unstandardized) hand wash procedures were followed. Levels of contamination of hands varied markedly between work units. Only in the meat cutting area could a significant difference be attributed to hand wash agents against transient bacteria on workers' hands. The hand wash agent with 4% chlorhexidine gluconate, the iodophor with 0.75% available iodine and the gel containing 0.3% Irgasan DP 300 were the only products that gave a significantly better reduction of transient bacteria than non-germicidal soap. Transient bacteria were detected on hands after washing, indicating that under the in-use conditions in the meat processing plant, hand wash techniques did not remove all of these bacteria from hands. The plant workers generally indicated a dislike for the iodophor products as germicides.

Stiles, M. E., and Sheena, A.Z. 1985. Efficacy of low-concentration iodophose for germicidal hand washing. J. Hyg. (Camb.) 94: 269-277.
The efficacy of iodophor germicides containing different concentrations of available iodine against transient (inoculated) bacteria and the natural hand microflora was compared with chlorhexidine gluconate (2 and 4%) liquid detergent (Habitant), non-germicidal soap and a tap water rinse. The tap water rinse was ineffective compared with all other treatments. Only 4% chlorhexidine gluconate liquid detergent and iodophor containing 0.75% available iodine were significantly better than the non-germicidal soap for reduction of transient bacteria, Escherichia coli and Pseudomonas fluorescens, that had been inoculated onto hands. These agents also cause a significant reduction in the number of natural microorganisms released from hands after a standard 15 second hand wash. The low-concentration iodophor products and the product containing 2% chlorhexidine gluconate failed to give results significantly better than the non-germicidal control soap. Baird-Parker medium and standard aerobic plate counts were highly correlated (r=0.82), so that for studies of Gram-negative bacteria inoculated onto hands as a transient microflora, counts on Baird-Parker medium give a reasonable indication of natural (residual hand microflora).

Taylor, L. J. 1978. An evaluation of hand washing techniques. Nursing Times (Jan. 12): 54-55.
Review article. Hand disinfection by ward staff with 70% alcohol is generally effective (Ayliffe, et al., 1975. In some instances a large number of organism survived this treatment, suggesting that the method of application was inadequate. This was confirmed in laboratory studies.
A preliminary test was carried out using the same technique but the addition of a dye to 70% alcohol. This revealed that one of the nurse volunteers failed to cover the tip of her thumb with the solution (Babb et al., 1977). The use of a dye for investigating the efficiency of applying disinfectants to the hands has been described previously (Reber, 1976), but this technique has not been used in this country to any extent.
Indications are that the dye method is a good way of studying the effectiveness of hand washing by all grades of a nursing staff.

Troller, J. A. 1983. Personal hygiene (Chapter 8). Sanitation in Food Processing. New York, N.Y., Academic Press: 166-179.
Excellent chapter on personal hygiene. Very good section on hand washing, supplies and location of hand washing facilities.
Extensive precautions such as those used to attempt to sterilize skin are not necessary for the food industry, however careful and frequent hand washing will do much to reduce hand contamination. ----Sufficient time and vigorous scrubbing are the two principle prerequisites. At least 30 sec. should be devoted to active scrubbing. Many food plants also make cleaning under fingernails a requirement.
Unless there are specific reasons for dipping hands in a solution of chlorine, iodine, or quats, it is not advised because of possible allergic conditions and chapping of hands.
Supports use of bar soaps, particularly those with bactericidal formulations instead of liquid soaps. Does not recommend use of skin lubricants or barrier creams because they can be carried into food product area. Recommends us of electric dryers or paper towels for drying hands (no use of the communal cloth towel).
Gloves Advantage of wearing gloves: A sterile contact surface (initially) is assured, and potentially pathogenic bacteria on the skin are not permitted to enter foods as long as the glove is not torn or breached in some way. Alternatively, skin under gloves is occluded and heavily contaminated perspiration builds up rapidly between the internal surface of the glove and the skin. Accidental rips or tears in the glove then allows massive contamination of food. Gloves seem to promote a kind of complacency that is not conducive to good hygienic habits. Gloves are expensive and occasionally they find their way into food products due to carelessness. Does not recommend glove use in food processing or in the serving environment, and that effective hand washing be strictly adhered to. At the same time there are specific circumstances and conditions that justify the use of gloves.

