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Keywords:

  • antibacterial soap;
  • handwashing;
  • personal hygiene;
  • skin damage;
  • skin flora;
  • water temperature

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results and discussion
  6. Conclusions
  7. References

For many years, sanitarians have specified that the hands of food service workers should be washed and rinsed in warm or hot water to reduce the risk of cross-contamination and disease transmission. In the food service environment, it has been suggested that handwashing with water at higher temperatures contributes to skin damage when frequent handwashing is necessitated, and that insistence on hot water usage is a deterrent to handwashing compliance. Separate handwashing studies involving different water temperatures and soap types (antibacterial versus non-antibacterial) were performed. The ‘glove-juice’ technique was employed for microbial recovery from hands in both studies. Initial work evaluated antimicrobial efficacy based on water temperature during normal handwashing with bland soap. Uninoculated, sterile menstrua (tryptic soy broth or hamburger meat) was used to study the effects of treatment temperatures (4.4°C, 12.8°C, 21.1°C, 35°C or 48.9°C) on the reduction of resident microflora, while Serratia marcescens-inoculated menstrua was used to evaluate treatment effects on the reduction of transient contamination. Results of this first study indicated that water temperature exhibits no effect on transient or resident bacterial reduction during normal handwashing with bland soap. The follow-up study examined the efficacy and skin irritation potential involving water temperatures with antimicrobial soaps. Hands of participants were contaminated with Escherichia coli inoculated ground beef, washed at one of two water temperatures (29°C or 43°C) using one of four highly active (USDA E2 equivalency) antibacterial soaps having different active ingredients (PCMX, Iodophor, Quat or Triclosan). Skin condition was recorded visually and with specialized instrumentation before and after repeated washing (12 times daily), measuring total moisture content, transepidermal water loss and erythema. Overall, the four soap products produced similar efficacy results. Although there were slight increases in Log10 reductions, visual skin irritation, loss of skin moisture content and transepidermal water loss at higher temperatures, results were not statistically significant for any parameter.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results and discussion
  6. Conclusions
  7. References

A critical and thorough evaluation of simple handwashing procedures reveals numerous variables to be considered by food service managers in order to achieve maximum or appropriate de-germing of the hands and fingernail regions. Numerous studies have explored issues such as type of soap (i.e. antibacterial versus plain, liquid versus bar), amount of soap, nailbrush use, drying technique (i.e. cloth versus paper towels, paper towels versus air-drying), and application of instant hand sanitizers (postwash liquids). Previous studies indicate that these variables are crucial in achieving effective removal of transient bacteria from the hands under controlled testing conditions. Rarely mentioned in the scientific literature is testing to determine specific guidelines for water temperatures and flow rates. Many of the currently employed handwashing practices are based on untested traditions that could possibly result in compromised skin health. It is expected that warm or hot water would be beneficial in reducing bacterial counts from hands during handwashing, as heat provides energy for the increased solubility and melting of fats, oils and other soils which may serve as vehicles for bacterial transfer from hands. Warm/hot water, combined with the detergents present in soap, should theoretically provide greater emulsification of contaminating soils on the skin, resulting in a more efficient lifting of these soils for rinsing away.

Some food safety experts strongly recommend the use of antimicrobial soaps for food service workers, while others are now focusing on handwashing frequency. With the rise of antibiotic resistance, increased concern has been expressed with respect to antimicrobial soap usage. The reasoning has been that when warm/hot water is combined with antimicrobial soap, the temperature of activation is approached, accelerating chemical reactions and improving kill rates. Soil emulsification should allow for greater exposure of microorganisms in the contaminating soil to the antimicrobial active agents. Thus, bacterial population numbers may be reduced two ways: through soil emulsification and lifting/rinsing away, and inactivation provided by the antimicrobial agent(s) with higher temperatures doing a significantly better job. The infected food worker is the focus of improved hygiene measures, and food safety managers and regulators would be remiss to not try to optimize effectiveness. Asymptomatic food handlers have been identified as being responsible for approximately one-third of outbreaks traced back to the infected worker. Poor personal hygiene has been cited as a contributory factor in an average of 30% of foodborne illness outbreaks occurring in the U.S. between the years of 1973 and 1997 (Bean & Griffin 1990; Bean et al. 1996; Olsen et al. 2000). The vast majority of foodborne illness outbreak cases attributed to the infected food handler occurs in the food service environment (Michaels et al. 2002).

