Soap

Introduction: Soap is a mixture of sodium salts of various naturally occurring fatty acids. Air bubbles added to a molten soap will decrease the density of the soap and thus it will float on water. If the fatty acid salt has potassium rather than sodium, a softer lather is the result. Soap is produced by a saponification or basic hydrolysis reaction of a fat or oil. Currently, sodium carbonate or sodium hydroxide is used to neutralize the fatty acid and convert it to the salt. General overall hydrolysis reaction: fat + NaOH ---> glycerol + sodium salt of fatty acid Although the reaction is shown as a one step reaction, it is in fact two steps. The net effect as that the ester bonds are broken. The glycerol turns back into an alcohol (addition of the green H's). The fatty acid portion is turned into a salt because of the presence of a basic solution of the NaOH. In the carboxyl group, one oxygen (red) now has a negative charge that attracts the positive sodium ion. Types of Soap: The type of fatty acid and length of the carbon chain determines the unique properties of various soaps. Tallow or animal fats give primarily sodium stearate (18 carbons) a very hard, insoluble soap. Fatty acids with longer chains are even more insoluble. As a matter of fact, zinc stearate is used in talcum powders because it is water repellent. Coconut oil is a source of lauric acid (12 carbons) which can be made into sodium laurate. This soap is very soluble and will lather easily even in sea water. Fatty acids with only 10 or fewer carbons are not used in soaps because they irritate the skin and have objectionable odors. Cleansing Action of Soap: The cleansing action of soap is determined by its polar and non-polar structures in conjunction with an application of solubility principles. The long hydrocarbon chain is of course non-polar and hydrophobic (repelled by water). The "salt" end of the soap molecule is ionic and hydrophilic (water soluble). Monolayer: When soap is added to water, the ionic-salt end of the molecule is attracted to water and dissolved in it. The non-polar hydrocarbon end of the soap molecule is repelled by water. A drop or two of soap in water forms a monolayer on the water surface as shown in the graphics on the left. The soap molecules "stand up" on the surface as the

polar carboxyl salt end is attracted to the polar water. The non-polar hydrocarbon tails are repelled by the water, which makes them appear to stand up. http://www.elmhurst.edu/~chm/vchembook/554soap.html

Soap in Ancient Times

Myth has it that in 1,000 B.C. soap was discovered on Sappo Hill in Rome by a group of women rinsing their clothes in the river at the base of a hill, below a higher elevation where animal sacrifice had taken place. They noticed the clothes coming clean as they came in contact with the soapy clay oozing down the hill and into the water. They later discovered that this same cleansing substance was formed when animal fat was soaked down through the wood ashes and into the clay soil. Factually, we know that soap has been around for about 2,800 years. The earliest known evidence of soap use are Babylonian clay cylinders dating from 2800 BC containing a soap-like substance. A formula for soap consisting of water, alkali and cassia oil was written on a Babylonian clay tablet around 2200 BC. The Ebers papyrus (Egypt, 1550 BC) indicates that ancient Egyptians bathed regularly and combined animal and vegetable oils with alkaline salts to create a soap-like substance. Egyptian documents mention that a soap-like substance was used in the preparation of wool for weaving. According to Pliny the Elder, the Phoenicians prepared it from goat's tallow and wood ashes in 600 BC and sometimes used it as an article of barter with the Gauls. The word "soap" appears first in a European language in Pliny the Elder's Historia Naturalis, which discusses the manufacture of soap from tallow and ashes, but the only use he mentions for it is as a pomade for hair; he mentions rather disapprovingly that among the Gauls and Germans, men are likelier to use it than women Soap was widely known in the Roman Empire; whether the Romans learned its use and manufacture from ancient Mediterranean peoples or from the Celts, inhabitants of Britannia, is not known. Early Romans made soaps in the first century A.D. from urine to make a soaplike substance. The urine contained ammonium carbonate which reacted with the oils and fat in wool for a partial saponification. People called fullones walked the city streets collecting urine to sell to the soapmakers. The Celts, who produced their soap from animal fats and plant ashes, named the product saipo, from which the word soap is derived. The importance of soap for washing and cleaning was apparently not recognized until the 2nd century A.D. ; the Greek physician Galen mentions it as a medicament and as a means of cleansing the body. Previously soap had been used as medicine.

The writings attributed to the 8th-century Arab savant Jabir ibn Hayyan (Geber) repeatedly mention soap as a cleansing agent. The Arabs made the soap from vegetable oil as olive oil or some aromatic oils such as thyme oil. Sodium Lye (Al-Soda Al-Kawia) NaOH was used for the first time and the formula hasn't changed from the current soap sold in the market. From the beginning of the 7th century soap was produced in Nablus (Palestine), Kufa (Iraq) and Basra (Iraq). Arabian Soap was perfumed and colored, some of the soaps were liquid and others were hard. They also had special soap for shaving. It was commercially sold for 3 Dirhams (0.3 Dinars) a piece in 981 AD.

Soap in the Middle Ages

Historically, soap was made by mixing animal fats with lye. Because of the caustic lye, this was a dangerous procedure (perhaps more dangerous than any present-day home activities) which could result in serious chemical burns or even blindness. Before commercially-produced lye was commonplace, it was produced at home for soap making from the ashes of a wood fire. In Europe, soap production in the Middle Ages centered first at Marseilles, later at Genoa, then at Venice. Although some soap manufacture developed in Germany, the substance was so little used in central Europe that a box of soap presented to the Duchess of Juelich in 1549 caused a sensation. As late as 1672, when a German, A. Leo, sent Lady von Schleinitz a parcel containing soap from Italy, he accompanied it with a detailed description of how to use the mysterious product. Castile soap, made entirely from olive oil, was produced in the Kingdom of Castile in Europe as early as the 16th century (about 1616). Fine sifted alkaline ash of the Salsola species of thistle, called barilla, was boiled with locally available olive oil, instead of tallow. By adding salty brine to the boiled liquor, the soap was made to float to the surface, where it could be skimmed off by the soap-boiler, leaving the excess lye and impurities to settle out. This produced what was probably the first white hard soap, which hardened further as it was aged, without losing its whiteness, forming jabon de Castila, which eventually became the generic name. http://www.goodscentscandles.us/soaphistory.php The first English soapmakers appeared at the end of the 12th century in Bristol. In the 13th and 14th centuries, a small community of them grew up in the neighborhood of Cheapside in London. In those days soapmakers had to pay a tax on all the soap they produced. After the Napoleonic Wars this tax rose as high as three pence per pound; soap-boiling pans were fitted with lids that could be locked every night by the tax collector in order to prevent production under cover of darkness. Not until 1853 was this high tax finally abolished, at a sacrifice to the state of over 1,000,000. Before this because of the high cost of soap, ordinary households made do without soap until about 1880, when cheap factory-made soap began to flood the market. Soap came into such common use in the 19th century that Justus von Liebig, a German chemist, declared that

the quantity of soap consumed by a nation was an accurate measure of its wealth and civilization. Soap was certainly known in England in the sixteenth century but as it was made of fat, and fat was needed for making candles and rushlights, it was always a prerogative of the rich. When soap was used it was primarily used for cleaning linens and clothes rather than the human body. Since little emphasis was placed on using soap for bodily cleanliness, people (shall we say) had an "air" about them that they tried to overcome by wearing sachets of herbs around their necks or carrying these sachets in their pockets. When baths were taken, whether soap was used or not, the bath water was traditionally shared among the family members with the small children being bathed last. The end result was water so dirty and murky, that a small child could literally be lost in the water hence the saying "Don't throw the baby out with the bath water".

Early Soap Production

Early soapmakers probably used ashes and animal fats. Simple wood or plant ashes containing potassium carbonate were dispersed in water, and fat was added to the solution. This mixture was then boiled; ashes were added again and again as the water evaporated. During this process a slow chemical splitting of the neutral fat took place; the fatty acids could then react with the alkali carbonates of the plant ash to form soap (this reaction is called saponification). Animal fats containing a percentage of free fatty acids were used by the Celts. The presence of free fatty acids certainly helped to get the process started. This method probably prevailed until the end of the Middle Ages, when slaked lime came to be used to causticize the alkali carbonate. Through this process, chemically neutral fats could be saponified easily with the caustic lye. The production of soap from a handicraft to an industry was helped by the introduction of the Leblanc process for the production of soda ash from brine (about 1790) and by the work of a French chemist, Michel Eugne Chevreul, who in 1823 showed that the process of saponification is the chemical process of splitting fat into the alkali salt of fatty acids (that is, soap) and glycerin. The method of producing soap by boiling with open steam, introduced at the end of the 19th century, was another step toward industrialization. The industrialization of soap making though tended to use more chemically produced ingredients and less natural ingredients, and produced in essence a detergent rather than a soap such as our ancestors used. With World War I and the shortages of fats and oils that occurred, people felt compelled to look for a replacement for soap, leading to the invention of synthetic detergents. These detergents, while being able to clean our clothes effectively, are comprised of harsh chemicals that clean, scent, and coat our clothes. Unfortunately, many of these synthetic detergents have found their way into our skin care products. This has caused in some people super sensitivity to these "soaps", rashes, skin irritations, and allergies plus a general drying out of the skin. Increasingly, we are required to use hand

