: Handwashing rose, then fell, during COVID-19 — are U.S. hygiene standards slipping?


Healthcare workers washed their hands more diligently in the pandemic’s early months but quickly reverted back to their normal hand-hygiene behavior, says a new study — and the findings have implications for patients and laypeople too.

Hand-hygiene compliance among staff at the University of Chicago Medical Center, as measured by the hospital’s automated system for monitoring hand sanitizer and soap use, reached as high as 100% on March 28, 2020, according to a recent research letter in the journal JAMA Internal Medicine — before declining to a daily low of 51.5% by Aug. 15.

That August saw a monthly low of 56%. Prior to COVID-19, monthly compliance was close to September 2019’s baseline of 54.5%, the study said.

“We found that hand hygiene went up naturally and astronomically above our greatest aspirations during the beginning of the pandemic, but also naturally fell back to about our normal level of hand hygiene within just a couple months,” said study co-author Emily Landon, the executive medical director of infection prevention and control at University of Chicago Medicine.

In other words, the good news is “we figured out how to get people to wash their hands: a pandemic,” Landon told MarketWatch. “The bad news is that that didn’t last — we’re still in the pandemic, and people are not washing their hands as much anymore. They’ve gone back to their baseline.”

Along with compliance, the researchers measured what they called “hand hygiene opportunities,” or entries and exits to rooms. They also looked at the number of COVID-positive inpatient admissions by month.

As they washed their hands more frequently at the beginning of the pandemic, workers also reduced the number of times they entered and exited patient rooms, “batching” tasks like bringing a patient pain medicine, a pillow or a glass of water to avoid unnecessary trips, Landon said. 

Minimizing these trips is important because a patient’s bacteria fills the entire room, she said. When staff touch items in the room, they can bring that bacteria out into the workspace and into other patients’ rooms.

But as workers stopped washing their hands as frequently over time, they also increased their frequency of making quick trips in and out of rooms, Landon added.

In the early stage of the pandemic, hospital staff “changed their behavior to really do infection control the right way,” Landon said. But what’s concerning “is then they stopped doing that.”

“It means that people didn’t really internalize that habit,” she suggested. “When they didn’t see the pandemic as as big of an existential threat, they started cutting corners again.”

These results suggest that “high compliance is possible, even with automated monitoring, yet difficult to sustain,” the study’s authors wrote.

Previous studies have also shown that healthcare providers, who are in theory well-aware of the importance of handwashing, don’t always wash their hands.

It’s important to note that the healthcare system is still struggling with “how to get things right every time, 100 times a day,” Landon said.

“We’re really good at getting your complex, advanced surgery right; we’re really good at making sure that your medicines are given to you properly,” she said. “Humans seem hard wired to just stick with the complex tasks — we just don’t do the easy stuff very well.”

‘You’ve developed that habit; don’t let it go’

As for non-healthcare folks, Landon urged them to keep up the hand-hygiene habits they developed in response to the pandemic. In the early days of COVID-19, Americans learned how to wash their hands frequently with soap and water for at least 20 seconds, about twice the length of the “Happy Birthday” song, and to use hand sanitizer containing at least 60% alcohol in a pinch.

A Centers for Disease Control and Prevention study published last year found that the odds of remembering to wash hands after coughing, sneezing or nose-blowing; before eating at a restaurant; and before eating at home were about two times higher in June 2020 than in pre-pandemic October 2019.

“The habits that you have of bringing your hand sanitizer with you, of washing your hands when you get inside, of being careful of washing before you eat — you’ve developed that habit; don’t let it go,” Landon said. “It’s one of the most effective techniques to prevent yourself from getting sick.”

Research shows humans don’t exactly have a spotless record on handwashing. One observational 2013 study published in the Journal of Environmental Health, for example, found that just 5% of people properly washed their hands for 15 seconds or longer after using the restroom. 

COVID-19 is believed to spread most commonly through close person-to-person contact and can sometimes spread by airborne transmission, the CDC says. As such, masks and physical distancing have become a cornerstone of COVID-19 mitigation. 

While the disease is less commonly transmitted by contact with contaminated surfaces, “it is possible that a person could get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or eyes,” the agency adds. The CDC urges people to wash their hands often and avoid touching their mouth, nose and eyes with unwashed hands.

“If hand hygiene was the main way to prevent the spread of COVID, I think we would’ve been a lot more focused on it and we probably could have sustained better hand-hygiene rates,” Landon said. The hospital in her study did not have an additional hand-hygiene campaign related to COVID-19, she added.

‘Everyone should demand transparency about hand hygiene’

Of course, handwashing has implications beyond the current public-health crisis. Improved hand hygiene is associated with a 31% reduction in the rate of gastrointestinal illness and a 21% reduction in the rate of respiratory illness, according to one 2008 meta-analysis in the American Journal of Public Health

Other studies have shown that “intensive handwashing promotion can reduce diarrheal and respiratory disease incidence,” and that hand-hygiene instruction in schools can help reduce illness-related absences during flu season.

Landon, for her part, says that “if people knew what hand hygiene really was in hospitals,” they would demand transparency on the matter. 

The healthcare watchdog organization Leapfrog Group, on whose hand-hygiene expert panel Landon serves, added a new hand-hygiene standard to its surveys for hospitals and ambulatory surgery centers in 2019.

“Everybody should demand transparency about hand hygiene, because then it will get better,” she said. “It’s only going to get better if people care about it.”

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