The main initiative in hand hygiene is the reduction of potentially pathogenic microorganisms from contaminated skin surfaces. Optimization of all variables involved in this task must not only provide sufficient removal and/or kill of potential pathogens, but must also refrain from damaging the skin, as this can affect handwashing compliance (Boyce and Pittet 2001) and seriously compromise food service safety. Skin damage associated with work from routine and frequent handwashing has also been seen to result in colonization of workers hands with potential pathogens.

With so many variables involved in such a ‘simple procedure’, it would make sense to explore and maximize all possible aspects of the process while minimizing negative collateral. This is especially important due to the many observations of food service workers revealing what is considered to be poor habits in handwashing techniques. Studies indicate that handwashing compliance drops considerably without supervision and monitoring, or in situations where skin damage occurs. This further amplifies the need to strengthen knowledge of all variables that might improve or weaken daily handwashing practices throughout the food processing and service industry.

As described by Price, two types of flora exist on the hands, transient and resident species (Price 1938). The transient flora is generally removed fairly easy. They do not have adhesion characteristics that hold them to the skins’ surface and are somewhat suppressed by secretions and competitive exclusion by the resident flora (Dunsmore 1972). Resident flora is removed more slowly. Because of coevolution, resident flora have adapted to conditions on the skins’ surface that cause rapid die-off of most transients. Invaginations such as the nail fold, hair follicles and sebum-producing sebaceous glands support a rich resident flora. Transient flora may consist of pathogens, spoilage bacteria or harmless environmental species. Under certain conditions, transient flora can change status and become permanent residents. Resident flora, as a rule, are not pathogenic types. Although colonization with coagulase-positive staphylococcus is fairly common (Noble & Pitcher 1978). Frequent or prolonged exposure of the skin to microbial contamination in soils, skin damage or fissures provide portals of entry to deeper tissue, and may result in many pathogenic bacteria found among the resident species (Price 1938; Kaul & Jewett 1981). Food workers in a number of different food industry segments (including catering and bakery) have been found colonized by varying numbers of potential pathogens (Seligman & Rosenbluth 1975).

The effective water temperature used for washing and rinsing hands was a topic of intense discussion at the U.S. Year 2000 Conference for Food Protection. This biannual conference assembles federal and state regulators, food safety academicians, food service industry scientists and safety managers to establish and recommend guidelines to the United States Food and Drug Administration (FDA) for inclusion into the FDA Model Food Code. This code, as adopted by individual US states, forms the basis for food safety regulation and enforcement activities to the food service industry. Several submitters of issues, brought before science and technology council (Council III), expressed their concern regarding the use of higher water temperatures as recommended of the food service/processing industry (Table 1). The United States Food and Drug Administration (FDA) Food Code provides recommendations for the food service industry to follow regarding food handling practices, application of HACCP principles and personal hygiene implementation (US Public Health Service 1999; US Public Health Service 2001). The main goal of the FDA has been the creation of uniform practices throughout all of the United States. The 1999 FDA Food Code requires sinks used for handwashing to be equipped so as to be ‘capable of providing water of at least 43°C (110°F), accomplished through use of a mixing valve or a combination faucet’ [tap] (US Public Health Service 1999).

Table 1.    Submitters and handwashing water temperature issues at the year 2000 Conference for Food Protection
SubmitterIssueReason
L. Wisniewski (Select Concepts – Consulting)‘Warm Water’1. Hand Discomfort
  Decreases Frequency
M. Scarborough (Georgia Department of Human Resources, Division of Public Health)37.7°C (100°F)1. No Science (43°C vs. 37.8°C)
  2. Plumbing Code @ 100°F Max. (Safety Concerns)
J. Budd (Healthminder/Sloan Valve Company)35°C (95°F)1. No Scientific Basis
  2. Max Soap Efficacy at 35°C
  3. Hand Comfort
  4. Hot Water Discourages Hand Washing
E. Rabotoski (Wisconson ConferenceFood Protection)‘Tempered’ 29.5°C (85°F) to1. Hand Discomfort
 43°C (110°F)2. Possible Scalding
B. Adler (Minnesota Department of Health)Impose Temp. Range 43°C 110°F 1. Need upper limit or subject to OSHA
 To 54.4°C (130°F)2. Food workers Don’t Wash 25 Sec.
  So Cannot Scald.
Reimers (H.E.B. Grocery Company)‘Tempered’ To Warm1. No Science .
  2. Max Soap Efficacy
  3. 43°C Risks Injury
  4. Waste Water as Wait for Temp. at 43°C

All but one of the submitters requested temperature decreases with the intent of improving hand comfort, as the discomfort associated with higher temperatures results in decreases in hand washing frequency or compliance. Several submitters note a lack of scientific information on the subject. There is concern that a minimum handwashing temperature of 43°C (110°F), in addition to causing discomfort, will result in injury or scalding and may even be in conflict with local plumbing codes. Two submitters point out that soaps currently available target maximum effectiveness at around 35°C (95°F). Two submitters requested that the minimum temperature of 110°F (43°C) be changed to warm water or that it be tempered to a range of 85°F (29.5°C) to 110°F (43°C). and finally, one submission sought to place an upper temperature limit of 130°F (54.4°C), for fear that these regulations would be subject to Occupational Safety and Health Administration (OSHA) scrutiny and criticism without a limit. Interestingly, it was noted in this submission, through reference to the Consumer Product Safety Commission, that second or third-degree burns have been shown to occur in the elderly at temperatures not much over 43°C (110°F). Council I and the General assembly of voting delegates passed a recommendation to lower the regulatory water temperature minimum to 29.5°C (85°F). In recognition of concern expressed by a number of stakeholders with regards to the issue of handwashing water temperature, the initial results of the work described in this report and the will of state voting delegates, the 2001 Food Code lowered the required handwash water temperature to 37.8°C (100°F) (US Public Health Service 2001).

The universe of food handling situations requiring effective personal hygiene spans from temporary handwash stations set up in produce fields and county fairs to advanced state of the art clean room style kitchens used to produce extended shelf life ready-to-eat foods sold at retail. In quick service restaurants, workers frequently switch between food and money handling. Due to the potential for money to carry potential pathogens, as described by Michaels, hands may require washing from up to 40 times or more in an 8-h shift (Michaels 2002). In many of these situations, it is difficult to provide water meeting strict temperature ranges. With regard to international settings, it is doubtful that underdeveloped parts of the world will easily be able to tap into warm/hot water supplies, much less into clean water sources at all. Water temperature shortcomings have been a common point of criticism by food safety experts when reviewing handwashing procedures in the developing world as part of HACCP activities. Further, no matter where the location, it is difficult to manage and monitor food handlers to insure that minimum temperature levels are maintained during all handwashing activities. When subject to regulatory inspections, in the U.S., violations are given to food industry entities based on Food Code specifications. In some cases, based on accumulation of violations with water temperature being one of them, mandatory 48 h closure can result. This appears to be both costly and unnecessary based on the results of the studies described here.

In an extensive literature review of the effect of water temperature on hygienic efficiency, only two existing experimental studies shed light on this issue. Both of these involved hand sampling studies, in which the objective was to remove, identify and enumerate as many bacteria on the hands as possible, either as normal or transient flora. In hand scrubbing experiments, Price found that at temperatures from 24°C (75.2°F) to 56°C (132.8°F) there was no difference in de-germing rate (Price 1938). Since he scrubbed hands with a brush for a specific period of time, each in turn in a series of sterile wash basins, he might have been capable of seeing differences upon counting the flora in each basin. After conducting over 80 experiments in a 9-year period, Price concluded that the largest variable in determining the rate of removal of bacteria from the hands was the vigorousness of scrubbing. Other factors such as soap used or water temperature were less important. In later hand sampling experiments by Larson and others (implementing the glove juice method for recovery of microorganisms), no differences in isolation rates were seen at either 6°C (42.8°F) or 23°C (73.4°F) (Larson et al. 1980). While this information is inconclusive and does not answer questions concerning bacterial loads suspended in a confounding soil, they tend to indicate that there may not be a noticeable difference in efficacy over a range of temperatures from 6°C (42.8°F) to 56°C (132.8°F).

