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Year : 2021  |  Volume : 48  |  Issue : 2  |  Page : 60-64

Practice of handwashing: An effective tool to control COVID-19 pandemic

Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission18-Nov-2020
Date of Acceptance01-May-2021
Date of Web Publication18-Aug-2021

Correspondence Address:
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jss.jss_110_20

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Coronavirus disease 2019 (COVID-19) is a dreaded disease affecting the whole world with no proven pharmaceutical intervention and also no proven vaccine available till now. It is caused by a novel virus called as severe acute respiratory syndrome coronavirus 2. This virus is highly contagious and spread through the droplets of the infected persons by coughing, sneezing, or even touching the infected surface. In such situation, prevention is an important option to control this COVID-19 infection. The role of the handwashing for preventing the communicable diseases has been known for more than century. Handwashing is an inexpensive and widely available protective measure for both personal and pandemic prevention of the viral respiratory tract infections. However, it remains a neglected public health measure in pandemic. Educating for hand hygiene is remarkably beneficial for prevention of the COVID-19 infections. Alcohol-based sanitizers with moisturizers have least irritancy and sensitizing potential in comparison to the soaps and synthetic detergents.

Keywords: Coronavirus disease 2019 pandemic, handwashing, sanitizers, severe acute respiratory syndrome coronavirus 2

How to cite this article:
Swain SK. Practice of handwashing: An effective tool to control COVID-19 pandemic. J Sci Soc 2021;48:60-4

How to cite this URL:
Swain SK. Practice of handwashing: An effective tool to control COVID-19 pandemic. J Sci Soc [serial online] 2021 [cited 2023 Mar 29];48:60-4. Available from: https://www.jscisociety.com/text.asp?2021/48/2/60/324071

  Introduction Top

Coronavirus disease 2019 (COVID-19) is an acute respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1] The outbreak of COVID-19 started at Wuhan, China in late December 2019 and rapidly spread to whole world.[2] It continues to spread globally and even outpacing the resources of the health care systems worldwide. The clinical presentations of the COVID-19 infection may take up to 14 days to appear after exposure of the person to the virus and the symptoms range from mild illness to severe form such pneumonia and may result in life-threatening complication such as respiratory failure and death.[3] The World Health Organization (WHO) declared COVID-19 outbreak as global pandemic in March 2020 and warned all countries for taking all measures to reduce the transmission of the infection.[4] Till now no established vaccines available for controlling COVID-19 infection. Handwashing is an important measure and in the present situation strongly adopted by the WHO to curb the transmission of the infection. The importance of handwashing in the prevention of the communicable disease has been known for century, yet it was neglected but rediscovered during current pandemic for prevention of the transmission of SARS-CoV-2 infections. Hand hygiene is widely accepted principle for the prevention of the transmission of this disease. Hence, it is important to know about the details of handwashing with sanitizers including its advantages and negative effect on the skin. Frequent handwashing makes exposure to water and other chemical or physical agents which may lead to certain pathophysiological alteration such as epidermal barrier disruption, changes in keratinocytes, release of pro-inflammatory cytokines, activation of the dermal immune system, and delayed type of hypersensitivity reactions. There are not many studies regarding handwashing. Here, this review article focuses on the importance of handwashing including its side effects during current COVID-19 pandemic.

  Methods of Literature Search Top

For searching the published articles, we conducted an electronic search of the Google Scholar, Medline, Scopus, and PubMed databases. The search term in the database included handwashing, hand hygiene, COVID-19 pandemic, and sanitizers. The abstracts of the published articles identified manually from the citations. This review article reviews the role of handwashing in COVID-19 pandemic. This article presents a baseline from where further prospective trials can be designed and help as a spur for further research in this common and easy technique of handwashing and its impact in current COVID-19 pandemic. This review article also gives awareness among the health care workers to stop the transmission of the COVID-19 infection with help of hand washing.

