Germs, disease sanitation in society

Conway McLEAN, DPM

Another week has passed, and we find ourselves here again. Today, I am hoping you are prepared to be educated. A subject of some debate (as well as a significant amount of ignorance and misinformation), is that of proper sanitary practice. The spread of disease because of poor practices is commonplace and not a rarity. Yet, many Americans are obsessed with “germs” and their place in our lives. Is this concern appropriate? And is it based in wisdom or hear-say. These are important questions which need to be answered.

Clearly, the basic sanitary practices we’ve developed as a society over the past few centuries have provided many health benefits. They are a critical reason so few Americans get infectious diseases like cholera or typhoid. One obvious example of these practices would be the creation of an infrastructure to remove garbage and sewage from cities. These systems were not always the norm.

Until the mid-19th century, we were uncertain what exactly caused infectious diseases. Contagions swept through Europe, especially urban areas, regularly. The reigning explanation for the spread of disease was the miasmic, or anticontagionist, theory.

This theory held that disease was caused by sewer gas, garbage fumes, and poor sanitation. Although false, these beliefs gave rise to the Great Sanitary Awakening, the rise of organized public initiatives to improve sanitation in the U.S. as well as urban centers in Europe.

Our awareness of “germs” and the field of infectious disease has come a long way. But has it come too far? Over the last thirty years or so, doctors have developed a new and rather odd hypothesis, one that may be counterintuitive, about our modern, ultra-sanitized world. Too much cleanliness may be causing us to develop autoimmune disorders at a significantly greater rate.

These include such common maladies as allergies, asthma, inflammatory bowel diseases, and others. A growing body of evidence seems to show that our immune system needs to be educated, that being exposed to microbes helps in the education of an infant’s immune system. Perhaps it is the lack of exposure to bacteria, viruses, and other allergens, for many wealthy children, that prevents the immune system from learning what to attack. Without this exposure, it may be more prone to attacking the wrong target: ourselves!

Indeed, researchers have found that a few specific autoimmune diseases — asthma, hay fever, inflammatory bowel diseases, and various allergies — have become much more common as we’ve become more sanitary. This would explain why they are much more prevalent in the wealthy world than the developing one. This connection was first made in the late 1980s, when a British epidemiologist was studying childhood allergies in Germany. In the dirtier, more polluted, less wealthy cities, children had much lower rates of hay fever and asthma than in the cleaner, richer cities. He proposed that their reduced exposure to bacteria and other antigens, normally acquired from other children, somehow affected their immune systems, leading to their increased chance of developing one of these autoimmune diseases.

Despite the possibility that fanatical cleanliness can cause real health issues, no one is suggesting proper sanitary methods are unnecessary. Certainly, in the health care field, they are essential. Infections acquired in a health care setting have become a tremendous concern. But our overuse of antibiotics has led to an abundance of resistant bacteria, which means treating an existing infection is becoming progressively more challenging. Thus, as per the well-worn cliche, an ounce of prevention is worth a pound of cure.

This is an issue appropriately receiving great attention. One in 25 patients acquires a health care-associated infection during their hospital care, adding up to about 722,000 infections a year. Of these, 75,000 patients die of their infections. Even the most advanced health care will not work if those involved in patient care neglect basic practices. Although new technology has made an impact, the most important preventative measure we are failing to implement fully may be the simplest. Hand sanitization has been clearly identified as the most easily instituted and impactful method of reducing hospital-acquired infections.

In the mid-1800s, the concept of hand hygiene was first introduced by a Hungarian physician named Semmelweis, who found that when physicians washed their hands before delivering babies, it prevented deaths in postpartum women. Although Semmelweis was initially ridiculed for this suggestion, eventually it was recognized that he was correct. All the efforts to reduce the spread of infectious organisms in the health care setting can easily be nullified if workers don’t wash their hands.

Many programs to promote a higher rate of hand sanitization have been instituted, but often have failed. It has been difficult to get to a level of compliance where we’re able to make changes to infection rates. Despite all the published and accepted guidelines for hand hygiene, and all the protocols for performing this task in hospitals, compliance rates for appropriate hand hygiene are far from where they should be. It has taken a long and sustained effort and a multifaceted intervention to change behavior that is already ingrained.

There is certainly an awareness of hand hygiene among health care workers. Everyone knows the importance and wants to perform the appropriate measures. Yet there remains a lack of compliance. One potential reason for this is the target is invisible. Many do not realize they are carrying pathogens on their hands because they cannot see them. Another reason is they cannot link their contact with a patient, when pathogens may be transmitted from their contaminated hands, to an infection that may result days or even months later. We need to make hand hygiene hardwired so that we do it without even thinking about it.

This leads to the next critical question: how best to achieve proper, effective hand hygiene? There seem to be a lot of strong opinions about what is the best method. Some people say that washing your hands with soap is better while others vouch for sanitizers. What is actually the best way to clean your hands and protect yourself against germs that can make you sick?

Alcohol-based hand rubs have been widely adopted in healthcare facilities because of their convenience, speed of use, skin health benefits, ability to be used independently of sinks, and superior efficacy. In a laboratory setting, alcohol-based hand rubs performed the best. Because of this, the Centers for Disease Control and Prevention has made the recommendation that these should be used in the majority of clinical situations. Yes, you read that correctly: when hands are not visibly soiled, hand sanitizers are recommended. Hand sanitizers work faster and are better for most things.

Now you know: if there is no visible debris or dirt, alcohol-based hand sanitizers are best (but only if it’s 60% or greater). And fanaticism is bad, certainly when it comes to an obsession about germs and sanitation. Microorganisms are part of our world, and we cannot change that. The use of exam gloves for any and all patient contact has had an impact, but proper hand hygiene techniques still need to be implemented in all health care facilities. So go to the store and get some hand sanitizer. Germs won’t be glad you did!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with an upcoming move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments