Hand Hygiene in PreK-12 Schools and Child Care Settings

Keeping hands clean is one of the simplest and most effective methods for preventing the transmission of infectious agents that cause common colds, diarrhea, influenza and food-borne illnesses.^1,2 As major settings for the transmission of these infections, child care and K-12 schools in the United States need to do everything possible to promote and enable correct and consistent hand hygiene among students and staff members.

The Centers for Disease Control and Prevention (CDC) estimates that 52.2 million cases of the common cold affect Americans under the age of 17 each year, resulting in nearly 22 million school days lost annually.³ On average, each year 5-20 percent of the U.S. population acquires influenza; young children are among the populations at high risk for serious flu complications.⁴ Diarrhea, a common symptom of infectious food-borne diseases, is second only to colds as a cause of lost working time and is responsible for approximately 25 days being lost from work or school for every 100 members of the population each year.⁵

Pandemic influenza preparation guidance from the World Health Organization (WHO) stresses that hand washing and respiratory hygiene/cough etiquette should be routine for all and strongly encouraged in public health messages, and that such practices should be facilitated by making hand-hygiene facilities available in schools, workplaces, and other settings where amplification of transmission would be expected.⁶ The U.S. Department of Health and Human Services (HHS) and CDC recommend that, in advance of a pandemic of influenza, schools implement effective infection prevention policies and procedures that help limit the spread of influenza.⁷

CDC recommends that that every person routinely practice cleaning hands with soap and water for 15-20 seconds before eating and preparing food; after using the bathroom, sneezing or coughing, handling animals and animal waste or raw meat, poultry, fish, or eggs; after caring for or touching a cut or sore; whenever hands are visibly soiled; and more frequently when someone is sick (health care and food services settings require more stringent measures).⁸ When soap and water are not available and hands are not visibly soiled, alcohol-based disposable hand wipes or gel sanitizers may be used in place of hand washing on most occasions.¹

Infections are frequently transmitted from person-to-person in preK-12 school settings due to the close environment, sharing of supplies and equipment, and inadequate hand hygiene.⁹

Several studies have demonstrated that appropriate hand hygiene can significantly reduce illness and absenteeism from school due to gastro-intestinal or respiratory illness.^10-15 One intervention with scheduled opportunities for cleaning hands throughout the school day produced as much as a 50 percent reduction in absences. ¹⁶

Hand washing behaviors are often established during early childhood but may not sufficiently persist into adolescence and adulthood; observational research among older school children reveals an overall compliance rate of approximately 50-60 percent.⁹, ^17-18 In one study, only 58 percent of female and 48 percent of male middle and high school students washed their hands after using the bathroom. Of these, only 33 percent of the females and 8 percent of the males used soap.⁹ Compliance with hand hygiene practices by adults working in health care facilities is estimated to only be around 50 percent.¹⁹ Many students fail to wash their hands because hand washing facilities or supplies are not available or are inconveniently located. Graffiti, vandalism, lack of upkeep, and general misuse are common restroom maintenance problems.²⁰ In a national survey of parents of middle and high school students, ¹⁴ percent said their children report that their school restrooms lack basic supplies like toilet paper, hand soap, or hand towels.²¹ Only five states have established statewide standards for public school restrooms.²²

Motivating individuals (including adults) to adopt hand washing behaviors involves a combination of education, motivation and system change.¹⁹ Strategies to promote system changes include written guidelines, accessible hand hygiene agents, hand hygiene facilities, administrative leadership, sanctions, reward and support. ¹⁹ The National Association of State Boards of Education suggests that "at a minimum, schools should have a hand washing policy for students and teachers. More broadly, policy-makers may want to consider expanding the number of hand washing facilities in schools to promote this activity among students."²³ The multiple strategies that have been used to improve hand hygiene behaviors including education, routine observation and feedback, convenient facilities, available alcohol-based hand rubs, reminders, institutional sanctions/rewards, institutional safety climate. For those working in occupations requiring frequent hand washing such as child care providers, some food service employees or health care workers, conditions such as chronic dryness, cracking and chapping of skin and dermatitis can be problematic and a factor influencing noncompliance with hand hygiene. For these occupations, an additional needed strategy to consider would be access to use of hand lotions.¹⁹

In recent years a variety of organizations and coalitions have been distributing evidence-based messages promoting hand washing in schools. They include but are not limited to the CDC, the Food and Drug Administration (FDA), the National Agriculture Library of the U.S. Department of Agriculture (USDA/NAL), the American Society for Microbiology (ASM), the Soap and Detergent Association (SDA), the Clean Hands Coalition (CHC), the Partnership for Food Safety Education (PFSE) and the National Coalition for Food Safe Schools (NCFSS). Resources produced by these organizations include Web sites and programs targeting school-based audiences such as CDC's Germstopper, Ounce of Prevention, and Clean Hands Web sites, ⁸, ^24-25 CDC and SDA's Healthy Schools, Healthy People, It's a SNAP program,²⁶ FDA's Science and Our Food Supply curriculum,²⁷ USDA/NAL's database of hand washing references,28 ASM's Don't Get Caught Dirty Handed campaign,²⁹ CHC's Web site with its annual Clean Hands Week,³⁰ PFSE's Fight Bac! campaign,³¹ and NCFSS's Food Safe-school Action Guide and Web site.³²

As noted in Healthy People 2010, schools have more influence on the lives of young people than any other social institution except the family and are appropriate settings for teaching lifelong health-enhancing behaviors.33 The American Public Health Association therefore recommends that:

1. All state legislatures and/or education agencies should adopt and enforce mandatory standards and funding for the provision of adequate hand washing facilities and supplies in childcare settings and in preK-12 school restrooms, classrooms and cafeterias;
2. State education agencies, school districts, public and private schools, and child care facilities should actively participate in coalitions and activities at the state and local levels to promote hand hygiene; ensure that education curricula at all levels teach students hand hygiene knowledge, skills, and behaviors; ensure that all students and staff members are provided convenient access to adequate hand washing facilities and supplies in restrooms, classrooms, and cafeterias; and ensure that all school staff members actively promote hand washing compliance and serve as models;
3. National health and education organizations with an interest in preK-12 schools and child care should actively participate, and promote the participation of their constituents, in coalitions and activities at the national (e.g., the Clean Hands Coalition and the annual "Clean Hands Week"), state and local levels to establish consistent messages and educate the public about the importance of clean hands in preventing illness; and
5. Public and private funding should be made available to expand the evidence base of effective programs and interventions that promote and enforce hand washing by students and staff in child care and K-12 (e.g., examining whether a reduction in school absences follows the interventions, examining how to sustain compliance to appropriate hand washing behaviors into adulthood).