  Epidemiology Top

Currently, the global attention is mainly on the COVID-19 pandemic. COVID-19 infection is highly contagious and dreaded infection of the respiratory system. The first case of COVID-19 was reported in Wuhan, China in late December 2019 where the outbreak of this novel coronavirus happened and now called as SARS-CoV-2 which spreaded worldwide in short span of time.[5] The death percentage among 2684 COVID-19 positive cases was around 2.84% as of January 25, 2020 and the median age of the patients those died was 75 years (age range 48–89 years).[6] By February 27, 2020, >82,000 COVID-19 positive cases and >2800 deaths have been documented of which around 95% of the cases and 97% of deaths were in China.[7] By March 26, 2020, there were 4,62,684 cases of the COVID-19 documented in 199 countries and now reaches to death toll of >1 million in the world.[8] Prevention of the human-to-human transmission is challenging since onset of the influenza pandemic in 1918.[9] SARS-CoV-2 mainly spread through respiratory droplets, air-borne and contaminated areas.[10] The WHO declared COVID-19 as pandemic on March 11, 2020.[11] After that, most of the countries declared preparedness plans for COVID-19 such as lock-down, self-isolation, social distancing, wearing face mask, and handwashing. Handwashing or hand hygiene is considered as a vital element for controlling the infection. During the outbreak of the SARS, handwashing was very effective in blocking the spread of the virus.[12] Different studies on handwashing are showing that respiratory illness can be controlled by effective handwashing through breaking the transmission cycle and it reduces the risk of transmission between 6% and 44%.[13],[14] Hand hygiene is a widely accepted principle in the prevention of the disease as hand hygiene has 24%–31% for the description of the likelihood of the reduction of the decreasing the transmissible disease.[15] Evidence from other studies showed that frequent hand washing will reduce the risk of viral transmission by 55%.[12]

  Coronavirus Disease 2019 Virus Top

COVID-19 infection is caused by the SARS-CoV-2. This virus is an encapsulated or enveloped positive-strand RNA virus [Figure 1] which can be classified into four genera such as alpha, beta, delta, and gamma. Out of these four types, alpha and beta are known to infect human beings.[16] The size of coronavirus ranges from 60 nm to 140 nm with spike-like projection from the surface as a crown-like appearance under electron microscope, so the name coronavirus.[17] The spikes over the surface of the SARS-CoV-2 are made up of glycoprotein which acts as critical for binding to the host cell receptors and plays an important role in severity of the infections of the host.[16] The incubation period of the SARS-CoV-2 virus ranges from 1 to 14 days with a median of 5–6 days. Although recent study document that the incubation period may extend to 24 days.[18] A longer incubation has implication in quarantine policies and the prevention of the spread of the disease. This virus is primarily not only transmitted through droplets but also it is seen in blood and stool, so raising question regarding the multiple modes of transmission.[19]
Figure 1: Structure of the coronavirus disease 2019 virus (red arrow is spike protein over lipid membrane, black arrow indicates RNA)

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  History of HandWashing Top

Handwashing is a fundamental preventive measure against several infectious diseases. Effective handwashing reduced the incidence of diarrhea, cholera, and pneumonia.[20] Poor handwashing enhances the risk of food-borne diseases. In underdeveloped countries, there is no basic handwashing facilities with soap and water. COVID-19 is a contagious disease which often spread by the droplets and touching the infected materials. By July 2020, the official death toll globally by COVID-19 infection had risen to 5, 28, 364.[21] There was frequent awareness in all media regarding frequent handwashing, wearing face mask, and social distancing. The center for disease control and prevention (CDC) and the WHO list frequent hand washing at the top of their preventive measures towards controlling the COVID-19 pandemic. In the month of March 2020, there are few potential adverse skin reactions which occur as a consequence of frequent hand washing. However, in current global pandemic, there is no way to deviate from strict protocol for hand hygiene rules which reduce the risk of transmission of the SARS-CoV-2.[22] The “Guardian” presented an article on hand hygiene and COVID-19 where a reputed biologist says: “Here's one thing you can do to lower your risk.”[23] The “New York Times” described by a professor of emergency medicine: Your hands carry all most all of year germs to lower airway. In March 20, 2020, Google doodle honored Dr. Semmelweis, the father of handwashing because of the work and emphasized about the correct hand washing for the prevention of COVID-19 infections.[24]