Various menstrua have been used for handwashing efficacy studies. For studies involving transient flora, the most often used soil is tryptic soy broth (TSB). Microorganisms exhibit good survivability, with even distribution of contaminating microorganisms into skin cracks, creases and invaginations being possible. Ground beef probably represents the most appropriate menstrua because of concern for risks of E. coli O157:H7 infection, but is only occasionally used (Sheena & Stiles 1982; Stiles & Sheena 1985). Meade and others have shown numerous sporadic cases of foodborne illness have been tied to poor personal hygiene after ground beef preparation (Mead et al. 1997). In addition, due to it's viscosity, thixotrophic properties and level of organic soil, it would appear to be a good surrogate for fecal material.

A review of pertinent literature was also undertaken to determine if, independent of efficacy, facts on skin damage support a lowering of the temperature. The Consumer Product Safety Commission (CPSC) has noted that residential water heater thermostat settings should be set at 49°C (120°F) to reduce the risk of the majority of tap water scald injuries. Although the majority of scalding attributed to the home occur in children under the age of five and the elderly, third-degree burns are known to result in a two second exposure to 66°C (150°F), six-seconds at 60°C (140°F) and 30 s at 54.4°C (130°F) (US Consumer Product Safety Commission 2000). As we age, our skin becomes thinner, loosing suppleness. This fact is important as many seniors are now actively involved in the food service industry. Due particularly to the elder risk, some have recommended that water be delivered from the tap at even lower temperatures of less than 43°C (110°F) (Stone et al. 2000).

The activity of soaps, friction and rinsing become crucial since the temperatures recommended in handwashing water alone would not provide thermal destruction of pathogenic microorganisms. Relevant to the discomfort issue associated with hot water is a previously conducted study by Horn and Briedigkeit involving dishwashing soaps (Horn & Briedigkeit 1967). In that study, participants were only able to withstand water temperatures at 43°C, 45°C, and 49°C (110°F, 113°F and 120°F), with tolerance levels due to discomfort peaking at one-minute (Horn & Briedigkeit 1967). Even though considerably longer than the 10–25 second exposure period that would result from handwashing, it is indicative of the fact that temperatures from 43°C and upwards (110°F and upwards) are at or near the human discomfort threshold.

Friction has been described as a key element in removing microbial contaminants from hands (Price 1938; Kaul & Jewett 1981). Friction applied during hand drying is instrumental in finishing the process (Madeline & Tournade 1980; Knights et al. 1993; Michaels et al. 2002). Removal of transient flora appears to be even more friction dependent than removing resident flora. Surfactant and antimicrobial compounds in soap are responsible for lifting soil and killing microorganisms suspended in the soil. When using bland soap to wash hands, handwashing efficacy appears to be dependent on the effects of surfactant action of the soap along with friction applied during the washing and rinsing process. Rinsing also provides the necessary removal by dilution. To facilitate appropriate rinsing of the hands, some personal hygiene consultants have suggested the practice of using thicker, higher viscosity soaps in larger doses, which would require a longer, more vigorous rinsing routine.

Price, upon noticing that in his scrubbing experiments that water temperature had little effect at de-germing of the skin, commented that water applied to the skin at a given temperature quickly reaches equilibrium with normal skin surface temperature unless hands are totally immersed (Price 1938).

Skin oils derived from sebum are liquid in the sebaceous gland and solidify on the skin surface. Beef tallow has a melting point range between 35°C and 40°C (95°F and 104°F), while lard or butterfat are liquefied at around 30°C (86°F) (Lide 1990). If handwashing efficacy for both resident and transient floras embedded in both natural and artificially applied fats depended on thermal melting, then log10 reduction figures should have been greatest at the highest temperature and least at temperatures causing fats and sebum to congeal.

Fats such as tallow or lard are distinguished from oils in that the latter are liquids at room temperature. Hand soap formulations are designed to lift soil through their foaming action, dispersing and solubilizing organic soils through action of detergent surfactants. Primary micelles are formed, having hydrophilic and hydrophobic groups attached to each end of the surfactant monomer. Soaps with multiple surfactants form mixed micelles, which increases efficiency with various soil mixtures. In water and organic soil mixtures, these form complex micelle structures around hydrocarbon moieties (encapsulation) resulting in microemulsions. Thus, the soap provides a ‘bridge’ between the oily droplet and water, permitting the soapy water to ‘wash away’ greasy material.

Materials and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results and discussion
  6. Conclusions
  7. References

The quantity of soap used for handwashing has the ability to effect handwashing efficacy, as shown by Larson (Larson et al. 1987). Various investigators (Michaud et al. 1972, 1976; Ojajarvi 1980; Stiles & Sheena 1987; Mahl 1989; Larson et al. 1990; Rotter & Koller 1992; Miller & James-Davis 1994; Paulson 1994) have used soap amounts in the range of 2.5–5.0 mL in their handwashing efficacy protocols. The higher levels are considered excessive, except in the area of hospital infection control. Many food service operations set soap dispensers at 1 mL per pump, and employees often times use multiple pumps. For this study, 3 mL of soap was chosen to represent an amount found to be significantly effective in an earlier study described (Larson et al. 1987).

Determination of appropriate handwashing duration for these studies (15 s) was arrived at through review of various governmental regulatory standards, test method guidelines and food safety specialist recommendations along with previous handwashing study observations. Suggested lathering times by specific entities are: The 1999 FDA Food Code (US Public Health Service 1999) (20 s), The American Society for Testing and Materials (American Society for Testing and Material 1995) (15 s), The Association for Professionals in Infection Control and Epidemiology (APIC) (Jennings & Manian 1999) (minimum of 10 s), and The American Society for Microbiology (American Society For Microbiology 1996) (a 10–15 second vigorous scrub). Several studies support a washing duration of at least 10 s, with sufficient transient removal efficiency achieved by 30 s. A study by Stiles and Sheena involving workers in a meat processing facility determined that a wash of 8–10 s was too short for adequate soil removal from the hands (Stiles & Sheena 1987). A study by Ojajarvi compared a 15 second and 2 minute wash, with the latter providing only an additional 3% transient bacterial reduction (Ojajarvi 1980). One observational study in food service indicates average duration times of 20 s in a silver service restaurant kitchen (Ayers 1998).

In our first study, the effects of water temperature on the reduction of both resident (normal) and transient bacteria during handwashing was performed at each of the following temperatures: 4.4°C (40°F), 12.8°C (55°F), 21.1°C (70°F), 35°C (95°F), or 48.9°C (120°F). Two separate laboratories participated in this work. Silliker Laboratories (South Holland, IL, USA) was responsible for transient flora experiments while BioScience Laboratories (Bozeman, MI, USA) performed normal flora studies. For transient flora studies, the experimental subjects’ hands were artificially contaminated with Serratia marcescens in Tryptic Soy Broth (TSB) or irradiated ground hamburger. Sterile, uninnoculated TSB and irradiated ground hamburger were used as confounding soils in testing for the reduction of the resident flora. Following hand contamination, baseline microbial counts were acquired using the ‘glove-juice’ method on one hand. Hands were moistened and washed/lathered for 15 seconds with 3 mL bland (nonantibacterial) soap, rinsed for 10 seconds (water flow rate of 7 L/minute) at the assigned water temperature (also used for the prelather moistening), and the opposing hand was then sampled using the same glove-juice technique. No drying of hands was performed, which would have had the effect of diminishing differences between experimental groups. Baseline and postwash readings were then compared to obtain bacterial reduction values. For this study, no skin condition assessments were performed.

The first study was performed using a non-antibacterial soap and examined temperature effects on bacterial reductions based on the solubility of greasy soils. It did not address the increased temperature effect on antimicrobial activation or possible skin damage. Therefore, the second study was undertaken, which not only involved a comparison of the microbial reduction effects of four antibacterial soaps at two different temperatures, but also evaluated skin conditions on the hands of participants throughout the study. The potential of each soap to cause negative skin changes at each water temperature combination was assessed by measuring the skin moisture content, rate of water loss from the skin, skin scaliness by computerized analysis of a digitized skin image, and by visual assessment of the dryness and erythema. This study was performed at BioScience Laboratories, employing eight subjects and using four different antimicrobial soaps, each having a different antimicrobial active ingredient. The soaps had antimicrobial activity equivalent to USDA E2 ratings (50-p.p.m. chlorine equivalency). The active ingredients in these products were Quaternary Ammonium (3% dual Quat formulation), Triclosan (1%), Parachlorometaxylenol (PCMX-3%), and Iodophor (7.5% PVP-I). Participants consisting of paid volunteers performed multiple handwashes during two five-day test periods (weeks one and two) seven days apart using Escherichia coli (ATCC #11229) contaminated gamma irradiated ground beef. On days one through five of weeks one and two, the skin condition was evaluated visually, for moisture content using the Corneometer® CM825, for total evaporative water loss using the TC350 Tewameter, and digitally using the Skin Visiometer® SV 500 with Visioscan® VC98. The visual skin dryness and erythema (redness) scoring was performed by a single blinded (unaware of subjects antimicrobial soap product/water temperature configuration) evaluator trained in assessment of skin damage or irritation using a 0–6 scoring system (see Table 2) as originally described by Griffith and others (Griffith et al. 1969). Log10 reduction data was determined with the first wash of days one, three and five under each water temperature condition. After handling the contaminated ground beef in a way to uniformly contaminate hands, one hand was sampled immediately (again, using the ‘glove-juice’ technique) for a baseline reading. The subjects’ then washed both hands at the specific water temperature (85°± 2°F for week one and 110°± 2°F for week two) with their randomly assigned product with their opposing hand being sampled to establish microbial counts. Each subject then washed 11 consecutive times with their assigned test product each day drying hands between washes, then hands were evaluated visually and digitally 30 minutesfollowing the last wash. In all washing cases, lathering was performed for 15 seconds and rinsing for 10 seconds with three mL of the assigned test product.

Table 2.    Grading scale for evaluating the skin of the hands*
GradeDescription
0No visible damage, ‘perfect’ skin
1Slight dryness, ashen appearance, usually involving dorsum only
2Marked dryness, slight flaking involving dorsum only
3Severe dryness dorsum, marked flaking, possibly fissures in webs
4Severe flaking dorsum, surface fissures possibly with slight palmar dryness
5Open fissures, slight erythema (>10% of dorsal and interdigital surface), with or without severe dryness, no bleeding
6Bleeding cracks, deep open fissures, or generalized erythema (>25% of area)

Results and discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results and discussion
  6. Conclusions
  7. References

After extensive statistical analysis of the results from the first set of experiments, it was determined that there was no significant difference in bacterial log10 reductions for either resident or transient bacteria at any of the test washing and rinsing temperatures. See Figs 1 and 2 for transient and resident flora data, respectively. Average log10 reduction results for each soap are presented in Fig. 3.

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Figure 1.   Handwashing efficacy (Log10 reduction) for transient flora (S. marcescens) in ground beef and TSB at selected water washing and rinsing temperatures.

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Figure 3.   Average Log10 reduction of transient flora (E. coli) in ground beef using selected antimicrobial soaps.

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After extensive statistical analysis of the second experiment with antibacterial soaps involving the 2 sample T-test, Kruskal–Wallis test and Mann–Whitney test, no statistical difference in log10 reductions was detected between the two wash temperatures for any of the products or as a group. Overall, the four products produced similar handwashing efficacy results. Although most of the washes at the higher temperature did produce a slight increase in bacterial reductions, it was not enough to be considered statistically significant. Figure 4 shows Tewameter® readings measuring trans epidermal water loss, while Figs 5 and 6 show visual dryness and baseline adjusted Corneometer® values, respectively. Skin scaliness values using a Visiometer® are shown in Fig. 7. Along with the slight additional reduction of bacteria at the higher temperature was increased skin visual dryness, increased transepidermal water loss and decreased scaliness, also determined to be statistically insignificant. Skin scaliness is highest on day one and two at the higher temperature but for days three, four and five, this reverses. It is conceivable that the higher temperatures more rapidly removed loose layers of stratum corneum.

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Figure 4.   Average Tewameter® readings selected antimicrobial soaps at 2 different water temperatures.

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Figure 5.   Average baseline-adjusted visual dryness scores (8 subjects) resulting from washing hands with 4 different E2 antimicrobial soaps for 5 days (12 ×/day).

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Figure 7.   Average baseline-adjusted skin scaliness (8 subjects) resulting from washing hands with 4 different antimicrobial temperatures as measured using Visiometer®.

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The results from both of these experiments are in agreement regarding the lack of hygienic benefits of washing hands at higher water temperatures and particularly at temperatures at the upper end of human tolerance, sometimes described as ‘hot as you can stand’. From the first study, it is realized that higher water temperatures have no significant effect on the reduction of resident or transient bacteria in either easy to remove soil (TSB) or difficult to remove soil (ground beef) when using plain soap at a wide range of temperatures and using a standard hand wash. The second study provides additional support to the results of the first study by showing no statistically significant effect for the use of 110°F water (compared to 85°F water) to remove transient microorganisms embedded in ground beef from the hands when using any one of four different antibacterial based soaps or antibacterial soaps as a group. This experiment did show the trend toward higher kill as well as higher level of skin damage supporting propositions put forward by both camps. Log10 reductions do reflect slightly greater efficacy at higher temperatures but not at the level of significance expected, most probably due to the rapid equilibration to hand temperature described by Price (Price 1938).

Water has been identified as a skin irritant in its own rite, and part of this irritant potential can be exacerbated by temperature increase (Tsai & Maibach 1999). Repeated water exposure causes extraction or dilution of natural moisturizing factors in the stratum corneum. The water-holding property of the stratum corneum is provided in part by intercellular lipids and lipid rich sebaceous gland secretions (Noble & Pitcher 1978). The intercellular lipids, which when chromatographically fractionated, can be separated into cholesterol, cholesterol esters, phospholipids, free fatty acids, glycolipids and ceramide (Noble 1975; Imokawa et al. 1986). Loss of these lipid components results in a chapped and scaly skin appearance (Imokawa & Hattori 1985). Water induced irritation is known to exist in workers involved in continuous wet work, resulting in chapped and dry skin after wet work is completed (Halkier-Sorensen & Thestrup-Pedersen 1991).

Instances of primary irritant dermatitis to certain chemicals has been found to occur when hot water at 43°C (110°F) was used rather than lukewarm at 23°C–25°C (73°F–77°F) (Rothenborg et al. 1977). Detergent/surfactant formulations are known to cause changes to the stratum corneum such as disaggregation, swelling and morphological deterioration of corneocytes (Shukuwa et al. 1997). It has been found that heat plays a part in accelerating irritation of certain chemicals found in these detergent formulations. Berardesca and others found a significant difference between the temperatures of 20°C and 40°C (68°F and 104°F) in skin irritation to 5% sodium lauryl sulphate solution for a 4-day exposure period (Berardesca et al. 1995; Ohlenschlaeger et al. 1996). This irritation is documented using transepidermal water loss (TEWL) measurements, erythema (skin redness), skin reflectance, hydration (capacitance) and desquamation (stripping). Gross hand edema has been found to occur at temperatures between 35°C (95°F) and 45°C (113°F) when hands are completely immersed at those temperatures (King 1993). A significant increase in blood flow has also been shown in comparisons between 37°C and 43°C degrees (99°F and 110°F) (Nagasaka et al. 1987). Overall, these studies tend to show that food service workers derive no significant measurable benefit by using hot water (105°F +) to wash and rinse hands. Use of water at higher temperatures does seem to result in physiological changes collectively described as skin damage. There may be severe consequences of frequent use of hot water for handwashing at temperatures above 43°C (110°F), which can damage skin and heighten susceptibility to both allergens present in the food service environment and/or colonization (Larson et al. 1998). Rather, water temperature should be set at what is considered comfortable and generally conducive to handwashing.

