Tuesday, March 09, 2010

The Kabuki Of Hand Washing

It started with my sister posting a link on her Facebook page to this Slate article by Darshak Sanhavi. Amy's a doctor so when it has to do with health, I pay attention. Then over the course of the past few days it seems like everywhere I turn on the internet, I run into this article. By now it's been forwarded to me by no fewer than 5 people.

I've been wanting to avoid it, and avoid writing about it in particular, because to do so requires a confession that may be among the worst one can make in this day and age. But the universe clearly wants me to share this, so I'll start with the admission of the ultimate preschool teacher sin: I don't think frequent hand washing does squat to protect children from anything.

Now before you jump down my throat, the children and adults of Woodland Park have a number of hand washing hurdles to overcome every day, including upon arrival and anytime we're around food, toilets, or snotty hands. We spend time at the beginning of the year making sure the children know how to properly wash up and we're forever sending or escorting (depending on their age) kids to the bathroom to use soap and running water. The adults are expected to wash their hands too, although we accept the hand sanitizer version, and have several bottles of the stuff around the room for their use. We do our best to follow hand washing protocol, but that has never stopped me from feeling like it was a kind of kabuki performance designed to pay homage to the "science" of disease transmission.

If you've spent any time at all around young children, you know that any hand washing designed to prevent the spread of illness is only valid until that child next touches her or his nose or mouth, which according to the FDA is on average once every three minutes, "and both adults and children come in contact with as many as 30 different objects every minute." I'll bet that number is higher in a preschool classroom like ours with a play-based, hands-on curriculum.

In fairness, the Slate article, entitled "How To Sell Germ Warfare," is focused on the use of alcohol-based hand sanitizers and other anti-bacterial products and how marketers are hyping germ fears in the interest of profits, but much of the data it presents can be extrapolated to hand washing in general. While hand washing and sanitizers do kill those germs in laboratories, the author's point is that this doesn't appear to be happening in the real world. He sites studies from doctors, Ivy League schools, the FDA, the CDC, and the Public Health Agency of Canada that have repeatedly shown that vigorous hand washing has no measurable impact on the spread of respiratory infections beyond the confines of a controlled experiment. (And, in fact, there is some research out there that indicates that the use of hand sanitizers actually increases the chance of a person getting sick because it kills "good" germs along with the "bad," and gives people a false sense of "immunity.")

As I've written before, I consider part of the "mission" of preschool education to be preparing our immune systems, as well as our minds, for the rigors of kindergarten, and it appears that all this focus on hand washing really isn't getting in the way of that. Yay?

We'll keep washing our hands, of course, because that's the official drill expected of us (and, frankly, because I've seen some of the things preschoolers do with their hands, and there is the simple "yuck factor" to consider). But honestly, come on, look at what we do with our hands in the world. We know it's mostly just for show.

Bookmark and Share


Unknown said...

What a great post. I have felt this way for such a long time.

Germs are abundant.

Cathy Geier said...

While I will agree that hand sanitizer likely may kill soem
'good germs', I disagree with much els eof your article.

Tyhe CDC an dother health organizations can not design a study which would provide conclusive evidence about handwashing vs. non-handwashing in citie sand the relationship to more or les sillness without segmenting off cities or villages etc.. just because these groups have not provided studies with evidence ther eis muc hantidotal evidence about handwashign reucing instance sof illness as well as MANY incidences of lack ofhandwashing or open sores touching food and people getting ill.. in cases like restaurant workers causing hepatitis, flu and likely more. The incidences of hepatitis being spread from one worker to people scattered in a large city is a huge reminder how powerful soem germs can be and how randomly they may spread.

Juliet Robertson said...

Hi Tom

You have raised a hot topic of debate! Here in Scotland there is a lot of negotiations currently happening around hand washing in pre-school settings - particularly nomadic outdoor kindergartens that by tradition do not necessarily have running water "on tap" (forgive the pun).

The matter is now in the hands of the director of our Care Commission. I can't comment as yet on the matter, other than to state that in my professional opinion, certainly in the UK we have some of the most strict and meticulous interpretation of health and safety laws that I've met anywhere - our pre-school professionals are very zealous about hand hygiene.

What is interesting is that the FDA link does not advocate "best practice" or "solutions" to infection control. There has been medical research on this matter - which I could search out - I've got it stuck in an email somewhere - that suggests unless a person adopts a strict hand washing procedure that last more than 15s, this is not as effective as hand wipes or foam sprays etc.

However, as you rightly point out, the dilemma is over the acceptable risk - it cannot be minimised - so what's the compromise?

As a parent I want my child to be exposed to germs. I do not want a serious infection if possible. The biggest risk here for pre-schoolers are farm visits - but even these are safe enough if sensible precautions are taken. However the faecal bacteria such as salmonella and E Coli that the FDA reports on are actually low risk in all other environments compared to farms. Thus to adopt the level of rigour required on a farm visit is unreasonable. This is worth remembering.

So...? The trick is to have clear policies and procedures that become embedded in everyday routines at your pre-school. These policies and procdures must be followed by all staff and shared with parents. Combined with effective monitoring of absences and illness, it all adds up to a very high standard of care which I am absolutely sure you

Rant over!

Launa Hall said...

I do think there is room to better teach children HOW to wash their hands, so that it doesn't feel quite so much like a kabuki production (love that metaphor). Just today I watched a Kindergartener, sent to the sink after picking his nose, do the most ridiculously ineffective job of "washing" his hands. He clearly THOUGHT of it as a useless exercise, and therefore it was.

We grown-ups could do a lot to help. So often I see faucets that are really hard for little hands to manipulate, soap dispensers that are out of soap, and a hot water system that doesn't spout hot water for at least a couple of minutes--or when the child is long gone.

Anonymous said...

Sure, it is important to wash your hands, but kids also need to eat dirt. If I ran my son to the sink every time I thought he needed to wash his hands, I should just keep a hazmat suit on him.

My wife is a doctor (pharmacy) and she isn't crazy about having the anti-bacterial soap everywhere in the house because she has seen some nasty, drug resistant stuff that has mutated because of our obsession with killing germs. So near many sinks in our house we have just normal old hand soap.

Ms Debbie said...

In Arkansas we are handwashing nazi's ! Our state funded pre-k programs use ECCRS for evaluations and it is washing every time you turn around. When you come in from outisde, before and after eatting, before and after playdoh, before and after sand and water play.. the list goes on and on. I once talked to a lady in Walmart that works at the public pre-k and she said.. " all I see those poor kids do all day is wash their hands. " To an outside it might appear that way. We have had to work all year to make sure that with the handwashing there isnt a lot of waiting -- which is also not good for children. I kinda lean toward Teacher Tom - I understand that hows and whys - but arent we going a little over board . No joke.. I had five little girls hands break out from too much washing with antibaterial soap in combination with the dryness from winter. How do you explain that one to a parent? Can't win for losing

Anonymous said...

As I type this with hands that are red, cracked, and bleeding in a couple places from constantly having them in water in this dry winter air...I am agreeing with you. And Ms. Debbie too...I was shocked when I found out just how often the kids are expected to wash for my first FCCERs assessment.

Floor Pie said...

I agree with you in spirit, Tom. I object less to actual handwashing than I do to the larger culture of fear / germ-o-phobia that touts it.

I became a bit more of a hand-washing "believer" after successfully keeping the kids from catching their dad's swine flu last fall. Of course, he kept himself quarrantined in the bedroom the whole time, so maybe hand-washing had little to do about it.

Just don't get me started on head lice...

kristin said...

if this was facebook, i'd click "Like."

Amy said...

Hi. I'm the aforementioned sister, Amy. I've been meaning to respond to Tom's post for a couple of days, but I'm glad I waited because I think this is such an interesting discussion.

As a preface, Tom and I agree on many things, and most of the important things in life; but it seems we do disagree on hand washing. I posted the Slate article because I generally dislike hand sanitizers, aside from using them at the port-a-potty (or other times there REALLY isn't water available). The reason that I dislike hand sanitizers is largely visceral - I've always felt that after using them I just have a bunch of nice-smelling dead germs on my hands, which grosses me out. I also believe that the best germ protection we have is our skin, and hand sanitizers jeopardize that by drying it out, leaving cracks and chapped skin which is then prone to infection. Alcohol and antimicrobial soaps are sort of the nuclear option, to me, while most things can be washed off with less extreme measures (washing with soap and water).

I think that proper hand washing is important. How else would I feel good about talking to and examining sick people all day and then coming home to my family? As it's been alluded to already, studies have shown that proper hand washing is a matter of time under the water and scrubbing. The recommendations are 15 seconds of friction under running water, and that's with plain old soap. When done properly hand washing does decrease the occurrence of disease transmission. I believe it's our job to teach our children how to wash their hands properly (whether they actually do it is eventually up to them).

The Slate article talks about the fact that upper respiratory infections (URIs) are the same in populations that use hand sanitizers versus those that don't, but URIs are mostly spread by saliva and other body fluids that get sneezed and coughed out (versus by touching each other with our hands). The Slate article only focuses on upper respiratory infections, while it's been proven that both hand washing and hand sanitizers decrease the transmission rates of gastrointestinal infections (stuff transmitted hand-to-mouth). The article also discusses a study that handed out antimicrobial supplies to folks and reports that it didn't change infection rates, but those studies didn't necessarily teach those folks how to properly use the supplies they were given. The bottom line for me is that there is nothing that hand sanitizers can do that proper hand washing can't (aside from the portability).

The preschool classroom is an interesting case in that it's a place to start teaching lifelong habits (learning, social, hygiene etc). I like the idea that at preschool we wash our hands when we arrive, after using the bathroom, before eating and after coming in from playing outside. I realize that most of these kids aren't washing for long enough, and then are picking their noses on the way to the snack table, but I think that it teaches them habits that eventually will help decrease the transmission of disease. All of that being said, transmission of disease (especially in the preschool setting) happens during wrestling, playing, hugging, coughing, sneezing, slobbering etc. versus contamination from hands of others.

I guess the bottom line, for me, is that I think we do well to teach our children when it's a good idea to wash their hands, but then let them wrestle around and bolster their immune systems. Whether that constitutes Kabuki I'm not sure.

Anonymous said...

Clipping of the fingernails too, can we talk about that? ;)

Unknown said...

TT: I'm with you on this one! I think part of the problem is that regulators of child care/welfare know that they are better off (personally, professionally, organizationally) as long as they are saying "take no risks, you will be delicensed if there are violations of the regulations."

Back in the days when my own kids were in daycare/preschool, I personally would have been perfectly happy with "wash before you fix food or eat" rules (oh yeah, and after picking nose!) -- and I'm sure the care providers themselves have a self interest in the washing up after messy activities (such as eating etc.); but geez, every time you touch a pet? (more applicable in home day care settings I'm sure); every time you come in from outside? I'll bet the outside environment is cleaner than the inside one! I know there are pets that can be more risky for things like salmonella but sheesh.

I have come to accept much of modern life (and regulation) as kabuki.