creams and lotions to prevent or reduce the dryness and roughness arising from exposure to household detergents, wind, sun, and dry atmospheres. Like facial creams, they act largely by replacing lost water and laying down an oil film to reduce subsequent moisture loss while the body's natural processes repair the damage. In modern times, the use of soap has become universal in industrialized nations due to a better understanding of the role of hygiene in reducing the population size of pathogenic microorganisms. Manufactured bar soaps first became available in the late nineteenth century, and advertising campaigns in Europe and the United States helped to increase popular awareness of the relationship between cleanliness and health. By the 1950s, soap had gained public acceptance as an instrument of personal hygiene. In recent years, there has been a grassroots return to making "natural" soap in the home. These cottage industries make soap from ingredients found in nature for its skin care qualities rather than a synthetic soap which relies upon laboratory-made chemicals to make the soap look and feel and act in a certain way. It is tempting for soap manufacturers to lean toward synthetics and away from natural materials. Synthetics are more stable in more situations and less expensive in the long run unlike the fats and oils which differ slightly from tree to tree and region to region. As Susan Miller Cavitch states in her book The Natural Soap Book: Making Herbal and Vegetable Based Soaps, "As we become more and more comfortable with synthetics in all areas of our lives, we run the risk of losing natural defenses and continually needed greater synthetic intervention. Skin care is but one facet of this phenomenon. Our skin is remarkably capable of functioning on its own to protect us, but, as we use more and more harsh, foreign substances, we alter the body's chemical makeup and leave our skin without its natural defenses. We risk becoming dependent on stronger and stronger synthetics to take the place of the body's natural systems. We must each, as individuals, decide which route to go - the way of nature or the way of the lab." Some individuals have chosen not to use the commercial "soaps" and continue to make soap in the home. The traditional name "soaper", for a soapmaker, is still used by those who make soap as a hobby. Those who make their own soaps are also known as soapcrafters. Many of these soapcrafters have expanded their soap making from a hobby basis to a business basis to make natural soap more available to the public at large. Many come up with their own recipes using different butters and essential oils to help those with sensitive skin or who just want to pamper their skin so that it retains its elasticity, moisture, and smoothness. The most popular soap making processes today is the cold process method, where fats such as olive oil react with lye. Soapmakers sometimes use the melt and pour process, where a premade soap base is melted and poured in individual molds. Some soapers also practice other processes, such as the historical hot process, and make special soaps such as clear soap (aka glycerin soap).

Handmade soap differs from industrial soap in that, usually, an excess of fat is used to consume the alkali (superfatting), and in that the glycerin is not removed. Superfatted soap, soap which contains excess fat, is more skin-friendly than industrial soap; though, if not properly formulated, it can leave users with a "greasy" feel to their skin. Often, emollients such as jojoba oil or shea butter are added 'at trace' (the point at which the saponification process is sufficiently advanced that the soap has begun to thicken), after most of the oils have saponified, so that they remain unreacted in the finished soap. Natural soapcrafters today have many different ingredients to select from to produce wonderful and varied soap bars. These ingredients consist of:

base oils available in today's market such as coconut oil, jojoba oil, avocado oil, castor oil, cottonseed oil, olive oil, palm oil, palm kernel oil, peanut oil and soybean oil various butters like shea butter, mango butter, and cocoa butter for extra moisturizing capabilities other nutrients such as sweet almond oil, avocado oil, aloe vera, calendula oil, carrot root oil, various clays, and seaweed essential oils including peppermint, eucalyptus, spearmint, chamomile, geranium, rosemary, lavender, etc for scenting and therapeutic effects and various herbs and spices for color

Soapmakers today can produce artistic therapeutic soap bars high in moisturizers for the discerning soap shopper.

History and Physiology of Hand Hygiene

5.1 Historical Perspective
For generations, handwashing with soap and water has been considered a measure of personal hygiene. The concept of cleansing hands with an antiseptic agent probably emerged in the early 19th century. As early as 1822, a French pharmacist demonstrated that solutions containing chlorides of lime or soda could eradicate the foul odors associated with human corpses and that such solutions could be used as disinfectants and antiseptics. In a paper published in 1825, this pharmacist stated that physicians and other persons attending patients with contagious diseases would benefit from moistening their hands with a liquid chloride solution. In 1846, Ignaz Semmelweis observed that women whose babies were delivered by students and physicians in the First Clinic at the General Hospital of Vienna consistently had a higher mortality rate than those whose babies were delivered by midwives in the Second Clinic. He noted that physicians who went directly from the autopsy suite to the obstetrics ward had a disagreeable odor on their hands despite washing their hands with soap and water upon entering the obstetrics clinic. He postulated that the puerperal fever that affected so many parturient women was caused by "cadaverous particles" transmitted from the autopsy suite to the obstetrics ward via the hands of students and physicians.

Perhaps because of the known deodorizing effect of chlorine compounds, as of May 1847, he insisted that students and physicians clean their hands with a chlorine solution between each patient in the clinic. The maternal mortality rate in the First Clinic subsequently dropped dramatically and remained low for years. This intervention by Semmelweis represents the first evidence indicating that cleansing heavily contaminated hands with an antiseptic agent between patient contacts may reduce health-care-associated transmission of contagious diseases more effectively than handwashing with plain soap and water. In 1843, Oliver Wendell Holmes concluded independently that puerperal fever was spread by the hands of health personnel. Although he described measures that could be taken to limit its spread, his recommendations had little impact on obstetric practices at the time. However, as a result of the seminal studies by Semmelweis and Holmes, handwashing gradually became accepted as one of the most important measures for preventing transmission of pathogens in health-care facilities. In 1961, the U. S. Public Health Service produced a training film that demonstrated handwashing techniques recommended for use by health-care workers (HCWs).. At the time, recommendations directed that personnel wash their hands with soap and water for 1--2 minutes before and after patient contact. Rinsing hands with an antiseptic agent was believed to be less effective than handwashing and was recommended only in emergencies or in areas where sinks were unavailable. In 1975 and 1985, formal written guidelines on handwashing practices in hospitals were published by CDC. These guidelines recommended handwashing with non-antimicrobial soap between the majority of patient contacts and washing with antimicrobial soap before and after performing invasive procedures or caring for patients at high risk. Use of waterless antiseptic agents (e.g., alcohol-based solutions) was recommended only in situations where sinks were not available. In 1988 and 1995, guidelines for handwashing and hand antisepsis were published by the Association for Professionals in Infection Control (APIC). Recommended indications for handwashing were similar to those listed in the CDC guidelines. The 1995 APIC guideline included more detailed discussion of alcohol-based hand rubs and supported their use in more clinical settings than had been recommended in earlier guidelines. In 1995 and 1996, the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended that either antimicrobial soap or a waterless antiseptic agent be used for cleaning hands upon leaving the rooms of patients with multidrug-resistant pathogens (e.g., vancomycin-resistant enterococci [VRE] and methicillin-resistant Staphylococcus aureus [MRSA]). These guidelines also provided recommendations for handwashing and hand antisepsis in other clinical settings, including routine patient care. Although the APIC and HICPAC guidelines have been adopted by the majority of hospitals, adherence of HCWs to recommended handwashing practices has remained low. Recent developments in the field have stimulated a review of the scientific data regarding hand hygiene and the development of new guidelines designed to improve hand-hygiene

practices in health-care facilities. This literature review and accompanying recommendations have been prepared by a Hand Hygiene Task Force, comprising representatives from HICPAC, the Society for Healthcare Epidemiology of America (SHEA), APIC, and the Infectious Diseases Society of America (IDSA).

5.2 Normal Bacterial Skin Flora

To understand the objectives of different approaches to hand cleansing, a knowledge of normal bacterial skin flora is essential. Normal human skin is colonized with bacteria; different areas of the body have varied total aerobic bacterial counts (e.g., 1 x 106 colony forming units (CFUs)/cm2 on the scalp, 5 x 105 CFUs/cm2 in the axilla, 4 x 104 CFUs/cm2 on the abdomen, and 1 x 104 CFUs/cm2 on the forearm) (13). Total bacterial counts on the hands of medical personnel have ranged from 3.9 x 104 to 4.6 x 106. In 1938, bacteria recovered from the hands were divided into two categories: transient and resident. Transient flora, which colonize the superficial layers of the skin, are more amenable to removal by routine handwashing. They are often acquired by HCWs during direct contact with patients or contact with contaminated environmental surfaces within close proximity of the patient. Transient flora are the organisms most frequently associated with healthcare--associated infections. Resident flora, which are attached to deeper layers of the skin, are more resistant to removal. In addition, resident flora (e.g., coagulase-negative staphylococci and diphtheroids) are less likely to be associated with such infections. The hands of HCWs may become persistently colonized with pathogenic flora (e.g., S. aureus), gram-negative bacilli, or yeast. Investigators have documented that, although the number of transient and resident flora varies considerably from person to person, it is often relatively constant for any specific person.

5.3 Physiology of Normal Skin

The primary function of the skin is to reduce water loss, provide protection against abrasive action and microorganisms, and act as a permeability barrier to the environment. The basic structure of skin includes, from outer- to inner-most layer, the superficial region (i.e., the stratum corneum or horny layer, which is 10- to 20-m thick), the viable epidermis (50- to 100-m thick), the dermis (1- to 2-mm thick), and the hypodermis (1to 2-mm thick). The barrier to percutaneous absorption lies within the stratum corneum, the thinnest and smallest compartment of the skin. The stratum corneum contains the corneocytes (or horny cells), which are flat, polyhedral-shaped nonnucleated cells, remnants of the terminally differentiated keratinocytes located in the viable epidermis. Corneocytes are composed primarily of insoluble bundled keratins surrounded by a cell envelope stabilized by cross-linked proteins and covalently bound lipid. Interconnecting the corneocytes of the stratum corneum are polar structures (e.g., corneodesmosomes), which contribute to stratum corneum cohesion. The intercellular region of the stratum corneum is composed of lipid primarily generated from the exocytosis of lamellar bodies during the terminal differentiation of the

keratinocytes. The intercellular lipid is required for a competent skin barrier and forms the only continuous domain. Directly under the stratum corneum is a stratified epidermis, which is composed primarily of 10--20 layers of keratinizing epithelial cells that are responsible for the synthesis of the stratum corneum. This layer also contains melanocytes involved in skin pigmentation; Langerhans cells, which are important for antigen presentation and immune responses; and Merkel cells, whose precise role in sensory reception has yet to be fully delineated. As keratinocytes undergo terminal differentiation, they begin to flatten out and assume the dimensions characteristic of the corneocytes (i.e., their diameter changes from 10--12 m to 20--30 m, and their volume increases by 10- to 20-fold). The viable epidermis does not contain a vascular network, and the keratinocytes obtain their nutrients from below by passive diffusion through the interstitial fluid. The skin is a dynamic structure. Barrier function does not simply arise from the dying, degeneration, and compaction of the underlying epidermis. Rather, the processes of cornification and desquamation are intimately linked; synthesis of the stratum corneum occurs at the same rate as loss. Substantial evidence now confirms that the formation of the skin barrier is under homeostatic control, which is illustrated by the epidermal response to barrier perturbation by skin stripping or solvent extraction. Circumstantial evidence indicates that the rate of keratinocyte proliferation directly influences the integrity of the skin barrier. A general increase in the rate of proliferation results in a decrease in the time available for 1) uptake of nutrients (e.g., essential fatty acids), 2) protein and lipid synthesis, and 3) processing of the precursor molecules required for skin-barrier function. Whether chronic but quantitatively smaller increases in rate of epidermal proliferation also lead to changes in skin-barrier function remains unclear. Thus, the extent to which the decreased barrier function caused by irritants is caused by an increased epidermal proliferation also is unknown. The current understanding of the formation of the stratum corneum has come from studies of the epidermal responses to perturbation of the skin barrier. Experimental manipulations that disrupt the skin barrier include 1) extraction of skin lipids with apolar solvents, 2) physical stripping of the stratum corneum using adhesive tape, and 3) chemically induced irritation. All of these experimental manipulations lead to a decreased skin barrier as determined by transepidermal water loss (TEWL). The most studied experimental system is the treatment of mouse skin with acetone. This experiment results in a marked and immediate increase in TEWL, and therefore a decrease in skin-barrier function. Acetone treatment selectively removes glycerolipids and sterols from the skin, which indicates that these lipids are necessary, though perhaps not sufficient in themselves, for barrier function. Detergents act like acetone on the intercellular lipid domain. The return to normal barrier function is biphasic: 50%--60% of barrier recovery typically occurs within 6 hours, but complete normalization of barrier function requires 5--6 days Source: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm

6.1 Hand Washing for the general public from the CDC

*The most important thing that you can do to keep from getting sick is to wash your hands. By frequently washing your hands you wash away germs that you have picked up from other people, or from contaminated surfaces, or from animals and animal waste. *What happens if you do not wash your hands frequently? You pick up germs from other sources and then you infect yourself when you

Touch your eyes Or your nose Or your mouth.

One of the most common ways people catch colds is by rubbing their nose or their eyes after their hands have been contaminated with the cold virus. You can also spread germs directly to others or onto surfaces that other people touch. And before you know it, everybody around you is getting sick. The important thing to remember is that, in addition to colds, some pretty serious diseases -- like hepatitis A, meningitis, and infectious diarrhea -- can easily be prevented if people make a habit of washing their hands. *When should you wash your hands? You should wash your hands often. Probably more often than you do now because you can't see germs with the naked eye or smell them, so you do not really know where they are hiding. It is especially important to wash your hands

Before, during, and after you prepare food Before you eat, and after you use the bathroom After handling animals or animal waste When your hands are dirty, and More frequently when someone in your home is sick.

*What is the correct way to wash your hands?

First wet your hands and apply liquid or clean bar soap. Place the bar soap on a rack and allow it to drain. Next rub your hands vigorously together and scrub all surfaces. Continue for 10 - 20 seconds or about the length of a little tune. It is the soap combined with the scrubbing action that helps dislodge and remove germs. Rinse well and dry your hands.

It is estimated that one out of three people do not wash their hands after using the restroom. So these tips are also important when you are out in public. Source: http://www.cdc.gov/ncidod/op/handwashing.htm

2.2 CDC 2002 Hand Hygiene Guidelines Fact Sheet

Improved adherence to hand hygiene (i.e. hand washing or use of alcohol-based hand rubs) has been shown to terminate outbreaks in health care facilities, to reduce transmission of antimicrobial resistant organisms (e.g. methicillin resistant staphylococcus aureus) and reduce overall infection rates. CDC is releasing guidelines to improve adherence to hand hygiene in health care settings. In addition to traditional handwashing with soap and water, CDC is recommending the use of alcohol-based handrubs by health care personnel for patient care because they address some of the obstacles that health care professionals face when taking care of patients. Handwashing with soap and water remains a sensible strategy for hand hygiene in non-health care settings and is recommended by CDC and other experts. When health care personnel's hands are visibly soiled, they should wash with soap and water. The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70 percent to 80 percent, prevent cross-contamination and protect patients and health care personnel from infection. Handrubs should be used before and after each patient just as gloves should be changed before and after each patient. When using an alcohol-based handrub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product. Alcohol-based handrubs significantly reduce the number of microorganisms on skin, are fast acting and cause less skin irritation. Health care personnel should avoid wearing artificial nails and keep natural nails less than one quarter of an inch long if they care for patients at high risk of acquiring infections (e.g. Patients in intensive care units or in transplant units When evaluating hand hygiene products for potential use in health care facilities, administrators or product selection committees should consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of hand hygiene products by personnel. Characteristics of a product that can affect acceptance and therefore usage include its smell, consistency, color and the effect of dryness on hands. As part of these recommendations, CDC is asking health care facilities to develop and implement a system for measuring improvements in adherence to these hand hygiene recommendations. Some of the suggested performance indicators

include: periodic monitoring of hand hygiene adherence and providing feedback to personnel regarding their performance, monitoring the volume of alcohol-based handrub used/1000 patient days, monitoring adherence to policies dealing with wearing artificial nails and focused assessment of the adequacy of health care personnel hand hygiene when outbreaks of infection occur. Allergic contact dermatitis due to alcohol hand rubs is very uncommon. However, with increasing use of such products by health care personnel, it is likely that true allergic reactions to such products will occasionally be encountered. Alcohol-based hand rubs take less time to use than traditional hand washing. In an eight-hour shift, an estimated one hour of an ICU nurse's time will be saved by using an alcohol-based handrub. These guidelines should not be construed to legalize product claims that are not allowed by an FDA product approval by FDA's Over-the-Counter Drug Review. The recommendations are not intended to apply to consumer use of the products discussed.

Source: http://www.cdc.gov/od/oc/media/pressrel/fs021025.htm 7.1 Plain (Non-Antimicrobial) Soap Soaps are detergent-based products that contain esterified fatty acids and sodium or potassium hydroxide. They are available in various forms including bar soap, tissue, leaflet, and liquid preparations. Their cleaning activity can be attributed to their detergent properties, which result in removal of dirt, soil, and various organic substances from the hands. Plain soaps have minimal, if any, antimicrobial activity. However, handwashing with plain soap can remove loosely adherent transient flora. For example, handwashing with plain soap and water for 15 seconds reduces bacterial counts on the skin by 0.6--1.1 log10, whereas washing for 30 seconds reduces counts by 1.8--2.8 log10. However, in several studies, handwashing with plain soap failed to remove pathogens from the hands of hospital personnel. Handwashing with plain soap can result in paradoxical increases in bacterial counts on the skin. Non-antimicrobial soaps may be associated with considerable skin irritation and dryness, although adding emollients to soap preparations may reduce their propensity to cause irritation. Occasionally, plain soaps have become contaminated, which may lead to colonization of hands of personnel with gram-negative bacilli. Source: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm 7.2 Alcohols The majority of alcohol-based hand antiseptics contain either isopropanol, ethanol, npropanol, or a combination of two of these products. Although n-propanol has been used in alcohol-based hand rubs in parts of Europe for many years, it is not listed in TFM as an approved active agent for HCW handwashes or surgical hand-scrub preparations in the United States. The majority of studies of alcohols have evaluated individual alcohols in varying concentrations. Other studies have focused on combinations of two alcohols or

