{{Distinguish|text = Hand washing}} {{For-multi|the figure of speech in the law-based context|Clean hands|the biblical passage|Pontius Pilate}} {{Short description|Act of cleaning one's hands}} {{Use dmy dates|date=December 2019}} {{Use American English|date=December 2017}} <noinclude>{{Infobox medical intervention | name = Hand washing | synonym = Handwashing, hand hygiene | image = OCD handwash.jpg | caption = Hand washing with soap and water at a sink | alt = | pronounce = | specialty = | synonyms = | ICD10 = | ICD9 = | ICD9unlinked = | CPT = | MeshID = | LOINC = | other_codes = | MedlinePlus = | eMedicine = }} </noinclude> '''Hand washing''' (or '''handwashing'''), also called hand hygiene, is the process of cleaning the hands with soap or handwash and water to eliminate bacteria, viruses, dirt, microorganisms, and other potentially harmful substances. Drying of the washed hands is part of the process as wet and moist hands are more easily recontaminated.<ref name="CDC2020Wash2">{{Cite web|date=2020-03-04|title=Show Me the Science – How to Wash Your Hands|url=https://www.cdc.gov/clean-hands/data-research/facts-stats/|access-date=2020-03-06|website=www.cdc.gov|language=en-us}}</ref><ref name="Huang2012" /> If soap and water are unavailable, hand sanitizer that is at least 60% (v/v) alcohol in water can be used as long as hands are not visibly excessively dirty or greasy.<ref>{{cite web |title=Coronavirus Disease 2019 (COVID-19) |url=https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/disinfecting-your-home.html |website=Centers for Disease Control and Prevention |language=en-us |date=11 February 2020}}</ref><ref name="Centers for Disease Control">{{cite web |title=Handwashing Facts|author= Centers for Disease Control |url=https://www.cdc.gov/handwashing/when-how-handwashing.html |website=cdc.gov |language=en-us |date=2 April 2020}}</ref> Hand hygiene is central to preventing the spread of infectious diseases in home and everyday life settings.<ref name="hand hygiene">{{cite journal|last1=Bloomfield|first1=Sally F.|last2=Aiello|first2=Allison E.|author2-link=Allison E. Aiello|last3=Cookson|first3=Barry|last4=O'Boyle|first4=Carol|last5=Larson|first5=Elaine L.|author5-link=Elaine L. Larson|date=December 2007|title=The effectiveness of hand hygiene procedures in reducing the risks of infections in home and community settings including hand washing and alcohol-based hand sanitizers|journal=American Journal of Infection Control|volume=35|issue=10|pages=S27–S64|doi=10.1016/j.ajic.2007.07.001|pmc=7115270}}</ref> Meta-analyses have shown that regular hand washing in community settings can significantly reduce respiratory and gastrointestinal infections.<ref>{{Cite journal |last=Aiello |first=Allison E. |last2=Coulborn |first2=Rebecca M. |last3=Perez |first3=Vanessa |last4=Larson |first4=Elaine L. |date=August 2008 |title=Effect of Hand Hygiene on Infectious Disease Risk in the Community Setting: A Meta-Analysis |journal=American Journal of Public Health |volume=98 |issue=8 |pages=1372–1381 |doi=10.2105/ajph.2007.124610 |issn=0090-0036|pmc=2446461 }}</ref>
The World Health Organization (WHO) recommends washing hands for at least 20 seconds before and after certain activities.<ref name=":7">{{Cite web|date=20 October 2015|title=WHO: How to handwash? With soap and water|url=https://www.youtube.com/watch?v=3PmVJQUCm4E|website=YouTube}}</ref><ref name=":8">{{cite web|title=Hand Hygiene: How, Why & When|url=https://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf|website=World Health Organization}}</ref> These include the five critical times during the day where washing hands with soap is important to reduce fecal-oral transmission of disease: after using the toilet (for urination, defecation, menstrual hygiene), after cleaning a child's bottom (changing diapers), before feeding a child, before eating and before/after preparing food or handling raw meat, fish, or poultry.<ref name=":2">{{Cite web|title=UNICEF Malawi|url=https://www.unicef.org/malawi/|access-date=2020-01-05|website=www.unicef.org|language=en}}</ref>
When neither hand washing nor using hand sanitizer is possible, hands can be cleaned with uncontaminated ash and clean water, although the benefits and risks are uncertain for reducing the spread of viral or bacterial infections.<ref name=":4" /> However, frequent hand washing can lead to skin damage due to drying of the skin.<ref name="hwcs">{{cite journal | vauthors = de Almeida e Borges LF, Silva BL, Gontijo Filho PP | title = Hand washing: changes in the skin flora | journal = American Journal of Infection Control | volume = 35 | issue = 6 | pages = 417–20 | date = August 2007 | pmid = 17660014 | doi = 10.1016/j.ajic.2006.07.012 }}</ref> Moisturizing lotion is often recommended to keep the hands from drying out; dry skin can lead to skin damage, which can increase the risk for the transmission of infection.<ref name="Wilkinson, Judith M. 2011">{{cite book|title=Fundamentals of Nursing|vauthors=Wilkinson JM, Treas LA|date=2011|publisher=F.A. Davis Co.|edition=2nd|location=Philadelphia}}</ref>
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== Steps and duration == thumb|Poster about when to wash hands to raise awareness about hygiene The United States Centers for Disease Control and Prevention (CDC) recommends the following steps when washing one's hands for the prevention of transmission of disease:<ref name="CDC2020Wash1">{{Cite web|date=2019-12-04|title=About Handwashing|url= https://www.cdc.gov/clean-hands/about/ |access-date=2025-07-03|website=www.cdc.gov|language=en-us}}</ref> # Wet hands with warm or cold running water.<ref name="CDC2020Wash1" /> Running water is recommended because standing basins may be contaminated, while the temperature of the water does not seem to make a difference, however some experts suggest warm, tepid water may be superior.<ref name="CDC2020Wash2" />{{Failed verification|date=July 2025}}{{Disputed-inline|talk=Talk:Hand washing#Claim that "...some experts suggest warm, tepid water may be superior" failed verification.|date=July 2025}} # Lather hands by rubbing them with a generous amount of soap, including the backs of hands, between fingers, and under nails.<ref name="CDC2020Wash1" /> Soap lifts pathogens from the skin, and studies show that people tend to wash their hands more thoroughly when soap is used rather than water alone.<ref name="CDC2020Wash2" /> # Scrub for ''at least 20 seconds''.<ref name="CDC2020Wash1" /> Scrubbing creates friction, which helps remove pathogens from skin, and scrubbing for longer periods removes more pathogens.<ref name="CDC2020Wash2" /> According to the CDC, scrubbing with soap for at least 20 seconds is necessary to remove most germs effectively, regardless of water temperature.<ref>{{Cite web |last=CDC |date=2024-06-11 |title=About Hand Hygiene for Patients in Healthcare Settings |url=https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html |access-date=2025-10-01 |website=Clean Hands |language=en-us}}</ref> # Rinse well under running water.<ref name="CDC2020Wash1" /> Rinsing in a basin can recontaminate hands.<ref name="CDC2020Wash2" /> # Dry with a clean towel or allow to air dry.<ref name="CDC2020Wash1" /> Wet and moist hands are more easily recontaminated.<ref name="CDC2020Wash2" /> The most commonly missed areas are the thumb, the wrist, the areas between the fingers, and under fingernails. Artificial nails and chipped nail polish may harbor microorganisms.<ref name="Wilkinson, Judith M. 2011" />
===When it is recommended=== There are five critical times during the day where washing hands with soap is important to reduce fecal-oral transmission of disease: after using the toilet (for urination, defecation, menstrual hygiene), after cleaning a child's bottom (changing diapers), before feeding a child, before eating and before/after preparing food or handling raw meat, fish, or poultry.<ref name=":2" /> Other occasions when proper hand washing techniques should be practiced to prevent the transmission of disease include before and after treating a cut or wound; after sneezing, coughing, or blowing your nose; after touching animal waste or handling animals; and after touching garbage.<ref>{{Cite web|date=2019-12-04|title=When and How to Wash Your Hands {{!}} Handwashing|url=https://www.cdc.gov/handwashing/when-how-handwashing.html|access-date=2020-03-07|website=www.cdc.gov|language=en-us}}</ref><ref>{{Cite web|title=The right way to wash your hands|url=https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/hand-washing/art-20046253|access-date=2020-03-07|website=Mayo Clinic|language=en}}</ref> In healthcare settings, the WHO (World Health Organization) also recommends "Five Moments for Hand Hygiene" before patient contact, before aseptic tasks, after exposure to body fluids, after patient contact, and after contact with patient surroundings.<ref>{{Cite journal |last=Boyce |first=John M. |last2=Pittet |first2=Didier |date=December 2002 |title=Guideline for hand hygiene in health-care settings |journal=American Journal of Infection Control |volume=30 |issue=8 |pages=S1–S46 |doi=10.1067/mic.2002.130391 |issn=0196-6553}}</ref>
== Public health == ===Health benefits=== left|thumb|Building a culture of handwashing with children can create a change in culture with widespread public health benefits. Hand washing has many significant health benefits, including minimizing the spread of influenza, COVID-19, and other infectious diseases;<ref name="fmhh">{{cite journal|display-authors=6|vauthors=Cowling BJ, Chan KH, Fang VJ, Cheng CK, Fung RO, Wai W, Sin J, Seto WH, Yung R, Chu DW, Chiu BC, Lee PW, Chiu MC, Lee HC, Uyeki TM, Houck PM, Peiris JS, Leung GM|date=October 2009|title=Facemasks and hand hygiene to prevent influenza transmission in households: a cluster randomized trial|journal=Annals of Internal Medicine|volume=151|issue=7|pages=437–46|doi=10.7326/0003-4819-151-7-200910060-00142|pmid=19652172|doi-access=free}}</ref><ref name="who-workplace-covid19">{{cite web|date=27 February 2020|title=Getting your workplace ready for COVID-19|url=https://www.who.int/docs/default-source/coronaviruse/getting-workplace-ready-for-covid-19.pdf|access-date=27 March 2020|publisher=World Health Organization}}</ref> preventing infectious causes of diarrhea;<ref name="cdwt">{{cite journal|vauthors=Luby SP, Agboatwalla M, Painter J, Altaf A, Billhimer W, Keswick B, Hoekstra RM|date=April 2006|title=Combining drinking water treatment and hand washing for diarrhoea prevention, a cluster randomised controlled trial|journal=Tropical Medicine & International Health|volume=11|issue=4|pages=479–89|doi=10.1111/j.1365-3156.2006.01592.x|pmid=16553931|doi-access=free|s2cid=7747732|title-link=cluster randomized controlled trial}}</ref> decreasing respiratory infections;<ref name="pcda">{{cite web|title=Protecting Children from Diarrhoea and Acute Respiratory Infections: The Role of Hand Washing Promotion in Water and Sanitation Programmes|url=http://www.searo.who.int/LinkFiles/Regional_Health_Forum_1.pdf#page=49|archive-url=https://web.archive.org/web/20090628221929/http://www.searo.who.int/LinkFiles/Regional_Health_Forum_1.pdf#page=49|archive-date=28 June 2009|access-date=21 May 2009|vauthors=Scott B, Curtis V, Rabie T}}</ref> and reducing infant mortality rate at home birth deliveries.<ref>{{cite journal|vauthors=Rhee V, Mullany LC, Khatry SK, Katz J, LeClerq SC, Darmstadt GL, Tielsch JM|date=July 2008|title=Maternal and birth attendant hand washing and neonatal mortality in southern Nepal|journal=Archives of Pediatrics & Adolescent Medicine|volume=162|issue=7|pages=603–8|doi=10.1001/archpedi.162.7.603|pmc=2587156|pmid=18606930}}</ref> A 2013 study showed that improved hand washing practices may lead to small improvements in the length growth in children under five years of age.<ref>{{cite journal|display-authors=6|vauthors=Dangour AD, Watson L, Cumming O, Boisson S, Che Y, Velleman Y, Cavill S, Allen E, Uauy R|date=August 2013|title=Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children|url=http://researchonline.lshtm.ac.uk/1119171/1/CD009382.pdf|journal=The Cochrane Database of Systematic Reviews|issue=8|article-number=CD009382|doi=10.1002/14651858.CD009382.pub2|pmid=23904195|pmc=11608819 |s2cid=205199671 }}</ref> Studies have shown that humans often touch their face over 20 times per hour; touching contaminated surfaces and their ones face can lead to viral transmission.<ref>{{Cite journal |last=Przekwas |first=Andrzej |last2=Chen |first2=Zhijian |date=2020-11-01 |title=Washing hands and the face may reduce COVID-19 infection |url=https://www.sciencedirect.com/science/article/pii/S0306987720324580 |journal=Medical Hypotheses |volume=144 |article-number=110261 |doi=10.1016/j.mehy.2020.110261 |issn=0306-9877}}</ref>In developing countries, childhood mortality rates related to respiratory and diarrheal diseases can be reduced by introducing simple behavioral changes, such as hand washing with soap. This simple action can reduce the rate of mortality from these diseases by almost 50%.<ref>{{cite journal|vauthors=Curtis V, Cairncross S|date=May 2003|title=Effect of washing hands with soap on diarrhoea risk in the community: a systematic review|journal=The Lancet. Infectious Diseases|volume=3|issue=5|pages=275–81|doi=10.1016/S1473-3099(03)00606-6|pmid=12726975}}</ref> Interventions that promote hand washing can reduce diarrhea episodes by about a third, and this is comparable to providing clean water in low income areas.<ref name="EjemotEhiri2009">{{cite journal|vauthors=Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA|year=2009|title=Cochrane review: Hand washing for preventing diarrhoea|journal=Evidence-Based Child Health|volume=4|issue=2|pages=893–939|doi=10.1002/ebch.373|issn=1557-6272}}</ref> 48% of reductions in diarrhea episodes can be associated with hand washing with soap.<ref name="CairncrossHunt2010">{{cite journal|vauthors=Cairncross S, Hunt C, Boisson S, Bostoen K, Curtis V, Fung IC, Schmidt WP|date=April 2010|title=Water, sanitation and hygiene for the prevention of diarrhoea|journal=International Journal of Epidemiology|volume=39 Suppl 1|issue=Supplement 1|pages=i193-205|doi=10.1093/ije/dyq035|pmc=2845874|pmid=20348121}}</ref>
Handwashing with soap is the single most effective and inexpensive way to prevent diarrhea and acute respiratory infections (ARI), as automatic behavior performed in homes, schools, and communities worldwide. Pneumonia, a major ARI, is the number one cause of mortality among children under five years old, taking the lives of an estimated 1.8 million children per year. Diarrhea and pneumonia together account for almost 3.5 million child deaths annually.<ref>{{cite book|url=https://www.unicef.org/reports/state-worlds-children-2008|title=The State of the World's Children 2008|date=November 2008|publisher=UNICEF|isbn=978-92-806-4191-2}}</ref> According to UNICEF, turning handwashing with soap before eating and after using the toilet into an ingrained habit can save more lives than any single vaccine or medical intervention, cutting deaths from diarrhea by almost half and deaths from acute respiratory infections by one-quarter. Hand washing is usually integrated with other sanitation interventions as part of water, sanitation, and hygiene (WASH) programs. Hand washing also protects against impetigo which is transmitted through direct physical contact.<ref>{{cite web|title=Impetigo|date=19 October 2017 |url=https://www.nhs.uk/conditions/impetigo/|access-date=2020-03-11|publisher=NHS}}</ref>
<div style="display:inline-table; vertical-align:top;"> {{owidslider |start = 2024 |list = Template:OWID/Number without basic handwashing#gallery |location = commons |caption = |title = |language = |file = link=|thumb|upright=1.6|right|Number without basic handwashing |startingView = World }} </div> <div style="display:inline-table; vertical-align:top;"> {{owidslider |start = 2023 |list = Template:OWID/Death rates no handwashing#gallery |location = commons |caption = |title = |language = |file = link=|thumb|upright=1.6|right|Death rates for no access to handwashing |startingView = World }} </div> <div style="display:inline-table; vertical-align:top;"> {{owidslider |start = 2023 |list = Template:OWID/Deaths due to lack of access to hand washing facilities#gallery |location = commons |caption = |title = |language = |file = link=|thumb|upright=1.6|right|Deaths due to lack of access to hand washing facilities |startingView = World }} </div> <div style="display:inline-table; vertical-align:top;"> {{owidslider |start = 2024 |list = Template:OWID/Proportion of population with basic handwashing facilities on premises#gallery |location = commons |caption = |title = |language = |file = link=|thumb|upright=1.6|right|Proportion of population with basic handwashing facilities on premises |startingView = World }} </div> <div style="display:inline-table; vertical-align:top;"> {{owidslider |start = 2024 |list = Template:OWID/Rural without basic handwashing#gallery |location = commons |caption = |title = |language = |file = link=|thumb|upright=1.6|right|Rural without basic handwashing |startingView = World }} </div>
===Adverse effects=== A small detrimental effect of handwashing is that frequent hand washing can lead to skin damage due to the drying of the skin.<ref name="hwcs"/> A 2012 Danish study found that excessive hand washing can lead to an itchy, flaky skin condition known as contact dermatitis, which is especially common among health-care workers.<ref>{{Cite web|title=Too-Clean Hands Can Lead to Eczema|url=https://www.everydayhealth.com/eczema/0411/too-clean-hands-can-lead-to-eczema.aspx|access-date=2020-01-24|website=EverydayHealth.com}}</ref> Frequent use of alcohol based hand sanitizers can also contribute to skin irritation and dryness, although this effect may be reduced by formulations that include moisturizers.<ref>{{Cite web |last=CDC |date=2024-06-11 |title=Clinical Safety: Hand Hygiene for Healthcare Workers |url=https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html |access-date=2025-10-01 |website=Clean Hands |language=en-us}}</ref>