References

1. Boyce J.M. and Pittet D. 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. October 25, 2002 / 51(RR16); 1-44. Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm. Accessed 8/21/06.
2. Larson E. A causal link between hand washing and risk of infection? Examination of the evidence. Infection Control and Hospital Epidemiology 1988; 9(1): 28-36.
3. Centers for Disease Control and Prevention. Stopping Germs at Home, Work and School. February 1, 2004. http://www.cdc.gov/germstopper/home_work_school.htm . Accessed 8/21/06
4. Centers for Disease Control and Prevention. Fact Sheet: Key Facts about Influenza and the Influenza Vaccine. Available: http://www.cdc.gov/flu/keyfacts.htm. Accessed 8/21/06.
5. Meers PD, Ayliffe GA, Emmerson AM, Leigh DA, Mayton-White RT, Mackintosh CA, Stronge JL. Report on the national survey of infection in hospitals. Journal of Hospital Infection, Supplement. 1981; 2:1-11.
6. World Health Organization Writing Group. Nonpharmaceutical interventions for pandemic influenza, national and community measures. Emerging Infectious Disease [serial on the Internet]. January 2006. Available: http://www.cdc.gov/ncidod/EID/vol12no01/05-1371.htm. Accessed 8/21/06.
7. Department of Health and Human Services. School District (K-12) Pandemic Influenza Planning Checklist. February 2006 (online document accessed March 12, 2006). Available: http://www.pandemicflu.gov/plan/schoolchecklist.html. Accessed 8/21/06.
8. Centers for Disease Control and Prevention. Clean Hands Save Lives! Available: http://www.cdc.gov/cleanhands. Accessed 8/21/06.
9. Guinan ME, McGuckin-Guinan M, Sevareid A. Who washes hands after using the bathroom? American Journal of Infection Control 1997; 25(5): 424-425.
10. Master D, Longe SH, Dickson H. Scheduled handwashing in an elementary school population. Family Medicine 1997; 29(5): 336-339.
11. Monsma M, Day R, St. Arnaud S. Handwashing makes a difference. Journal of School Health Mar 1992; 62(3): 109-111.
12. Day R, St. Arnaud S, Monsma M. Effectiveness of a handwashing program. Clinical Nursing Research 1993; 2(1):24-40.
13. Kimel LS, Handwashing education can decrease illness absenteeism. Journal of School Nursing 1996; 12:14-18.
14. Early E, Battle K, Cantwell E, English J, Lavin J, Larson E. Effect of several interventions on the frequency of handwashing among elementary public school children. American Journal of Infection Control 1998; 26: 263-269.
15. Hammond B, Yusuf A, Fendler E, Dolan M. Effect of hand sanitizer use on elementary school absenteeism. American Journal of Infection Control 2000; 28: 340-346.
16. Dyer DL, Gerenraich KB, Wadhamas PS. Testing a new alcohol-free hand sanitizer to combat infection. AORN Journal 1998; 68: 239-301.
17. ete JM. Handwashing practices among various school age students. Health Education December 1986/ January 1987; 37-39.
18. Bayer Pharmaceutical Division and Wirthlin Worldwide Research. Handwashing Survey. Fact Sheet Distributed at American society for Microbiology Annual Meeting, New Orleans, 1996. Also available on the National Food Safety Database: Hot Topics. International Food Safety Council. Handwashing-Related Research Findings. September 1998. Available: http://www.foodsafety.org/ht/ht234.html. Accessed 8/21/06.
19. Pitter, Didier. Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infectious Diseases 2001. 7(2). http://www.cdc.gov/ncidod/eid/vol7no2/pittet.htm. Accessed 8/21/2006.
20. Enderle, J. A National Disgrace? School Planning and Management, December 2005. Available: http://www.peterli.com/archive/spm/1036.shtm. Accessed 8/21/06.
21. Kimberly-Clark Professional, Parents Sound Off on School Restroom Conditions (press release) October 15, 2002. Available: http://www.ncdjjdp.org/cpsv/Acrobatfiles/Restroom_Survey02.PDF. Accessed 8/21/06.
22. Enderle, J. Improving School Restroom Facilitites. School Planning and Management, March 2004. Available: http://www.peterli.com/archive/spm/627.shtm. Accessed 8/21/06.
23. National Association of State Boards of Education. Policy Update. National Association of State Boards of Education. 2005; 13(11), 1-2.
24. CDC Germstopper: http://www.cdc.gov/germstopper. Accessed 8/21/06.
25. CDC Ounce of Prevention: http://www.cdc.gov/ncidod/op/handwashing.htm. Accessed 8/21/06.
26. CDC and the Soap and Detergent Association (SDA), Healthy Schools, Health People, It's a SNAP: http://www.itsasnap.org/index.asp. Accessed 8/21/06.
27. Food and Drug Administration (FDA), Science and Our Food Supply: http://www.cfsan.fda.gov/~dms/tchcuric.html. Accessed 8/21/06.
28. USDA National Agriculture Library (USDA/NAL) database of handwashing references: http://grande.nal.usda.gov/foodborne/fbindex/resourcelist.php?Topic=Hand%20Washing. Accessed 8/21/06
29. American Society for Microbiology (ASM), Don't get Caught Dirty Handed Campaign: http://www.washup.org. Accessed 8/21/06.
30. Clean Hands Coalition (CHC): http://www.cleanhandscoalition.org. Accessed 8/21/06.
31. Partnership for Food Safety Education (PFSE), Fight Bac!: http://www.fightbac.org/main.cfm. Accessed 8/21/06.
32. National Coalition for Food Safe Schools (NCFSS): http://www.foodsafeschools.org. Accessed 8/21/06.
33. United States Department of Health and Human Services. (2000). Healthy People 2010: Understanding and improving health (2nd ed.). Washington, D.C.: United States Government Printing 

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