The central components of effective handwashing thus consist of soap use in a way that promotes emulsification of soil (through vigorous friction/mechanical action) followed by thorough rinsing and drying, which again adds friction to the equation. Guidelines for handwashing in food service should probably not specify water temperature descriptors other than perhaps the word ‘comfortable’ when it comes to defining effective handwash standards. ‘Warm’ or ‘tempered’ would probably be acceptable, but more importantly as indicated by Jennings and Manian (1999), ‘running water’ should be to rinse away emulsified soils and associated transient contamination. Fingertips should be pointed down and hands rinsed and dried in a way to focus on parts of the hand that have shown to be missed during normal handwashing. This includes fingertips, thumbs and fingernail regions.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results and discussion
  6. Conclusions
  7. References

A review of the literature on the subject of handwashing water temperature requirements showed considerable variation with respect to expert opinion on optimal temperature for removal of microbial contaminants form hands. There in fact was a virtual absence of data to back up the various positions on the subject. Sanitarians and food safety experts have specified water temperatures varying from room temperature (running water) up to ‘as hot as you can stand’, the latter of which is probably in the range of from 49°C (120°F) to 55°C (131°F). Regulations in the US and elsewhere tend to focus on temperatures between 43°C (110°F) and 49°C (120°F). Concern that these temperatures could be detrimental to skin health without documented efficacy led to the experiments described here. Hands were contaminated with soils similar to those encountered in the food service environment. These soils contained marker bacteria allowing handwashing efficacy to be determined at specified water temperatures against both transient flora and resident flora simultaneously.

The initial experiment involved testing with bland non-antimicrobial soap at 5 temperatures from 4.4°C (40°F) to 49°C (120°F). Independent of soil or bacterial type (resident or transient) there was no significant difference in efficacy attributed to water temperature. In the second experiment antimicrobial soaps (4) were used having different antimicrobial active ingredients, at each of two water temperatures, 29.5°C (85°F) and 43°C (110°F). Skin condition was monitored with frequent handwashes (12 ×/day) for the second set of water washing temperature experiments. In this experiment, even though slightly higher efficacy with was seen with antimicrobial soaps at higher temperatures, overall, there was no statistical difference in efficacy as measured in Log10 reduction at the two water temperatures (regardless of soil or microflora types). Concomitant to the increase in efficacy at higher temperatures was a consistent trend for increases in measures of skin damage, such as skin moisture content, transepidermal water loss and erythema. This was also found not to be statistically significant.

Both the trend for higher efficacy of soaps with attendant skin damage at higher temperatures are grounded in theory. Under the conditions of these experiments neither was shown to be proven for practical application. Since efficacy is not markedly improved at higher temperatures but rather the real danger exists of skin damage, requirements for specific handwashing water temperature should be relaxed to improve acceptance of frequent handwashing by food workers at appropriate times to reduce foodborne illness potential. Water temperature should be in a comfortable range, perhaps tempered.

As has been shown by many previous researchers, overall handwashing effectiveness is more dependent on the vigorousness of execution than details such as the type of soap, the length of handwash or in this case water temperature. The results obtained in these experiments confirm the observations made by Price (Price 1938) and Larson (Larson et al. 1980) indicating water temperature had little or no effect on the removal of bacteria from hands. While their original reports dealt with optimizing skin sampling efficacy, for the types of experiments performed and described in the current report.

Unfortunately, food service regulatory authorities, health inspectors and environmental health officers in the US and elsewhere have fixated on handwashing water temperature because it is measurable and in the somewhat mistaken belief that higher temperatures would result in cleaner hands. Up until recently, the existence of adequate hygiene facilities (functioning toilet, toilet paper, functioning sink, soap and paper towels) and water temperature measurement were to some extent the only measurable qualities whereby food safety inspectors could cite food service facilities for violation. Poor personal hygiene is often used after the fact to describe as a contributing factor aiding to an outbreak. With handwash monitoring devices employees’ handwashing can be monitored, documented and verified within the HACCP framework (Michaels 2002). With this new technology and information from this report indicating that water temperature for handwashing is relatively unimportant, perhaps regulatory authorities will be able to focus on other more important factors having a bigger impact on food safety.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results and discussion
  6. Conclusions
  7. References
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