How important is hand-washing outside of a hospital environment?

I recently spent a weekend visiting a friend out of state and quickly came to realize that he rarely washed his hands. Before eating? No. After the gym? No. Even after going to the bathroom…and not just urination. No washing! I was disgusted and could not convince him of the same. How could an educated adult be so naïve to the needs of hand-hygiene? But, it’s not only him! On a weekly basis, I witness other adults in the workplace or public bathrooms, leaving without washing their hands properly, or at all. But should I speak out to strangers? If a friend ignores my requests for hand-hygiene, how can I expect a stranger to heed my complaints and warnings? Does the data support the importance of hand-washing in our everyday environment?

Fecal matter is almost everywhere, as it can easily be spread from hands to surfaces. Investigating the fecal bacteria of the hands of commuters in the UK found that 28% of the people sampled had fecal contaminated hands. A study of the holds in climbing gyms indicated 100% contaminated with fecal matter. A 2009 study performed at an England gas station found that only 65% of women and 31% of men washed their hands with soap after using the restroom. This finding is common. If fecal matter is everywhere, is it making us sick? If hand-washing is one of the best ways to prevent the spread of infectious diseases, how do we go about motivating those outside of a healthcare setting, who ignore the benefits of hand-washing?

But rather, how necessary is it? Yes, it is gross that fecal matter is all over and contaminating many hands outside of the hospital. But, outside of hospitals where infection rates with nasty pathogens like Clostridium difficile, a common diarrhea causing bacterium which infects an average of 13/1000 patients in U.S. hospitals, are significantly decreased (75% of cases are hospital-acquired), do we need to worry so much? Many people carry C. difficile normally, but don’t get sick from it, unless immunocompromised or have had their normal gut flora knocked-out by antibiotic use. The majority of fecal material should not cause disease. So is it really a matter of reducing infection rates outside of hospitals? With the hygiene hypothesis (also known as the “old friends” hypothesis), maybe people, especially children, are actually benefitting from being exposed to these sources of bacteria.

Although it may not be detrimental to forget to wash your hands as it could be for a doctor to do the same, hand-washing is still presently the first step in preventing the spread potentially infectious bacteria. Hand-washing with soap and water can drastically reduce the number of bacteria on the hands. On hands not visibly soiled, use of an alcohol-based sanitizer is even more effective at reducing microbe numbers. Hospital-wide policy for the use of alcohol-based sanitizers rather than soap, have shown a reduction in the number of C. difficile infections, although this does not eliminate the spores which can still be spread to other surfaces. The Clean Your Hands Campaign in the UK, which involved interventions such as bedside alcohol sanitizer, promotional materials about hand-hygiene, institutional engagement, and hand washing audits, tripled the use of alcohol rub and soap, and drastically reduced the C. difficile infection rate. C. difficile can also be transmitted within communities, outside the hospital. A number of studies have shown reduced rates of other hospital-acquired infections, following programs implemented to improve hand-hygiene adherence (see CDC).

There are a number of factors that go into promoting effective hand-washing behavior.These involve environmental factors, such as access to cleaning products and social norms, as well as personal factors, like individual motivation and habits of cleanliness. So when I try to motivate my friend to wash his hands, I tend to hit on multiple factors. I show my own disgust and give statistics on the likely number of fecal bacteria contaminating his hands. I make hand-washing the norm. But what do I do when nothing seems to convince him? Am I even right in trying so hard to do so, when it may not be so necessary outside of hospitals? How important is it for any one person to implement these strategies into daily life? Should I put up reminders in my office bathroom? How about a sign in my friend’s bathroom? Should I give folks in public restrooms the stink eye as they ignore the sinks?

Ultimately, the decision to wash your hands is personal. Consider your everyday environment and potential risks or even benefits it poses. Consider the facts. Consider your health, but also the health of those around you.



Bräuer, S.L., Vuono, D., Carmichael, M.J. et al. The microbiome of the built environment and mental health. Curr Microbiol (2014) 69: 681.

Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR (2002) 51.

Judah G., Aunger R., Schmidt W.P., Michie S., Granger S., Curtis V. Experimental pretesting of hand-washing interventions in a natural setting. Am J Public Health (2009) 99: S405–11.

Judah, G., Donachie, P., Cobb, E., Schmidt, W., Holland, M., & Curtis, V. Dirty hands: Bacteria of faecal origin on commuters’ hands. Epidemiology and Infection (2010) 138(3), 409-414.

Stone S., Paul, Fuller C., Savage, J., Cookson B., Hayward A., Cooper B. et al. Evaluation of the national Clean your hands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study BMJ (2012) 344 :e3005.

WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. Geneva: World Health Organization (2009) 20.

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