===Behavior change=== [[Image:HandCleaning.JPG|thumb|Hand cleaning station at the entrance of the Toronto General Hospital, Canada]]In many countries, there is a low rate of hand washing with soap. A study of hand washing in 54 countries in 2015 found that on average, 38.7% of households practiced hand washing with soap.<ref>{{Cite web|title=JMP handwashing dataset|url=https://www.wssinfo.org/handwashing/|archive-url=https://web.archive.org/web/20160402160817/http://www.wssinfo.org/handwashing/|archive-date=2 April 2016|access-date=20 March 2017|quote=WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation}}</ref>
A 2014 study showed that Saudi Arabia had the highest rate of 97%; the United States near the middle with 77%; and China with the lowest rate of 23%.<ref>{{Cite web|last=BreakingWeb|title=Les Français et le savonnage des mains après être allé aux toilettes|url=https://www.bva-group.com/sondages/les-francais-et-le-savonnage-des-mains-apres-etre-alle-aux-toilettes/|access-date=2020-02-09|website=BVA Group|date=23 November 2015 |language=fr-FR}}</ref>
Several behavior change methodologies now exist to increase uptake of the behavior of hand washing with soap at the critical times.<ref>Abdi & Gautam, R. & O.P, ''[http://www.wateraid.org/policy-practice-and-advocacy/hygiene/resources Approaches to promoting behaviour-change around handwashing-with-soap] {{Webarchive|url=https://web.archive.org/web/20170321082616/http://www.wateraid.org/policy-practice-and-advocacy/hygiene/resources|date=21 March 2017}}''</ref><ref>{{Cite web|title=How to Trigger for Handwashing with Soap|url=https://sanitationlearninghub.org/resource/how-to-trigger-for-handwashing-with-soap/|access-date=2021-12-13|website=Sanitation Learning Hub|language=en-GB}}</ref>
Group hand washing for school children at set times of the day is one option in developing countries to engrain hand washing in children's behaviors.<ref name="UNICEF2016">UNICEF, GIZ (2016). [http://www.susana.org/en/resources/library/details/2641 Scaling up group handwashing in schools – Compendium of group washing facilities across the globe]. New York; Eschborn, Germany</ref> The "Essential Health Care Program" implemented by the Department of Education in the Philippines is an example of at scale action to promote children's health and education.<ref name="UNICEF2012">UNICEF (2012) [http://www.unicef.org/wash/schools/files/Raising_Even_More_Clean_Hands_Web_17_October_2012(1).pdf Raising Even More Clean Hands: Advancing Health, Learning and Equity through WASH in Schools] {{Webarchive|url=https://web.archive.org/web/20160304081726/http://www.unicef.org/wash/schools/files/Raising_Even_More_Clean_Hands_Web_17_October_2012(1).pdf |date=4 March 2016 }}, Joint Call to Action</ref> Deworming twice a year, supplemented with washing hands daily with soap, brushing teeth daily with fluoride, is at the core of this national program. It has also been successfully implemented in Indonesia.<ref>{{cite book|url=http://www.susana.org/en/resources/library/details/1513|title=School Community Manual – Indonesia (formerly Manual for teachers), Fit for School|date=2014|publisher=GIZ Fit for School, Philippines|isbn=978-3-95645-250-5}}</ref>
===Recent Global Initiatives (2020-present)=== In recent years, hand hygiene has remained central to global infection prevention efforts, particularly following the COVID-19 pandemic. The World Health Organization (WHO) reported in 2023 that fewer than 60% of health-care facilities in low- and middle-income countries have adequate hand hygiene resources at points of care.<ref>{{cite web |title=WASH in health care facilities: 2023 data update |url=https://www.who.int/publications/m/item/wash-in-health-care-facilities-2023-data-update |publisher=World Health Organization |date=2023 |access-date=24 October 2025}}</ref> To address this gap, the WHO and UNICEF launched the ''Hand Hygiene for All'' initiative in 2020 to promote integration of hand hygiene into national health policies.<ref>{{cite web |title=Hand Hygiene for All: 2020 initiative brief |url=https://www.unicef.org/media/71776/file/Hand-hygiene-for-all-2020.pdf |publisher=UNICEF and World Health Organization |date=2020 |access-date=24 October 2025}}</ref> Early research emphasized the critical role of hand hygiene in preventing health care–associated infections.<ref>{{cite journal |last1=Allegranzi |first1=B. |last2=Pittet |first2=D. |title=Role of hand hygiene in health care–associated infection prevention |journal=The Lancet Infectious Diseases |volume=9 |issue=2 |pages=99–110 |year=2009 |doi=10.1016/j.jhin.2009.04.019}}</ref> Sustained behavioral interventions and system-level investments remain essential to improve compliance and reduce health care–associated infections worldwide. Improving hand hygiene practices is also a key target within the WHO ''Global Patient Safety Action Plan 2021–2030'', which aims to reduce health care–associated infections and antimicrobial resistance.
In 2025, the World Health Organization introduced updated hand-hygiene recommendations emphasizing the need for reliable access to water, soap, and alcohol-based hand rubs with safe grey-water disposal; clear guidance on when, why, and how hand hygiene should be performed; and a supportive physical and social environment that ensures facilities are accessible and convenient.<ref>{{Cite web |title=New guidelines on community hand hygiene to help governments reduce the spread of infectious diseases |url=https://www.who.int/news/item/15-10-2025-new-guidelines-on-community-hand-hygiene-to-help-governments-reduce-the-spread-of-infectious-diseases |access-date=2025-12-11 |website=www.who.int |language=en}}</ref>
== Substances used ==
===Soap and detergents=== Removal of microorganisms from skin is enhanced by the addition of soaps or detergents to water.<ref>{{Cite web|url=http://www.hi-tm.com/Documents/Handflow.html|title=Double hand washing with a fingernail brush. HACCP – HITM: food science safety and HACCP training and certification provider|date=2019-07-02|archive-url=https://web.archive.org/web/20190702021337/http://www.hi-tm.com/Documents/Handflow.html|access-date=2020-04-08|archive-date=2 July 2019}}</ref> Soap and detergents are surfactants that kill microorganisms by disorganizing their membrane lipid bilayer and denaturing their proteins. It also emulsifies oils, enabling them to be carried away by running water.<ref>{{Cite web|url=http://cool.conservation-us.org/waac/wn/wn23/wn23-3/wn23-304.html|title=A brief history of aluminum stearate as a component of paint| vauthors = Tumosa CS |date=2001-09-01|website=cool.conservation-us.org|language=en|access-date=2017-04-05|url-status=live|archive-url=https://web.archive.org/web/20170318085239/http://cool.conservation-us.org/waac/wn/wn23/wn23-3/wn23-304.html|archive-date=2017-03-18}}</ref>
===={{anchor|Solid_soap|_ss}}Solid soap==== Solid soap, because of its reusable nature, may hold bacteria acquired from previous uses.<ref>{{cite journal | vauthors = McBride ME | title = Microbial flora of in-use soap products | journal = Applied and Environmental Microbiology | volume = 48 | issue = 2 | pages = 338–41 | date = August 1984 | pmid = 6486782 | pmc = 241514 | doi = 10.1128/AEM.48.2.338-341.1984 | bibcode = 1984ApEnM..48..338M }}</ref> A small number of studies which have looked at the bacterial transfer from contaminated solid soap have concluded transfer is unlikely as the bacteria are rinsed off with the foam.<ref>{{cite journal | vauthors = Heinze JE, Yackovich F | title = Washing with contaminated bar soap is unlikely to transfer bacteria | journal = Epidemiology and Infection | volume = 101 | issue = 1 | pages = 135–42 | date = August 1988 | pmid = 3402545 | pmc = 2249330 | doi = 10.1017/s0950268800029290 }}</ref> The CDC still states "liquid soap with hands-free controls for dispensing is preferable".<ref>{{cite web|title=Infection Control: Frequently Asked Questions – Hand Hygiene|url=https://www.cdc.gov/oralhealth/infectioncontrol/faq/hand.htm|publisher=Centers for Disease Control and Prevention|access-date=30 September 2016}}</ref>
