Handwashing: Are You Doing it Right? WHO Disagrees

As it turns out, there’s a wrong way to wash your hands.

Recently, a study, published in Infection Control and Hospital Epidemiology, examined the Centers for Disease Control and Prevention's (CDC) three-step handwashing method in comparison to the World Health Organization's (WHO) six-step method. The randomized control trial found the six-step method to be more effective in reducing the bacterial count on an individual's hands.

Handwashing Differences

Although the CDC and WHO each have a different suggested method for ‘proper’ handwashing, they both agree that handwashing is the most effective way to ward off infections both in and outside of hospital settings. The CDC states that regular handwashing is a “do-it-yourself vaccine” that can hinder the spread of gastrointestinal and respiratory infections, as well as food-borne infections. Additionally, WHO states that “hands are the main pathways of germ transmission during health care.”

Dorothy McCoy, PharmD, BCPS-AQ ID, Clinical Associate Professor at the Ernest Mario School of Pharmacy at Rutgers University and Clinical Pharmacist, Infectious Diseases Hackensack University Medical Center, highlights the importance of handwashing when she explains why the norovirus spreads so efficiently.

When to Wash Your Hands

The CDC recommends that individuals should wash their hands before and after:

• Preparing food
• Eating
• Caring for a sick individual
• Treating a wound
• Changing diapers or handling feces of any kind (including animals’)
• Coughing, sneezing, blowing your nose
• Touching garbage

In addition, WHO recommends that healthcare providers should wash their hands before and after:

• Touching a patient
• Touching patient surroundings
• Fluid exposure
• Performing cleaning/aseptic procedures

Not only is it important for healthcare providers to wash their hands after touching a patient (to reduce the risk of contracting a disease or infection), but it’s important to do so before touching a patient to reduce the risk of exposing the patient to additional infection.

The Study

The recent trial studied the effectiveness of the CDC's three-step method vs WHO's six-step method using an alcohol-based handrub (ABHR) to “compare the microbiologic effectiveness of the techniques on hand coverage and reduction of bacterial contamination on the hands of healthcare workers.” The authors studied a group of 42 doctors and 78 nurses who worked in different medical and surgical specialties, including an intensive care unit. The study was conducted on weekdays from February 1, 2014 to March 31, 2014.

The authors placed the participants into two groups: one group was instructed to follow the six-step method; the other group was instructed to follow the three-step method. At the end of the study, the authors found that 65% of the participants in the six-step group followed the full six-step handwashing method, while 100% of the participants in the three-step group followed the three-step method.

The authors measured the median log₁₀ bacterial count before and after hand washing for those who fully complied with the respective techniques. The initial bacterial count was 3.28 CFU/mL (95% CI, 3.11—3.38 CFU/mL). After the three-step method, a drop in bacterial count ranged from 3.08 CFU/mL (95% CI, 2.97–3.27 CFU/mL) to 2.88 CFU/mL (2.58–3.15 CFU/mL). However, the six-step method showed a significant drop from the initial (pre-hygiene) bacterial count to 2.58 CFU/mL (2.08–2.93 CFU/mL).

The study found that although WHO's six-step handwashing method did not cover more surface-area, and took 42.5 seconds, 7.5 seconds longer to perform than the three-step method, it was superior to the three-step method in reducing bacterial count on an individual's hands.

A full pictorial representation of WHO's six-step method is available here. According to WHO, “washing your hands properly takes about as long as singing "Happy Birthday" twice.”