  Sanitizers Top

Hand hygiene products are available in different forms such as liquid or bar soaps, antiseptic handwashes, synthetic detergents, and alcohol-based hand sanitizers (ABHSs). Although each type of sanitizer can be used against COVID-19, these may alter the skin barrier integrity and function, so result in chance of dermatitis of the hand. The WHO recommends ABHS with atleast 60% alcohol as an alternative if soap and water are not available.[25] However, the CDC recommends the use of the ABHS for hand hygiene during patient care activities. ABHSs with moisturizers have minimal sensitizing and irritation in comparison to the soaps and synthetic detergents. ABHSs work by penetrating into the viral membrane to denature and coagulate the proteins, block the cellular metabolism and enhance the lyses of the viral particles.[26] One study evaluated the virucidal activity of the ABHSs where ethanol-based and isopropyl ABHSs were effective against SARS-CoV outbreak in 2002.[27] For COVID-19 infection, the CDC recommended ethanol >60% or isopropanol >70% for hand washing.[28] Isopropyl alcohol percentage is estimated on the basis of weight or by volume, for example, 70% alcohol by weight is equivalent to 76.8% by volume if preparation done at 158C or 80.5% if preparation done at 258C.[29] CDC also recommends ABHS which contains additionally emollients or moisturizers with low allergenicity. Disinfectant wipes are often used for disinfections. Hand wipes are usually formulated for the skin use and contain ingredients such as benzethonium chloride or alcohol for disinfection. Hand wipes contain antimicrobial ingredients which disrupt the viral membrane of the SARS-CoV-2. Alcohol-based hand wipes also damage the integrity of the viral membranes as in ABHS and so helpful in the COVID-19 pandemic. Wipes are usually designed for cleaning the surfaces and should not be applied on the skin. As the wipes have harsh disinfectants, these may cause chemical irritation and so should not used for hand hygiene.[30]

  Technique of HandWashing Top

The technique of rinsing the hands should be done gently to prevent physical irritation of the skin. The liberal application or use of the moisturizers after proper handwashing is an important step for maintaining the hydration of the skin and prevent any abnormal changes in the skin. It should be done just after handwashing. The combination of the humectants and occlusive emollients is a good choice for moisturizer of the hands. Humectants include topical urea, propylene glycol which attracts water to the stratum corneum and occlusive emollients. To prevent transmission of the virus, CDC recommends frequent handwashing by soap and water for 20 s. If the soap and water are not available, the hand sanitizer should contain at least 60% of the alcohol.[31] The temperature of the water does not affect the removal of the microbes, so it is recommended that lukewarm or cold water for avoiding skin irritation.[32] Hot water can affect the stratum corneum by lipid fluidization or disturbed lipid structure, causing increased skin permeability. Handwashing by soap and water just after or before the use of alcohol-based products is not required and increased the chances of hand dermatitis.[32]