===={{anchor|Antibacterial_soap|_as}}Antibacterial soap==== Antibacterial soaps have been heavily promoted to a health-conscious public. To date, there is no evidence that using recommended antiseptics or disinfectants selects for antibiotic-resistant organisms in nature.<ref>{{cite journal | vauthors = Weber DJ, Rutala WA | title = Use of germicides in the home and the healthcare setting: is there a relationship between germicide use and antibiotic resistance? | journal = Infection Control and Hospital Epidemiology | volume = 27 | issue = 10 | pages = 1107–19 | date = October 2006 | pmid = 17006819 | doi = 10.1086/507964 | s2cid = 20734025 }}</ref> However, antibacterial soaps contain common antibacterial agents such as triclosan, which has an extensive list of resistant strains of organisms. So, even if antibiotic resistant strains are not selected for by antibacterial soaps, they might not be as effective as they are marketed to be. Besides the surfactant and skin-protecting agent, the sophisticated formulations may contain acids (acetic acid, ascorbic acid, lactic acid) as pH regulator, antimicrobially active benzoic acid and further skin conditioners (aloe vera, vitamins, menthol, plant extracts).<ref>{{Cite patent|title=Microbicidal and sanitizing soap compositions|gdate=1997-09-04|url=https://patents.google.com/patent/US5942478A/en|number=US5942478A}}</ref>
A 2007 meta-analysis from the University of Oregon School of Public Health indicated that plain soaps are as effective as consumer-grade anti-bacterial soaps containing triclosan in preventing illness and removing bacteria from the hands.<ref>{{cite web |url=http://www.physorg.com/news106418144.html |title=Plain soap as effective as antibacterial but without the risk |access-date=17 August 2007 }}</ref> Dissenting, a 2011 meta-analysis in the ''Journal of Food Protection'' argued that when properly formulated, triclosan can grant a small but detectable improvement, as can chlorhexidine gluconate, iodophor, or povidone.<ref>{{cite journal | vauthors = Montville R, Schaffner DW | title = A meta-analysis of the published literature on the effectiveness of antimicrobial soaps | journal = Journal of Food Protection | volume = 74 | issue = 11 | pages = 1875–82 | date = November 2011 | pmid = 22054188 | doi = 10.4315/0362-028X.JFP-11-122 | doi-access = free }}</ref><ref>{{cite news |title=Antibacterial Soap Has Poor Killing Power |url=https://www.scientificamerican.com/article/antibacterial-soap-has-poor-killing-power/ |access-date=14 April 2020 |work=Scientific American |date=24 September 2015 |language=en}}</ref>
===Warm water=== Hot water that is still comfortable for washing hands is not hot enough to kill bacteria. Bacteria grow much faster at body temperature (37 °C). WHO considers warm soapy water to be more effective than cold, soapy water at removing natural oils which hold soils and bacteria.<ref name=wghh/> But CDC mentions that warm water causes skin irritations more often and its ecological footprint is more significant.<ref name=CDC2020Wash2/> Water temperatures from 4 to 40 °C do not differ significantly regarding removal of microbes. The most important factor is proper scrubbing.<ref name=Michaels/>
Contrary to popular belief, scientific studies have shown that using warm water has no effect on reducing the microbial load on hands.<ref name=Michaels>{{cite journal| vauthors = Michaels B, Gangar V, Schultz A, Arenas M, Curiale M, Ayers T, Paulson D | title = Water temperature as a factor in handwashing efficacy| journal = Food Service Technology | volume = 2 |issue = 3 |pages = 139–49 |year = 2002 |doi=10.1046/j.1471-5740.2002.00043.x | doi-access = free }}</ref><ref>{{cite journal | vauthors = Laestadius JG, Dimberg L | title = Hot water for handwashing--where is the proof? | journal = Journal of Occupational and Environmental Medicine | volume = 47 | issue = 4 | pages = 434–5 | date = April 2005 | pmid = 15824636 | doi = 10.1097/01.jom.0000158737.06755.15 | s2cid = 37287489 }}</ref> Using hot water for handwashing can even be regarded as a waste of energy.<ref>{{cite journal | vauthors = Carrico AR, Spoden M, Wallston KA, Vandenbergh MP | title = The Environmental Cost of Misinformation: Why the Recommendation to Use Elevated Temperatures for Handwashing is Problematic | journal = International Journal of Consumer Studies | volume = 37 | issue = 4 | pages = 433–441 | date = July 2013 | pmid = 23814480 | pmc = 3692566 | doi = 10.1111/ijcs.12012 }}</ref>
===Antiseptics (hand sanitizer)=== thumb|250px|Hand disinfection procedure according to the German standard DIN EN 1500 {{Main|Hand sanitizer}}
In situations where hand washing with soap is not an option (e.g., when in a public place with no access to wash facilities), a waterless hand sanitizer such as an alcohol hand gel can be used. They can be used in addition to hand washing to minimize risks when caring for "at-risk" groups. To be effective, alcohol hand gels should contain not less than 60%v/v alcohol. Enough hand antiseptic or alcohol rub must be used to thoroughly wet or cover both hands. The front and back of both hands and between and the ends of all fingers must be rubbed for approximately 30 seconds until the liquid, foam or gel is dry. Fingertips must be washed well too, rubbing them in both palms.<ref>{{cite journal |title=Alcohol Sanitizer|url=https://www.ncbi.nlm.nih.gov/books/NBK513254/|access-date=2020-03-12|journal=StatPearls [Internet] |vauthors=Gold NA, Avva U|year=2021|pmid=30020626}}</ref>
A hand sanitizer or hand antiseptic is a non-water-based hand hygiene agent. In the late 1990s and early part of the 21st century, alcohol rub non-water-based hand hygiene agents (also known as alcohol-based hand rubs, antiseptic hand rubs, or hand sanitizers) began to gain popularity. Most are based on isopropyl alcohol or ethanol formulated together with a thickening agent such as Carbomer (polymer of acrylic acid) into a gel, or a humectant such as glycerin into a liquid, or foam for ease of use and to decrease the drying effect of the alcohol.<ref name=":3">{{cite journal | vauthors = Menegueti MG, Laus AM, Ciol MA, Auxiliadora-Martins M, Basile-Filho A, Gir E, Pires D, Pittet D, Bellissimo-Rodrigues F | display-authors = 6 | title = Glycerol content within the WHO ethanol-based handrub formulation: balancing tolerability with antimicrobial efficacy | journal = Antimicrobial Resistance and Infection Control | volume = 8 | issue = 1 | article-number = 109 | date = 2019-06-24 | pmid = 31285821 | pmc = 6591802 | doi = 10.1186/s13756-019-0553-z | doi-access = free }}</ref> Adding diluted hydrogen peroxide increases further the antimicrobial activity.<ref>{{Cite book | author = National Center for Biotechnology Information |url=https://www.ncbi.nlm.nih.gov/books/NBK144054/|title=WHO-recommended handrub formulations|date=2009|publisher=World Health Organization|language=en}}</ref>
Hand sanitizers are most effective against bacteria and less effective against some viruses. Alcohol-based hand sanitizers are almost entirely ineffective against norovirus (or Norwalk) type viruses, the most common cause of contagious gastroenteritis.<ref>{{Cite web|url=https://www.cdc.gov/norovirus/preventing-infection.html|title=Preventing Norovirus Infection|date=9 March 2018|website=www.cdc.gov|language=en-us|access-date=2018-05-17|archive-url=https://web.archive.org/web/20180507202556/https://www.cdc.gov/norovirus/preventing-infection.html|archive-date=2018-05-07}}</ref>
US Centers for Disease Control and Prevention recommend hand washing with soap over hand sanitizer rubs, particularly when hands are visibly dirty.<ref>{{cite web|url=https://www.cdc.gov/handwashing/ |title=Handwashing: Clean Hands Save Lives |publisher=Center for Disease Control and Prevention |date=16 March 2020 |access-date=26 July 2012}}</ref> The increasing use of these agents is based on their ease of use and rapid killing activity against micro-organisms; however, they should not serve as a replacement for proper hand washing unless soap and water are unavailable. Despite their effectiveness, non-water agents do not cleanse the hands of organic material but simply disinfect them. It is for this reason that hand sanitizers are not as effective as soap and water at preventing the spread of many pathogens, since the pathogens remain on the hands.{{citation needed|date=July 2023}}
=== Wipes === Hand washing using hand sanitizing wipes is an alternative during traveling in the absence of soap and water.<ref name="Butz">{{cite journal | vauthors = Butz AM, Laughon BE, Gullette DL, Larson EL | title = Alcohol-impregnated wipes as an alternative in hand hygiene | journal = American Journal of Infection Control | volume = 18 | issue = 2 | pages = 70–6 | date = April 1990 | pmid = 2337257 | doi = 10.1016/0196-6553(90)90084-6 | doi-access = free }}</ref> Alcohol-based hand sanitizer should contain at least 60% alcohol.<ref name="Center for Disease Control Guidelines">{{cite web | url = https://www.cdc.gov/handwashing/when-how-handwashing.html | title = When and How to Wash Your Hands | date = 10 August 2021 | publisher = CDC }}</ref>
===Ash or mud=== Many people in low-income communities cannot afford soap and use ash or soil instead. The World Health Organization recommended ash or sand as an alternative to soap when soap is not available.<ref>{{cite web|publisher=WHO |year=2014|title= Water Sanitation Health. How can personal hygiene be maintained in difficult circumstances? |url=https://www.who.int/water_sanitation_health/emergencies/qa/emergencies_qa17/en/|archive-url=https://web.archive.org/web/20050214144405/http://www.who.int/water_sanitation_health/emergencies/qa/emergencies_qa17/en/|archive-date=14 February 2005|access-date=2020-03-12}}</ref> Use of ash is common in rural areas of developing countries and has, in experiments, been shown at least as effective as soap for removing pathogens.<ref>{{cite journal|last1=Baker|first1=K.K.|last2=Dil Farzana|first2=F.|last3=Ferdous|first3=F.|last4=Ahmed|first4=S.|last5=Kumar Das|first5=S.|last6=Faruque|first6=A.S.G.|last7=Nasrin|first7=D.|last8=Kotloff|first8=K.L.|last9=Nataro|first9=J.P.|last10=Kolappaswamy|first10=K.|last11=Levine|first11=M.M.|date=28 April 2014|title=Association between Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multi center Study (GEMS) and Types of Hand washing Materials Used by Caretakers in Mirzapur, Bangladesh|journal=American Journal of Tropical Medicine and Hygiene|volume=91|issue=1|pages=181–89|doi=10.4269/ajtmh.13-0509|pmc=4080560|pmid=24778193}}</ref> However, evidence to support the use of ash to wash hands is of poor quality. It is not clear if washing hands with ash is effective at reducing viral or bacterial spreading compared to washing with mud, not washing, or with washing with water alone.<ref name=":4">{{cite journal | vauthors = Paludan-Müller AS, Boesen K, Klerings I, Jørgensen KJ, Munkholm K | title = Hand cleaning with ash for reducing the spread of viral and bacterial infections: a rapid review | journal = The Cochrane Database of Systematic Reviews | volume = 4 | article-number = CD013597 | date = April 2020 | issue = 7 | pmid = 32343408 | pmc = 7192094 | doi = 10.1002/14651858.cd013597 }}</ref> There is a concern that if the soil or ash used is contaminated with microorganisms, handwashing with these materials could potentially spread disease rather than reduce it.<ref>{{cite conference | vauthors = Bloomfield SF, Nath KJ | title = Use of ash and mud for handwashing in low income communities | conference = International Scientific Forum on Home Hygiene (IFH). | location = Somerset, England| date = October 2009 | url = http://www.ifh-homehygiene.org/best-practice-review/use-ash-and-mud-handwashing-low-income-communities }}</ref> However, there is also no clear evidence to determine the level of risk.<ref name=":4" /> Like soap, ash is also a disinfecting agent because in contact with water, it forms an alkaline solution.<ref>{{cite book | vauthors = Howard G, Bogh C | title = Healthy villages: a guide for communities and community health workers. | publisher = World Health Organization | date = 2002 | chapter = Chapter 8 Personal, domestic and community hygiene | isbn = 978-92-4-154553-2 | chapter-url = https://books.google.com/books?id=o1Q0DgAAQBAJ&pg=PA65 }}</ref>
== Technologies and design aspects ==
===Low-cost options when water is scarce=== [[File:Pupil washes hands during COVID-19 pandemic in Ghana.jpg|thumb|A school girl using a Veronica Bucket in Ghana for handwashing ]]Various low-cost options can be made to facilitate hand washing where tap-water and/or soap is not available e.g. pouring water from a hanging jerrycan or gourd with suitable holes and/or using ash if needed in developing countries.<ref name="hip.fhi360.org">{{cite web|url=http://www.hip.fhi360.org/page/2644.html|title=The Hygiene Improvement Project (HIP) – Tippy-Tap: A simple low-cost technology for handwashing when water is scarce|website=USAID|archive-url=https://web.archive.org/web/20141025004538/http://www.hip.fhi360.org/page/2644.html|archive-date=25 October 2014|access-date=30 September 2015}}</ref>
In situations with limited water supply (such as schools or rural areas in developing countries), there are water-conserving solutions, such as "tippy-taps" and other low-cost options.<ref name=":1" /> A tippy-tap is a simple technology using a jug suspended by a rope, and a foot-operated lever to pour a small amount of water over the hands and a bar of soap.<ref>{{cite news | vauthors = Rao A |title = When Low-Tech Solutions Win|url = http://www.slate.com/blogs/future_tense/2014/09/11/tippytap_handwashing_stations_demonstrate_how_low_tech_solutions_can_win.html|newspaper = Slate|date = 11 September 2014|issn = 1091-2339}}</ref>
Low-cost hand washing technologies for households may differ from facilities for multiple users.<ref name=":5">Coultas, M. and Iyer, R. with Myers, J. (2020). [https://www.susana.org/en/knowledge-hub/resources-and-publications/library/details/3846 Handwashing Compendium for Low Resource Settings: A Living Document]. Edition 1, The Sanitation Learning Hub, Brighton: IDS, {{ISBN|978-1-78118-638-1}} ([https://www.ids.ac.uk/publications/handwashing-compendium-for-low-resource-settings-a-living-document/ alternative URL])</ref> For households, options include tippy taps, bucket/container with tap (such as a Veronica Bucket), conventional tap with/without basin, valve/tap fitted to bottles, bucket and cup, camp sink.<ref name=":5" /> Options for multiple users include: adapting household technologies for multiple users, water container fitted to a pipe with multiple taps, water container fitted to a pipe with holes.<ref name=":5" />
===Advanced technologies=== Several companies around the globe have developed technologies that aim to improve the hand washing process. Among the different inventions, there are eco-friendly devices that use 90% less water and 60% less soap compared to hand washing under a faucet.<ref>{{cite web | vauthors = Carni Y | date = 10 July 2019 | title = By Gamifying Hand Washing, Soapy Might Just Save Civilization | work = Forbes | url = https://www.forbes.com/sites/startupnationcentral/2019/07/10/by-gamifying-hand-washing-soapy-might-just-save-civilization/#43bc44c6645e }}</ref><ref>{{cite web | date = 12 May 2020 | work = GGBa Invest Western Switzerland | title = How Swiss scale-up Smixin battles the spread of infectious disease worldwide| url = https://www.ggba-switzerland.ch/en/how-swiss-scale-up-smixin-battles-the-spread-of-infectious-disease-worldwide/}}</ref> Another device uses light-based rays to detect contaminants on the hands after they have been washed.<ref>{{cite web | date = 21 July 2020 | vauthors = Sun DD | work = KIRO 7 News | title = New safety tool at SEA Airport scans restaurant employee hands to ensure cleanliness | url = https://www.kiro7.com/news/local/new-safety-tool-sea-airport-scans-restaurant-employee-hands-ensure-cleanliness/VGPBI4QYYVFNXBYO435RI6LCBQ/}}</ref>
Certain environments are especially sensitive to the transmission of pathogenic microorganisms, like health care and food production. Organizations attempting to prevent infection transmission in these environments have started using programmed washing cycles that provide sufficient time for scrubbing the hands with soap and rinsing them with water. Combined with AI-powered software, these technological advancements turn the hand-washing process into digital data, allowing individuals to receive insights and improve their hand hygiene practices.<ref>{{cite web | vauthors = Pick A | date = 3 September 2020 | work = Calcalist | title = This Startup Wants to Fight Coronavirus With Soap and Water | url = https://www.calcalistech.com/ctech/articles/0,7340,L-3799860,00.html }}</ref><ref>{{cite web | date = 4 April 2020 | vauthors = Stahl J | publisher = The Christian Broadcasting Network, Inc | title = Interest in Israeli Smart Hand-Washing Device Surges with Coronavirus | url = https://www1.cbn.com/cbnnews/israel/2020/april/interest-in-israeli-smart-hand-washing-device-surges-with-coronavirus}}</ref><ref>{{cite web | vauthors = Joe | work = JLM-BioCity | title = Soapy Washes Your Hands Clean Of Corona! | date = 7 April 2020 | url = https://jlm-biocity.org/soapy-washes-your-hands-clean-of-corona/ }}</ref> thumb|left|A nurse uses a smart hand washing device.
===Drying with towels or hand driers=== {{Further|Hand dryer}} Effective drying of the hands is an essential part of the hand hygiene process. Therefore, the proper drying of hands after washing should be an integral part of the hand hygiene process in health care.<ref name="Huang2012">{{cite journal | vauthors = Huang C, Ma W, Stack S | title = The hygienic efficacy of different hand-drying methods: a review of the evidence | journal = Mayo Clinic Proceedings | volume = 87 | issue = 8 | pages = 791–8 | date = August 2012 | pmid = 22656243 | pmc = 3538484 | doi = 10.1016/j.mayocp.2012.02.019 | doi-access = free }}</ref>
The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) are clear and straightforward concerning hand hygiene, and recommend paper towels and hand dryers equally. Both have stressed the importance of frequent and thorough hand washing followed by their complete drying as a means to stop the spread of pathogens, like COVID-19. Specifically, the World Health Organization recommends that everyone "frequently clean [their] hands..." and "dry [them] thoroughly by using paper towels or a warm air dryer." The CDC report that, "Both [clean towels or air hand dryers] are effective ways to dry hands."
A study in 2020 found that hand dryers and paper towels were both found to be equally hygienic hand-drying solutions.<ref name=":6">{{cite journal | vauthors = Reynolds KA, Sexton JD, Norman A, McClelland DJ | title = Comparison of electric hand dryers and paper towels for hand hygiene: a critical review of the literature | journal = Journal of Applied Microbiology | volume = 130 | issue = 1 | pages = 25–39 | date = January 2021 | pmid = 32794646 | doi = 10.1111/jam.14796 | pmc = 7818469 | doi-access = free }}</ref>
However, there is some debate over the most effective form of drying in public toilets. A growing volume of research suggests paper towels are much more hygienic than the electric hand dryers found in many public toilets. A review in 2012 concluded that "From a hygiene standpoint, paper towels are superior to air dryers; therefore, paper towels should be recommended for use in locations in which hygiene is paramount, such as hospitals and clinics."<ref name="Huang2012" />
Jet-air dryers were found to be capable of blowing micro-organisms from the hands and the unit and potentially contaminating other users and the environment up to {{Convert|2|m|ft|abbr=off}} away.<ref>{{cite report | url = http://www.europeantissue.com/pdfs/090402-2008%20WUS%20Westminster%20University%20hygiene%20study,%20nov2008.pdf | title = A comparative study of three different hand drying methods: paper towel, warm air dryer, jet air dryer | vauthors = Redway K, Fawdar S | date = November 2008 | publisher = The School of Biosciences, University of Westminster London }}</ref> In the same study in 2008 (sponsored by the paper-towel industry the European Tissue Symposium), use of a warm-air hand dryer spread micro-organisms only up to {{Convert|0.25|m|ft|abbr=off}} from the dryer, and paper towels showed no significant spread of micro-organisms. No studies have found a correlation to hand dryers and human health, however, making these findings inconsequential.
=== Accessibility === [[File:In Rwanda build where everyone can wash hand in prevention of covid-19.jpg|thumb|A community handwashing facility in Rwanda with sinks for people of different heights. During the COVID-19 pandemic in Rwanda handwashing was part of a system of public health measures encouraged to reduce transmission.]] Making hand washing facilities accessible (inclusive) to everyone is crucial to maintain hand washing behavior.<ref name=":5" />{{rp|27}} Considerations for accessibility include age, disability, seasonality (with rains and muddiness), location and more. Important aspects for good accessibility include: Placement of the technology, paths, ramps, steps, type of tap, soap placement.<ref name=":5" />{{rp|27}}
==Medical use== Medical hand-washing became mandatory long after Hungarian physician Ignaz Semmelweis discovered its effectiveness (in 1846) in preventing disease in a hospital environment.<ref name="NPR2015">{{cite news| vauthors = Davis R |title=The Doctor Who Championed Hand-Washing And Briefly Saved Lives|url=https://www.npr.org/sections/health-shots/2015/01/12/375663920/the-doctor-who-championed-hand-washing-and-saved-women-s-lives|agency=NPR|date=2015}}</ref> There are electronic devices that provide feedback to remind hospital staff to wash their hands when they forget.<ref>{{cite journal | vauthors = Boyce JM | title = Measuring healthcare worker hand hygiene activity: current practices and emerging technologies | journal = Infection Control and Hospital Epidemiology | volume = 32 | issue = 10 | pages = 1016–28 | date = October 2011 | pmid = 21931253 | doi = 10.1086/662015 | s2cid = 19428439 }}</ref> One study has found decreased infection rates with their use.<ref>{{cite journal | vauthors = Swoboda SM, Earsing K, Strauss K, Lane S, Lipsett PA | title = Electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit | journal = Critical Care Medicine | volume = 32 | issue = 2 | pages = 358–63 | date = February 2004 | pmid = 14758148 | doi = 10.1097/01.CCM.0000108866.48795.0F | s2cid = 9817602 }}</ref>
===Method=== Medical hand-washing is for a minimum of 15 seconds, using generous amounts of soap and water or gel to lather and rub each part of the hands.<ref>{{cite journal | vauthors = Larson EL | title = APIC guideline for handwashing and hand antisepsis in health care settings | journal = American Journal of Infection Control | volume = 23 | issue = 4 | pages = 251–69 | date = August 1995 | pmid = 7503437 | doi = 10.1016/0196-6553(95)90070-5 | url = http://www.handhygiene.net/hand-washing/ | doi-access = free | url-access = subscription }}</ref> Hands should be rubbed together with digits interlocking. If there is debris under fingernails, a bristle brush may be used to remove it. Since pathogens may remain in the water on the hands, it is important to rinse well and wipe dry with a clean towel.<ref>{{cite web |website=World Health Organization |url= https://www.who.int/gpsc/5may/hh-surgicalA3.pdf |archive-url=https://web.archive.org/web/20160429050330/https://www.who.int/gpsc/5may/hh-surgicalA3.pdf |archive-date=2016-04-29 |title= Surgical Handrubbing Technique |language= en }}</ref> After drying, the paper towel should be used to turn off the water (and open any exit door if necessary). This avoids re-contaminating the hands from those surfaces.
The purpose of hand-washing in the health-care setting is to remove pathogenic microorganisms ("germs") and avoid transmitting them. The ''New England Journal of Medicine'' reports that a lack of hand-washing remains at unacceptable levels in most medical environments, with large numbers of doctors and nurses routinely forgetting to wash their hands before touching patients, thus transmitting microorganisms.<ref>{{cite journal | vauthors = Goldmann D | title = System failure versus personal accountability--the case for clean hands | journal = The New England Journal of Medicine | volume = 355 | issue = 2 | pages = 121–3 | date = July 2006 | pmid = 16837675 | doi = 10.1056/NEJMp068118 | doi-access = free }}</ref> One study showed that proper hand-washing and other simple procedures can decrease the rate of catheter-related bloodstream infections by 66%.<ref>{{cite journal | vauthors = Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C | display-authors = 6 | title = An intervention to decrease catheter-related bloodstream infections in the ICU | journal = The New England Journal of Medicine | volume = 355 | issue = 26 | pages = 2725–32 | date = December 2006 | pmid = 17192537 | doi = 10.1056/NEJMoa061115 | doi-access = free }}</ref> thumb|Video demonstration on hand washing
The World Health Organization has published a sheet demonstrating standard hand-washing and hand-rubbing in health-care sectors.<ref name=hhhh>{{cite web | last = World Health Organization | title = How to Handrub & How to Handwash | url =https://www.who.int/gpsc/tools/GPSC-HandRub-Wash.pdf | access-date = 21 July 2008 | author-link = World Health Organization}}</ref> The draft guidance of hand hygiene by the organization can also be found at its website for public comment.<ref name=wghh>{{cite web | last = World Health Organization | title = WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft) | url =https://www.who.int/patientsafety/information_centre/Last_April_versionHH_Guidelines%5B3%5D.pdf | access-date = 21 July 2008 | archive-url = https://web.archive.org/web/20220308042712/https://www.who.int/patientsafety/information_centre/Last_April_versionHH_Guidelines[3].pdf | archive-date = 8 March 2022 | author-link = World Health Organization}}</ref> A relevant review was conducted by Whitby ''et al.''<ref name=cvvs>{{cite journal | vauthors = Whitby M, Pessoa-Silva CL, McLaws ML, Allegranzi B, Sax H, Larson E, Seto WH, Donaldson L, Pittet D | display-authors = 6 | title = Behavioural considerations for hand hygiene practices: the basic building blocks | journal = The Journal of Hospital Infection | volume = 65 | issue = 1 | pages = 1–8 | date = January 2007 | pmid = 17145101 | doi = 10.1016/j.jhin.2006.09.026 }}</ref> Commercial devices can measure and validate hand hygiene, if demonstration of regulatory compliance is required.
The World Health Organization has "Five Moments" for washing hands: * before patient care * after environmental contact * after exposure to blood/body fluids * before an aseptic task, and * after patient care. The addition of antiseptic chemicals to soap ("medicated" or "antimicrobial" soaps) confers killing action to a hand-washing agent. Such killing action may be desired before performing surgery or in settings in which antibiotic-resistant organisms are highly prevalent.<ref>[https://www.who.int/patientsafety/events/05/HH_en.pdf WHO Guidelines on Hand Hygiene in Health Care]</ref>
To 'scrub' one's hands for a surgical operation, it is necessary to have a tap that can be turned on and off without touching it with the hands, some chlorhexidine or iodine wash, sterile towels for drying the hands after washing, and a sterile brush for scrubbing and another sterile instrument for cleaning under the fingernails. All jewelry should be removed. This procedure requires washing the hands and forearms up to the elbow, usually 2–6 minutes. Long scrub-times (10 minutes) are not necessary. When rinsing, water on the forearms must be prevented from running back to the hands. After hand-washing is completed, the hands are dried with a sterile cloth and a surgical gown is donned.{{citation needed|date=June 2020}}
{{Further|Jewelry hygiene}}
===Effectiveness in healthcare settings=== thumb|Microbial growth on a cultivation plate without procedures (A), after washing hands with soap (B) and after disinfection with alcohol (C)|leftTo reduce the spread of pathogens, it is better to wash the hands or use a hand antiseptic before and after tending to a sick person.
