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Introduction: the potential role of hand antisepsis and environmental disinfection in day care and the home

Goldmann, Donald A. M.D.

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The Pediatric Infectious Disease Journal: October 2000 - Volume 19 - Issue 10 - p S95-S96
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The Healthy Home Summit (HHS) was convened to initiate an academic and professional dialog regarding prevention of infectious diseases that occur frequently in day care and the home. Specifically, participants were asked to critically examine whether proper use of antiseptics and disinfectants can reduce the transmission of infectious agents in these settings.

The faculty first reviewed the modes of transmission of common viral pathogens. Dr. Goldmann discussed evidence that respiratory syncytial virus is spread primarily by contamination of the hands with secretions from infected children or contaminated objects in the environment. Influenza can be transmitted through the air by droplet nuclei. Evidence regarding the principal mode of spread of rhinovirus is somewhat contradictory, with some studies favoring droplet or airborne transmission and others supporting inoculation of the eyes or nose with virus-contaminated hands. Dr. Dennehy reviewed the importance of rotavirus as a cause of diarrhea in infancy. She noted that the primary mode of spread undoubtedly is fecal-oral via contaminated hands. Rotavirus survives quite well on environmental surfaces, and some disinfectants do not kill virus effectively. Similarly handwashing with soap and water is not very effective in eliminating virus from the hands. In contrast alcohol-based disinfectants and alcohol-containing waterless hand gels kill rotavirus. Dr. Huskins reviewed transmission of important respiratory and gastrointestinal pathogens in day care. He provided an evaluation of published studies regarding interventions to reduce cross-infection in day care, noting that all had considerable methodologic problems.

Dr. Scott explored another threat to health in the home, foodborne bacterial pathogens. She also noted that raw meat and poultry are especially prone to contamination with pathogenic bacteria, including Campylobacter, enterohemorrhagic Escherichia coli and Salmonella. She noted that these microorganisms can survive in the kitchen environment on sponges and cutting surfaces and suggested that proper use of disinfectants may reduce inadvertent contamination of the hands and cross-contamination of foods that are consumed raw.

Dr. Ross-Degnan made the very important point that it is not enough to demonstrate that a particular practice or antimicrobial agent is effective in an experimental setting; people working in day care or living in the home must actually follow the recommended practices and procedures. He reviewed basic psychologic and sociologic approaches to changing behavior, noting that education alone has only a limited impact on practice. Dr. Levy reminded the faculty that antibiotic resistance has reached a critical stage throughout the world. He cautioned that antimicrobials are now being used indiscriminately in soaps and household products and that evidence is growing that bacteria can become resistant to these agents.

Dr. Krilov summarized his study of a multifaceted intervention (including use of an alcohol-based disinfectant) to reduce cross-infection in day care centers. Dr. Ackerman presented a cost effectiveness analysis of environmental disinfection, using the assumptions from Dr. Krilov’s study. Dr. Ross-Degnan and other members of the HHS faculty noted that the day care study represented an ambitious effort to perform a study in difficult experimental conditions, but noted that there were methodologic problems with the experiment. Therefore Dr. Ackerman’s findings should be viewed cautiously.

Mr. Rubino (Reckitt Benckiser) reviewed a considerable body of data demonstrating that Lysol, the alcohol-based disinfectant spray, has good in vitro and in vivo activity against viruses responsible for infection in day care and the home. Mr. Rosenberg (Reckitt Benckiser) presented a thorough review of current consumer attitudes regarding antisepsis and disinfection in the home and provided the faculty with insight into recent trends in the market for antiseptics and disinfectants.

On the basis of these presentations and the ensuing discussion, the HHS faculty considered unmet research needs. It was concluded that there are enormous methodologic hurdles to performing studies of interventions in day care and the home but that such studies are extremely important if consumers are to have sound, evidence-based advice regarding prevention of cross-infection. The faculty reached consensus on the following conclusions:

1. Infections acquired in the home, or brought into the home by a child in day care, have a significant impact on the health and quality of life of families as well as imposing a substantial economic burden on families and society.

2. Viral respiratory and gastrointestinal infections are a universal and ubiquitous feature of childhood. Although most of these viral infections are short-lived and do not cause serious illness, they can produce considerable morbidity, especially in children with underlying diseases. Bacterial gastroenteritis, caused by either contaminated food or person-to-person transmission, is increasingly recognized as a serious problem in day care and the home.

3. Although complete prevention of the spread of infection in the home is not possible, simple hygienic practices can play an important role in limiting exposure to disease-causing viruses and bacteria.

4. Handwashing is the single most important strategy for preventing transmission of many infectious diseases. Appropriate handwashing may reduce the risk of infection when performed after contact with contaminated body secretions and wastes from infected individuals, handling of certain raw foods and contact with contaminated objects and surfaces.

5. Targeted disinfection of objects and surfaces that are contaminated with stool or respiratory secretions from infected individuals may reduce the risk of cross-infection.

6. Disinfection of kitchen surfaces, as well as implements contaminated during preparation of raw meat, poultry and eggs, can help limit the risk of gastroenteritis by preventing cross-contamination of other foods that are not cooked before consumption.

7. Excessive use of antibiotics by individuals has led to the development of antibiotic resistance. Whether excessive use of antimicrobial agents (such as antimicrobial soap) in day care and the home plays a role in the development of resistance is unclear but will require intensive surveillance and further study.

8. An alliance among the medical community, scientists, epidemiologists, the media and parent and health care advocacy groups is needed to fully address control of disease transmission in day care and the home.

9. Further discussions are warranted to create practical, achievable and scientifically valid protocols to study the cost effectiveness of home and institutional use of antiseptics and disinfectants.

Keywords:

Handwashing; disinfection; day care; home

© 2000 Lippincott Williams & Wilkins, Inc.