alcohol solutions containing limited amounts of hexachlorophene, quaternary ammonium compounds, povidone-iodine, triclosan, or chlorhexidine gluconate. The antimicrobial activity of alcohols can be attributed to their ability to denature proteins. Alcohol solutions containing 60%--95% alcohol are most effective, and higher concentrations are less potent because proteins are not denatured easily in the absence of water. The alcohol content of solutions may be expressed as percent by weight (w/w), which is not affected by temperature or other variables, or as percent by volume (vol/vol), which can be affected by temperature, specific gravity, and reaction concentration. For example, 70% alcohol by weight is equivalent to 76.8% by volume if prepared at 15C, or 80.5% if prepared at 25C. Alcohol concentrations in antiseptic hand rubs are often expressed as percent by volume. 7.3 Fingernails and Artificial Nails Although the relationship between fingernail length and wound infection is unknown, keeping nails short is considered key because the majority of flora on the hands are found under and around the fingernails. Fingernails should be short enough to allow DHCP to thoroughly clean underneath them and prevent glove tears. Sharp nail edges or broken nails are also likely to increase glove failure. Long artificial or natural nails can make donning gloves more difficult and can cause gloves to tear more readily. Hand carriage of gram-negative organisms has been determined to be greater among wearers of artificial nails than among nonwearers, both before and after handwashing. In addition, artificial fingernails or extenders have been epidemiologically implicated in multiple outbreaks involving fungal and bacterial infections in hospital intensive-care units and operating rooms. Freshly applied nail polish on natural nails does not increase the microbial load from periungual skin if fingernails are short; however, chipped nail polish can harbor added bacteria. 7.4 Jewelry Studies have demonstrated that skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings. In a study of intensive-care nurses, multivariable analysis determined rings were the only substantial risk factor for carriage of gram-negative bacilli and Staphylococcus aureus, and the concentration of organisms correlated with the number of rings worn. However, two other studies demonstrated that mean bacterial colony counts on hands after handwashing were similar among persons wearing rings and those not wearing rings. Whether wearing rings increases the likelihood of transmitting a pathogen is unknown; further studies are needed to establish whether rings result in higher transmission of pathogens in health-care settings. However, rings and decorative nail jewelry can make donning gloves more difficult and cause gloves to tear more readily. Thus, jewelry should not interfere with glove use (e.g., impair ability to wear the correct-sized glove or alter glove integrity). Source: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

7.5 Water Temperature Overall, it is mainly for the hand washee's comfort level that in temperate climes hot water is supplied, so that the water temperature will be at or just above body temperature, i.e. 37 C (98.6 F) up to about 45 C. (110 F). I would also suggest warmer water would have a greater potential to dissolve and suspend soil, sebum deposits on skin and soap from hand washing, as compared to colder water. In short, warm water has both functional and motivational reasons for use in hand washing.

From soap and water, to waterless agents: Update on hand hygiene in health care settings Joanne Langley, MD MSc FRCPC Joanne Langley, Clinical Trials Research Centre - Infectious Diseases, IWK Health Centre, Halifax, Nova Scotia; Correspondence and reprints: Dr Joanne M Langley, Infection Control Services and the Clinical Trials Research Centre, IWK Health Centre, Halifax, Nova Scotia B3J 3G9. Telephone 902-470-8498, fax 902-470-7217, e-mail joanne.langley@dal.ca

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The hands of those who provide health care to children palpate, percuss, perform procedures, wipe noses, change diapers, comfort parents and hold children, among many other activities. These multiple physical contacts provide opportunities for microorganisms to travel between the caregiver and the child. Hand washing has traditionally been identified as the most important infection control intervention to prevent disease transmission and is recommended before and after contact with patients, body fluids and dirty material; between dirty and clean procedures on the same patient; before and after performing invasive procedures; and after using the washroom (1). In recent years, a plethora of hand hygiene products, including many with antimicrobial activity, has become available and some are marketed to the general public. In the present note, the various agents available for hand hygiene are reviewed and suggestions for their appropriate use in nonsurgical health care settings are made. Just like other bodily organs, human skin has a normal physiological state. The function of skin as a barrier is maintained by water content, intercellular lipids, temperature and rates of desquamation (2). Skin normally is colonized by bacteria that can reach counts as high as 1000 colony-forming units/cm2 near the hands (3). Bacteria are thought to be resident if they are attached to deeper layers of skin, and transient if they colonize superficial layers of skin. Hand hygiene eliminates the transient flora that are acquired by caregivers during direct contact with patients or contaminated environmental surfaces adjacent to a patient. The products available can be categorized into hand washing agents (plain soaps or antiseptic soaps) and handrubs (antiseptic waterless agents) (4).