For control of staphylococcal infections in hospitals, it has been found that the greatest benefit from hand-cleansing came from the first 20% of washing, and that very little additional benefit was gained when hand cleansing frequency was increased beyond 35%.<ref>{{cite journal | vauthors = Beggs CB, Shepherd SJ, Kerr KG | title = Increasing the frequency of hand washing by healthcare workers does not lead to commensurate reductions in staphylococcal infection in a hospital ward | journal = BMC Infectious Diseases | volume = 8 | article-number = 114 | date = September 2008 | pmid = 18764942 | pmc = 2553083 | doi = 10.1186/1471-2334-8-114 | doi-access = free }}</ref> Washing with plain soap results in more than triple the rate of bacterial infectious disease transmitted to food as compared to washing with antibacterial soap.<ref>{{cite journal | vauthors = Fischler GE, Fuls JL, Dail EW, Duran MH, Rodgers ND, Waggoner AL | title = Effect of hand wash agents on controlling the transmission of pathogenic bacteria from hands to food | journal = Journal of Food Protection | volume = 70 | issue = 12 | pages = 2873–7 | date = December 2007 | pmid = 18095447 | doi = 10.4315/0362-028X-70.12.2873 | doi-access = free }}</ref>
Comparing hand-rubbing with alcohol-based solution with hand washing with antibacterial soap for a median time of 30 seconds each showed that the alcohol hand-rubbing reduced bacterial contamination 26% more than the antibacterial soap.<ref>{{cite journal | vauthors = Girou E, Loyeau S, Legrand P, Oppein F, Brun-Buisson C | title = Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial | journal = BMJ | volume = 325 | issue = 7360 | page = 362 | date = August 2002 | pmid = 12183307 | pmc = 117885 | doi = 10.1136/bmj.325.7360.362 }}</ref> But soap and water is more effective than alcohol-based hand rubs for reducing H1N1 influenza A virus<ref>{{cite journal | vauthors = Grayson ML, Melvani S, Druce J, Barr IG, Ballard SA, Johnson PD, Mastorakos T, Birch C | display-authors = 6 | title = Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers | journal = Clinical Infectious Diseases | volume = 48 | issue = 3 | pages = 285–91 | date = February 2009 | pmid = 19115974 | doi = 10.1086/595845 | doi-access = free }}</ref> and Clostridioides difficile spores from hands.<ref>{{cite journal | vauthors = Jabbar U, Leischner J, Kasper D, Gerber R, Sambol SP, Parada JP, Johnson S, Gerding DN | display-authors = 6 | title = Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands | journal = Infection Control and Hospital Epidemiology | volume = 31 | issue = 6 | pages = 565–70 | date = June 2010 | pmid = 20429659 | doi = 10.1086/652772 | s2cid = 205994880 }}</ref>
Interventions to improve hand hygiene in healthcare settings can involve education for staff on hand washing, increasing the availability of alcohol-based hand rub, and written and verbal reminders to staff.<ref name=":0" /> There is a need for more research into which of these interventions are most effective in different healthcare settings.<ref name=":0">{{cite journal | vauthors = Gould DJ, Moralejo D, Drey N, Chudleigh JH, Taljaard M | title = Interventions to improve hand hygiene compliance in patient care | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | article-number = CD005186 | date = September 2017 | issue = 9 | pmid = 28862335 | pmc = 6483670 | doi = 10.1002/14651858.CD005186.pub4 }}</ref>
==Developing countries== {{owidslider |start = 2024 |list = Template:OWID/Share rural basic handwashing#gallery |location = commons |caption = |title = |language = |file = link=|thumb|upright=1.6|right|Share rural basic handwashing |startingView = World }} [[File:Proportion of population with basic handwashing facilities on premises, OWID.svg|thumb|World map for SDG 6 Indicator 6.2.1b in 2022: "Share of the population with basic handwashing facilities on premises"<ref name="OWID-handwashing">Ritchie, Roser, Mispy, Ortiz-Ospina (2018) [https://sdg-tracker.org/water-and-sanitation "Measuring progress towards the Sustainable Development Goals." (SDG 6)] ''SDG-Tracker.org, website''</ref>]]In developing countries, hand washing with soap is recognized as a cost-effective, essential tool for achieving good health, and even good nutrition.<ref name="UNICEF2012" /> However, a lack of reliable water supply, soap or hand washing facilities in people's homes, at schools and the workplace make it a challenge to achieve universal hand washing behaviors. For example, in most of rural Africa hand washing taps close to every private or public toilet are scarce, even though cheap options exist to build hand washing stations.<ref name=":1">{{cite web | vauthors = Morgan P | date = 2011 | url = http://www.susana.org/en/resources/library/details/1490 | title = Hand washing devices – How to make and use | publisher = Aquamor Pvt Ltd. | location = Zimbabwe }}</ref> However, low hand washing rates can also be the result of engrained habits rather than due to a lack of soap or water.<ref>{{cite web | vauthors = Curtis V, Scott B, Cardosi J | date = 2000 | url = http://www.susana.org/en/resources/library/details/427 | title = The Handwashing Handbook – A guide for developing a hygiene promotion program to increase handwashing with soap. | publisher = The International Bank for Reconstruction and Development/The World Bank }}</ref>
Hand washing at a global level has its own indicator within Sustainable Development Goal 6, Target 6.2 which states "By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations.<ref name="OWID-handwashing" /> The corresponding Indicator 6.2.1 is formulated as follows: "Proportion of population using (a) safely managed sanitation services and (b) a hand-washing facility with soap and water" (see map to the right with data worldwide from 2017)."
===Promotion campaigns=== The promotion and advocacy of hand washing with soap can influence policy decisions, raise awareness about the benefits of hand washing and lead to long-term behavior change of the population.<ref>{{cite book | vauthors = Vujcic J, Ram PK | date = 2013 | url = http://www.susana.org/en/resources/library/details/1939 | title = Handwashing Promotion – Monitoring and Evaluation Module | publisher = UNICEF | location = New York }}</ref> For this to work effectively, monitoring and evaluation are necessary. A systematic review of 70 studies found that community-based approaches are effective at increasing hand washing in LMICs, while social marketing campaigns are less effective.<ref>{{Cite journal| vauthors = De Buck E, Van Remoortel H, Hannes K, Govender T, Naidoo S, Avau B, Veegaete AJ, Musekiwa A, Lutje V, Cargo M, Mosler HJ |date=19 May 2017|title=Approaches to promote handwashing and sanitation behaviour change in low- and middle-income countries: a mixed method systematic review|journal=Campbell Systematic Reviews |volume=13 |issue=1 |pages=1–447 |doi=10.4073/csr.2017.7 |doi-access=free}}</ref> thumb|Poster used in Africa for raising awareness about hand washing after using the toilet with simple low-cost hand washing device
One example for hand washing promotion in schools is the "Three Star Approach" by UNICEF that encourages schools to take simple, inexpensive steps to ensure that students wash their hands with soap, among other hygienic requirements. When minimum standards are achieved, schools can move from one to ultimately three stars.<ref>{{cite book | author = UNICEF, GIZ | date =2013 | title = Field Guide | chapter-url = http://www.susana.org/en/resources/library/details/1839 | chapter = The Three Star Approach for WASH in Schools | publisher = United Nations Children's Fund and Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) | location = Eschborn, Germany }}</ref> Building hand washing stations can be a part of hand washing promotion campaigns that are carried out to reduce diseases and child mortality.
Global Handwashing Day is another example of an awareness-raising campaign that is trying to achieve behavior change.<ref>{{cite book | author = PPPHW | date = 2014 | url = http://globalhandwashing.org/resources/ghd-planners-guide/ | title = Global Handwashing Day Planner's Guide | edition = 3rd | publisher = FHI 360 for the Global Public-Private Partnership for Handwashing with Soap }}</ref> World Hand Hygiene Day, which is commemorated annually on 5 May, is a global initiative aimed at promoting awareness of the pivotal role of hand hygiene in preventing infections in healthcare settings. The programme was initiated by the World Health Organization (WHO) in 2009.<ref>{{Cite web |title=World Hand Hygiene Day |url=https://www.who.int/campaigns/world-hand-hygiene-day |access-date=2025-11-13 |website=www.who.int |language=en}}</ref>
As a result of the ongoing COVID-19 pandemic, UNICEF promoted the adoption of a hand washing emoji.<ref>{{Cite web|url=https://www.unicef.org/eap/handwashing-emoji|title=What about a handwashing emoji??!|website=www.unicef.org|language=en|access-date=2020-03-13}}</ref>
Designing hand washing facilities that encourage use can use the following aspects:<ref name=":5" /> * Nudges, cues and reminders * Hand washing facilities should be placed at convenient locations to encourage people to use them regularly and at the right times; they should be attractive and well maintained.