  Adverse Effects of the Frequent Use of Sanitizers Top

In the COVID-19 pandemic, the essential recommendations by the WHO are hand washing frequently and correctly. In the process of intensified handwashing, it may result in several adverse effects on the skin of the hand. Frequent handwashing of the hands may produce several changes in the skin texture ranging from cutaneous xerosis/dryness of the skin to irritant contact dermatitis or rarely allergic contact dermatitis. These skin manifestations are usually induced by different physical, chemical, and immunological mechanisms. There are several adverse dermatological effects found in case of excessive handwashings such as excessive dryness of the skin or even contact dermatitis especially in persons with history of the atopic dermatitis. Maceration, eczema, dermatitis, and erosion of the hand skin are found due to frequent handwashing in current COVID-19 pandemic.[33] Health care professionals usually perform frequent handwashing with water and soap, causing potential complication of the damage to the skin. In one survey of 526 frontline COVID-19 health care professionals, 74.5% showed damage to the skin of the hand.[34] Health care professionals those washed their hands more than ten times per day showed more damage to the skin of the hand.[34] The damage to the skin may create a route for entry of the COVID-19 infection. Hence, basic skincare measure must be taken after hand washing. The cell receptor for the SARS-CoV-2 entry is angiotensin-converting enzyme 2 (ACE2), abundantly found in capillaries/blood vessels of the skin, particularly in the basal layer of the epidermis and hair follicles. These ACE2 is also present in eccrine glands.[35] Allergic contact dermatitis is a common side effect found in frequent hand washing. The development of intact allergic dermatitis needs sensitization to the particular allergen, followed by elicitation of the inflammatory response by secondary exposure to the allergen. There are several hand hygiene components are responsible for allergic contact dermatitis in hand including preservatives, surfactants, and antimicrobial agents.[36] Alcohol-based hand sanitizers may also possess allergens including propylene glycol and fragrance.[37] There are several measures for preventing hand eczema, erosion, and maceration due to frequent handwashing. Qualified sanitizers with ethanol as main constituent are helpful for hand decontamination and the use of the hand cream or moisturizers on the intact skin are helpful after hand washing.[33] At the time of hand washing, overly hot water can cause contact dermatitis, so this should be avoided.

  Best Practice of HandWashing Top

In the COVID-19 pandemic, it is very important to adopt the handwashing habits to ensure the protection against the SARS-CoV-2 spread and lower the risk of the adverse dermatological reaction on the hands. Universal precautions must be done in current pandemic because many COVID-19 positive patients are asymptomatic. As per the WHO recommendations, hand washing should be done thoroughly including inter-digital web spaces, wrists, and fingernails for at least 20 s with use of lukewarm water and soap particularly before meals, after sneezing or coughing, after being in public areas, after using toilets and whenever the hands are dirty. After handwashing, the rinsing of the hands should be done gentle without causing physical irritation to the skin. Health care professionals should wash their hands both before and after encountering the patients with the use of alcohol-based handwash and antiseptics with antiviral activity.[38] Handwashing must be done properly and special attention is needed for equal washing of all the areas of the hands. One study showed that fingertips, hypothenar eminence, and dorsum of the hand are commonly missed areas during hand washing.[39] Special care should be done for these missed areas during hand washing. Hypoallergic moisturizers, hand sanitizers, and gloves are important for the prevention of hand eczema. After hand washing, applying moisturizing skincare products is essential to keep the skin hydrated and to prevent further abnormal dermatological reactions. These hydrating products should be applied liberally, several times per day, specifically after hand washing. In case of person with highly sensitive skin which easily develops dermatitis, short course of topical corticosteroids can be used to minimize the signs and symptoms of the inflammations of the skin. Those who are wearing protective gloves, it is recommended to wash the hands and use moisturizers whenever gloves are taken off. Awareness about adverse effects for hand washing should be promoted such as avoids excessive handwashing, prolonged surgical scrubbing, and prolonged use of the gloves.[39] Regular skin hydration is the key factor for preventing hand dermatitis as a result of the frequent hand washing. For health care professionals, hand washing should be done both before and after touching the patients with the help of the strong ABHSs and antiseptics with antiviral activity.[29]

  Conclusion Top

COVID-19 infection is currently spreading to all countries of the world. Handwashing along with other preventive measures is considered as important part for the treatment of COVID-19 infection. Current COVID-19 pandemic resulted in increased awareness regarding hand hygiene. Hand washing is an accepted practice for the prevention of the transmission of the infectious disease. Hand hygiene is essential for decreasing the transmission of the COVID-19 infection. CDC recommends frequent hand washing with soap for preventing the transmission of the SARS-CoV-2. Hand hygiene products are available in different forms and each of them may be effective against SARS-CoV-2. There are variety of sanitizers for hand hygiene with varying safety and efficacy. Because of the risk for hand skin damage, rational hand hygiene measures should be done along with proper use of the hand gloves and moisturizers in current COVID-19 pandemic.

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