PLAIN SOAP Hand washing with plain soap suspends microorganisms and mechanically removes them by rinsing with water. Plain bar soap, leaf, tissue or liquid preparations are comprised of detergents with surfactant or 'surface-active' activity that holds dirt or transient flora in suspension. Cleaning is due to the physical removal of foreign material or microorganisms, not killing. ANTIMICROBIAL SOAP An antimicrobial soap combines the cleaning action of the physical removal of foreign material with an antiseptic agent that kills microorganisms. The antimicrobial agents (eg, alcohol, chlorhexidine, iodine, triclosan, hexachlorophene) usually have sustained activity on the skin that continues to reduce the number of microbial flora after the hand wash is complete.

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WATERLESS AGENTS Antiseptic handrubs are waterless agents with disinfectant properties that decrease the number of microorganisms present. The individual applies a small amount (approximately 3 mL) to the hands, then rubs the hands together until theagent has dried. An antiseptic handrub does not require the use of exogenous water. Most alcohol-based hand antiseptics contain either isopropanol, ethanol, n-propanolol or a combination of two of these products (4). They are available in varying concentrations, or in combination with a small amount of other antiseptics. Antimicrobial activity is due to their ability to denature proteins. Because these handrubs do not remove organic material, they cannot beused if hands are visibly soiled.

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CONSIDERATIONS FOR USE The important considerations in evaluating the suitability of a hand hygiene product for use in a clinical setting are its efficacy in preventing the transmission of microorganisms, adverse consequences (odour, skin damage) for health care providers, ease of access for users, affordability (5), and concerns about the induction of resistant bacteria (6). Skin irritation from hand washing (dryness, dermatitis) affects compliance with hand hygiene and increases the ability of pathogenic bacteria to adhere to skin (5,7). Difficult access and the time required to practise hand hygiene limit its implementation. For example, approximately 62 s are needed to complete a hand wash and, therefore, 16 h of nursing time per shift could be expended for hand washing in a 12-unit intensive care unit. By contrast, only 4 h per shift would be used for hand hygiene if a bedside alcohol hand disinfectant were used (5). Studies of the efficacy of hand hygiene agents have shown that antiseptic agents (antimicrobial soaps or waterless antiseptic hand rubs) are significantly more effective in reducing microbial counts on skin than plain soap and water hand washing in reducing skin flora (4,8-10). The Draft Guideline for Hand Hygiene in Healthcare Settings (10) produced by a joint task force of national infection control societies and the Centers for Disease Control and Prevention concluded that alcohol-based handrubs are more

effective than washing hands with antimicrobial or nonantimicrobial soap, can be made more accessible, require less time to use and are less prone to cause irritant contact dermatitis (10). In health care settings that involve ambulatory patients who are not at high risk for serious infectious diseases, and in the home, mild plain soaps will likely be sufficient. If the risk of infection is thought to be increased, an antimicrobial hand hygiene agent will reduce the risk of transmission of pathogen organisms. Waterless agents have the additional benefit of not requiring access to water and sinks, ease of use, rapid action and no risk of antimicrobial resistance. Infection control personnel are an invaluable resource when making a choice among the plethora of hand hygiene agents that balance patient safety, health care worker acceptability and affordability.

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RECOMMENDATIONS

Hand hygiene is an important infection control intervention to prevent the transmission of micro-organisms and should be practised before and after patient contact, when hands are visibly dirty, after using the washroom and at other times when hands may be soiled. For some ambulatory, low risk patient care contacts, cleansing the hands with a mild, nonantimicrobial cleansing product is sufficient to prevent infectious disease transmission. For patient care in areas with high risk patients or before invasive procedures where there will be a healthcare benefit in decreasing the microbial load on healthcare worker hands, an antiseptic agent (waterless handrub or antimicrobial soap) should be used for hand hygiene. Waterless hand hygiene rubs are a proven alternative to hand washing agents and are preferred in some settings, including when there are time constraints or lack of access to sinks and running water. Visible organic material must be removed for waterless agents to exert their antimicrobial activity. Skin emollients should be used to prevent skin damage from frequent hand washing. If skin emollients are used, care must be taken to ensure that specific products do not interfere with the activity of hand antiseptic hand hygiene products.