===Cost effectiveness=== [[File:Handwashing stands - WASH in schools - India (37547981435).jpg|thumb|Hand washing stands at a school in Mysore district, Karnataka, India]]Few studies have considered the overall cost effectiveness of hand washing in developing countries in relationship to DALYs averted. However, one review suggests that promoting hand washing with soap is significantly more cost-effective than other water and sanitation interventions.<ref name="cairncross2006">{{cite book| vauthors = Cairncross S, Valdmanis V | veditors = Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, Jha P, Mills A, Musgrove P | display-editors = 6 |title=Disease Control Priorities in Developing Countries|date=2006|publisher=World Bank Group|isbn=978-0-8213-6179-5| doi=10.1596/978-0-8213-6179-5| pages=771–92|chapter-url=http://dcp-3.org/sites/default/files/dcp2/DCP41.pdf |chapter=41: Water Supply, Sanitation, and Hygiene Promotion |pmid=21250333 |edition=Second}}</ref>
{| class="wikitable" |+ Cost-Effectiveness of Water Supply, Sanitation and Hygiene Promotion<ref name="cairncross2006" /> |- ! Intervention ! Costs (US$/DALY) |- | Hand-pump or standpost | 94 |- | House water connection | 223 |- | Water sector regulation | 47 |- |Basic sanitation – construction and promotion | ≤270 |- |Sanitation promotion only | 11.2 |- |Hygiene promotion |3.4 |}
==History== [[File:Wash your hands DC metro.jpg|thumb|Electronic sign inside a Washington Metro station during the COVID-19 pandemic]]
The importance of hand washing for human health{{snd}}particularly for people in vulnerable circumstances like mothers who had just given birth or wounded soldiers in hospitals{{snd}}was recognized by several pioneers of medicine during the 18th and 19th century: the English obstetrician Charles White in 1777, the Scottish physician Alexander Gordon in 1795,<ref>{{Cite journal |last=Moore |first=Wendy |date=2007-08-25 |title=Now wash your hands |journal=BMJ |language=en |volume=335 |issue=7616 |pages=402.2–402 |doi=10.1136/bmj.39314.598854.59 |issn=0959-8138 |pmc=1952521}}</ref> the Scottish obstetrician James Young Simpson in 1840,<ref>{{Cite journal |last=Wong |first=Cynthia A. |date=2011-09-01 |title=Simpson |url=http://www.jci.org/articles/view/58960 |journal=Journal of Clinical Investigation |language=en |volume=121 |issue=9 |page=3365 |doi=10.1172/JCI58960 |issn=0021-9738}}</ref> the American physician Oliver Wendell Holmes in 1843;<ref>{{Cite web |last=Markel |first=Howard |author-link=Howard Markel |date=2020-08-28 |title=Why you can thank Oliver Wendell Holmes Sr. for doctors washing their hands |url=https://www.pbs.org/newshour/health/why-you-can-thank-oliver-wendell-holmes-sr-for-doctors-washing-their-hands |access-date=2025-08-02 |website=PBS News |language=en-us}}</ref><ref name=":9">{{Cite journal |last1=Lane |first1=Hilary J. |last2=Blum |first2=Nava |last3=Fee |first3=Elizabeth |date=June 2010 |title=Oliver Wendell Holmes (1809–1894) and Ignaz Philipp Semmelweis (1818–1865): Preventing the Transmission of Puerperal Fever |journal=American Journal of Public Health |language=en |volume=100 |issue=6 |pages=1008–1009 |doi=10.2105/AJPH.2009.185363 |pmid=20395569 |issn=0090-0036|pmc=2866610 }}</ref> the Hungarian obstetrician Ignaz Semmelweis in 1847;<ref name=":9" /><ref>{{Cite journal |last1=Tyagi |first1=Uvi |last2=Barwal |first2=Kailash Chander |date=May 21, 2020 |title=Ignac Semmelweis—Father of Hand Hygiene |journal=Indian Journal of Surgery |language=en |volume=82 |issue=3 |pages=276–277 |doi=10.1007/s12262-020-02386-6 |issn=0972-2068 |pmc=7240806 |pmid=32837058}}</ref> and Florence Nightingale, the English "founder of modern nursing", during the Crimean War.<ref>{{Cite journal |last1=Martini |first1=Mariano |last2=Lippi |first2=Donatella |date=2021-10-15 |title=SARS-CoV-2 (COVID-19) and the Teaching of Ignaz Semmelweis and Florence Nightingale: a Lesson of Public Health from History, after the "Introduction of Handwashing" (1847) |url=https://www.jpmh.org/index.php/jpmh/article/view/2161 |journal=Journal of Preventive Medicine and Hygiene |volume=62 |issue=3 |language=en |pages=E621–E624 |doi=10.15167/2421-4248/JPMH2021.62.3.2161 |pmc=8639136 |pmid=34909488}}</ref> At the time, most people still believed that infections were caused by foul odors called miasmas.
In the 1980s, foodborne outbreaks and healthcare-associated infections led the United States Centers for Disease Control and Prevention to more actively promote hand hygiene as an important way to prevent the spread of infection.{{citation needed|date=April 2015}} The outbreak of swine flu in 2009 and the COVID-19 pandemic in 2020 led to increased awareness in many countries of the importance of washing hands with soap to protect oneself from such infectious diseases.<ref name="who-workplace-covid19"/> For example, posters with "correct hand washing techniques" were hung up next to hand washing sinks in public toilets and in the toilets of office buildings and airports in Germany.{{citation needed|date=April 2015}} Research indicates that the COVID pandemic shifted social norms regarding hand washing, making it more prevalent worldwide.<ref>{{Cite journal |last1=Andrighetto |first1=Giulia |last2=Szekely |first2=Aron |last3=Guido |first3=Andrea |last4=Gelfand |first4=Michele |last5=Abernathy |first5=Jered |last6=Arikan |first6=Gizem |last7=Aycan |first7=Zeynep |last8=Bankar |first8=Shweta |last9=Barrera |first9=Davide |last10=Basnight-Brown |first10=Dana |last11=Belaus |first11=Anabel |last12=Berezina |first12=Elizaveta |last13=Blumen |first13=Sheyla |last14=Boski |first14=Paweł |last15=Bui |first15=Huyen Thi Thu |date=2024 |title=Changes in social norms during the early stages of the COVID-19 pandemic across 43 countries |journal=Nature Communications |language=en |volume=15 |issue=1 |page=1436 |doi=10.1038/s41467-024-44999-5 |pmid=38365869 |pmc=10873354 |bibcode=2024NatCo..15.1436A |issn=2041-1723|hdl=10071/31245 |hdl-access=free }}</ref>
==Society and culture==
===Moral aspects=== The phrase "washing one's hands of" something, means declaring one's unwillingness to take responsibility for the thing or share complicity in it. It originates from the bible passage in Matthew where Pontius Pilate washed his hands of the decision to crucify Jesus Christ, but has become a phrase with a much wider usage in some English communities.<ref>{{Cite OED|term=wash|id=1093006561|subsection=to wash one's hands of|subid=5628170136|access-date=August 2, 2016}}</ref>
In Shakespeare's Macbeth, Lady Macbeth begins to compulsively wash her hands in an attempt to cleanse an imagined stain, representing her guilty conscience regarding crimes she had committed and induced her husband to commit.<ref>{{cite journal | vauthors = Zhong CB, Liljenquist K | title = Washing away your sins: threatened morality and physical cleansing | journal = Science | volume = 313 | issue = 5792 | pages = 1451–2 | date = September 2006 | pmid = 16960010 | doi = 10.1126/science.1130726 | s2cid = 33103635 | citeseerx = 10.1.1.181.571 | bibcode = 2006Sci...313.1451Z }}<br />{{cite journal | vauthors = Wheatley T, Haidt J | title = Hypnotic disgust makes moral judgments more severe | journal = Psychological Science | volume = 16 | issue = 10 | pages = 780–4 | date = October 2005 | pmid = 16181440 | doi = 10.1111/j.1467-9280.2005.01614.x | s2cid = 14114448 }}</ref>
== See also == {{Portal|Viruses}}
{{Columns-list|colwidth=30em| * Antibiotic resistance * Didier Pittet, an infectious diseases expert * Food safety * Bactericide * Global Handwashing Day * Nosocomial infection * Occupational biosafety * Public health * Patient safety * Rubbing alcohol * Virucide }}
== References == {{reflist}}
== External links == {{Commons category|Hand washing}} {{Wikiquote}} {{Wiktionary|handwashing}} {{Wikiversity|Healthy lifestyle/Hand washing}} * [https://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf Hand Hygiene: Why, How & When?] (PDF from the World Health Organization) * [https://www.cdc.gov/handhygiene/ Centers for Disease Control on hand hygiene in healthcare settings] * [https://globalhandwashing.org/ Global Public-Private Partnership for Hand washing] * [https://www.flickr.com/photos/gtzecosan/sets/72157625967026368/ Photos of low-cost hand washing installations in developing countries] (collected by Sustainable Sanitation Alliance) * [https://manhattancbt.com/archives/198/handwashing-how-much-is-too-much/ OCD and Hand Washing] * [https://www.youtube.com/watch?v=3PmVJQUCm4E WHO: How to handwash with soap and water] (video)
{{Offline|med-inline|Hand washing}} {{Medical harm}} {{public health}} {{Bathroom appliances}} {{Concepts in infectious disease}} {{Authority control}}
{{DEFAULTSORT:Hand Washing}} Category:Articles containing video clips Category:Hand Category:Hygiene Category:Medical hygiene Category:Sanitation