Updegraff, D. M. 1964. A cultural method of quantitatively studying the microorganisms in the skin. J. Invest. Dermatol. 43: 129-137.
The purpose of this study was to develop a method for enumerating the number of bacteria in human skin with regard to depth in the stratum corneum as well as area. None of the many methods employed to date can accomplish this purpose. Such a method should find use in the study of the flora of both normal and pathological skin, and in the comparative evaluation of skin.
A plastic-tape stripping method was developed for the quantitative enumeration and cultivation of the microorganisms present in human skin. It was found that many tapes are highly bacteriostatic. A suitable transparent tape was found which has little or no bacteriostatic activity, and a culture medium was developed which has little or no bacteriostatic activity, and a culture medium was developed which neutralizes any residual bacteriostatic action. Using this tape, Scotch brand 850 (3-M, St. Paul, ::MN.) 14 successive layers of the stratum corneum, one cell thick were removed and examined culturally for microorganisms. The total number of colonies obtained was compared with counts obtained by other methods. The counts were much lower, indicating that the tape stripping method enumerates colonies of bacteria, while the other published methods enumerate the total number of individual cells.

van der Hoeven, E., Hinton, N.A. 1968. An assessment of the prolonged effect of antiseptic scrubs on the bacterial flora of the hands. Can. Med. Assoc. J. 99: 402-407.
The degree to which the bacterial flora of the hands is altered by serial basin scrum technique to estimate skin flora, the effects of povidone-iodine, hexachlorophene, hexachlorophene-chloroxylenol were compared. A 10 minute daily scrub with any other agents tested substantially reduced the bacterial flora of the hands for prolonged periods of time. Hexachlorophene-chloroxylenol produced the most prolonged reduction. It is recommended that all hospital personnel having contact with patients should be required to perform a surgical-type hand scrub with a hexachlorophene preparation once a day and to wash the hands with hexachlorophene soap between patient contacts.

Vesley, D., Lillquist, D.R., and Le, C.T. 1985. Evaluation of non-germicidal hand washing protocols for removal of transient microbial flora. Appl Environ. Microbiol. 49(5): 1067-1071.
A method is described which compared the efficacy of different non-germicidal hand washing protocols for removal of transient microbial flora without the necessity of establishing or relying on a previously determined baseline for an individual subject. The wash effluent was collected, and colony counts for the effluent reflect the number removed by the wash protocol. A second standard wash in a hand washing machine was performed and the test is the percent removed in the test wash based on the sum of total CFU recovered from the two washes. The method was used to compare an 8 second cycle for a newly developed hand washing machine with a conventional 15 second Ivory soap wash. When machine pressure was adequate (42 lb/in2), there was no statistically significant difference in the percent removal of transient flora by the two methods (48.8% from the machine versus 45.1% from the Ivory soap wash). At 32 lb/in2, the Ivory soap wash recovered 60.3%, where as the machine recovered 45.1%.

Voss, J. G. 1975. Effects of an antibacterial soap on the ecology of aerobic bacterial flora of human skin. Appl. Microbiol. 30(4): 551-556.
The effects of ad lib used of an antibacterial soap containing 1.0% trichlorobarnilide and 0.5% trifluoromethyldichlorocarbanilide on the bacterial flora of six skin sites of 132 subjects were measured by comparison with the flora of 93 control subjects who avoided the use of topical anti bacterials. Each subject was examined once. The test soap produced significant reductions on the geometric mean counts of the total aerobic flora on the back, chest, forearm, calf, and foot; counts were also reduced in the axilla, but not to a significant extent. The overall reduction by the test soap on all sites was 62% (P<0.001). Neither age nor sex influenced the effect of the soap on the flora. The antibacterial soap also reduced the prevalence of Staphylococcus aureus on the skin, mostly by virtually eliminating it from areas other than the axilla; Klebsiella pneumoniae and Enterobacter aerogenes were the species most commonly found.

Weatheral, J. A. C., and Winner, H.I. 1963. The intermittent use of hexachlorophene soap -- a controlled trial. J. Hyg. (Camb.) 61: 443-449.
In this investigation, nurses used hexachlorophene soap only while at work. Any washing with other soaps or detergents while not at work probably removed any hexachlorophene which had accumulated during work, so that no effective antibacterial concentration of hexachlorophene was ever reached.
This work shows that hexachlorophene soap has no effect in reducing the number of superficial bacteria on the hands. The number of bacteria on the hands of nurses using 2% hexachlorophene soap intermittently was compared with the numbers of bacteria on the hands of nurses using ordinary soap. No significant differences were observed.

Wedderburn, D. L. 1960. Antiseptic cream for use on the hands in food establishments. Brit. J. Indust. Med. 17: 125-129.
An antiseptic cream containing benzalkonium chloride as germicide has been developed for use on the hands. It inhibits growth on agar of staphylococci, E. Coli, and S. typhimurium. It persists on the fingers, kills organisms applied to the skin and reduces the normal bacterial population of skin. It is convenient to apply and has been found acceptable by workers in several food factories.

Williams, R. E. O. 1963. Healthy carriage of Staphylococcus aureus; its prevalence and importance. Bacteriol. Rev. 27: 56-71.
Discussion of carriage of Staphylococcus aureus on the human body. Normally present in the nose.
 

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