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Hand Hygiene

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Kindling a Culture of Cleanliness

Come Compete in the Handwashing For Life Olympics

Handwashing For Life® overcomes underwashing of hands and high-touch surfaces by integrating a series of best practices. At the Food Safety Consortium, being staged at the Schaumburg Conference Center, on December 4th & 5th, attendees will learn how to assess their hand hygiene related risks and assemble a sustainable solution. The program is a driver to establish a culture of cleanliness, one handwash at a time.

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What Constitutes a Handwash?

Blending available resources into an effective protocol.

From a Food Code perspective there is but one handwash. We like to think of it as a minimum and one of perhaps many. Handwashing For Life designates a soap-water 15 second hand wash, with a 2.0 gpm flow of warm water and paper towel drying, as its Core Hand Wash. Depending on risk, adjustments are made at the operator level to exceed the minimum where required.

Technically, a handwash is blend of four factors, four resource categories:

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Training Handwashing: A Sisyphean Task

Sometimes training handwashing feels futile and frustrating. For the professional who daily works through this repetitive task, we found a parallel image from back in Greek mythology. Sisyphus, the king of Corinth, was charged with rolling a stone uphill for eternity.

Luckily for our dedicated handwash trainers, their toil has a more rewarding outcome, especially when they introduce performance standards and incorporate success into staff rewards.

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The Case For Added Hand Wash/Cleanse/Sanitize Protocols

Light duty hand cleaning may increase frequency

The Model Food Code serves as a minimum standard, providing a foundation on which operators can build solutions tailored to their operation and their assessment of risk.

There is an unresolved handwashing dilemma in the Model Food Code in that it prescribes the same wash whether the hands are very lightly contaminated (visibly unsoiled) or are heavily soiled. The identical 15 second scrub time is specified for both.

Intuitively this doesn't make sense to the kitchen staff. Some, perhaps many, compensate by not washing at all when hands are seen as unsoiled. This likely accounts for over half of the 8.6 hand washes per employee hour identified in a CDC observational study as the number required to conform to the Model Food Code. (J Food Prot. 2006 Oct;69(10):2417-23)

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Restroom Research Drives Integrated Solution

Toilet Paper RollFDA's Captain Wendy Fanaselle took attendees of the Food Safety Summit on a research guided graphical trip of the restroom to emphasize the importance of killing the fecal-pathogens before they escape into public areas.

Toilet paper, designed by those more concerned about flushability than its barrier properties, doesn't do the job. Single or double ply, soft or strong, research indicates pathogens still escape the basic maneuver and often proceed beyond the restroom doors.

Toilet paper is an advance over at least three of its earlier substitutes:

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Hand Hygiene Outbreak Factor Established for Foodservice

The Southwest Environmental Health Association, during their 2013 annual meeting, volunteered to help establish a reference number for restaurant outbreaks due to poor hand hygiene. The group, largely local, state and national regulators, was asked What percentage of foodborne outbreaks are attributable to poor hand hygiene? They were given these choices: 20%, 40%, 60% or 80%.

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Norovirus-Focused Handwashing in Restaurants (Part one)

Defining a safe level for handwashing frequency

Norovirus outbreaks commonly raise this question: What is a safe level for handwashing frequency?

If we look to the FDA for answers, the Model Food Code wisely avoids getting over prescriptive, considering all the variables.

The CDC conducted a valuable observational study using the Model Food Code as its benchmark. They concluded 8.6 Handwashes/Employee Hour (HW/EH) were required to be code-compliant, a total of 69 Handwashes per 8 hour shift

This led to other questions: Is the Model Food Code already over-prescriptive or truly risk-based? Would this level of handwashing be in conflict with customer service? In general, a level of 8.6 HW/EH is seen as too much to ask of employees. Regulators generally agree.

More effective use of tongs and wraps can lower the need for handwashing but the basic issue remains. Some situations, like following restroom use, clearly demand a good handwash. A casual touch of the face or hair is a lot less risky yet the Code specifies the same handwash for both. Is that risk-based or inspection based?

A frequency rate target of 8.6 HW/EH discourages reasonable, attainable compliance improvement. It protects the status quo. "Don't let perfect be the enemy of good."

We believe the Food Code in this case should prioritize the risks by establishing categories of High, Moderate and Low. Operators then set up a controllable process based on risk, a process to which they are committed. We will be discussing this at CFP 2014 and will likely propose this change at CFP 2016. Read more about Norovirus-Focused Handwashing in Restaurants (Part one)

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Paper Towel Choices

Why poor hand washers need better paper

Single-use paper toweling is a critical component in professional handwashing, whether in restaurants, schools, the workplace or hospitals and nursing homes. The choice of drying method and materials is first driven by user habits and the risks resulting from potential failures in the hand cleansing process. Hand hygiene breakdowns are measured by some in illness outbreaks and by others in absenteeism rates.

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Day One Handwashing: Motivating New Employee Behaviors

At a food safety meeting in Las Vegas a few years ago, Frank Yiannis, Wal-Mart's VP of Food Safety, recounted his 19 year stint with Disney, asking the audience "What do you remember most in your career path?"

His answer? Day one of the new job, that immersion into the new culture.

Handwashing For Life's Day One Handwashing program leverages this reality. Entering the kitchen for the first time provides a unique opportunity to install handwashing as a job-critical priority. It is potentially a behavior-changing moment where the new employee is anxious to understand expectations and please the new boss. The Day One training personalizes and visualizes both the problem and solution.

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Respect for the Qu’ran in Foodservice Hand Hygiene Training

Ethnic considerations along with language proficiency must be factored into foodservice hand hygiene training programs. All food handling staff must be aware that “Failure in hand hygiene systems is the number one contributing factor in foodservice outbreaks.” according to Jim Mann, executive director of the Handwashing For Life Institute. Dr. D. Pettit of the World Health Organization (WHO) reflects a supporting view in his healthcare work where he considers hand hygiene as the most effective tool in preventing cross-contamination and lowering HAI, hospital acquired infections.

Within the foodservice industry, public health officials, lead by the Centers for Disease Control and Prevention, agree that regular handwashing is the most effective defense against the spread of foodborne illness.  It is the responsibility of foodservice management to offer effective hand hygiene facilities complete with best practice protocols, products and training in order to keep their customers and workforce safe

Handwashing training involves not only education, but also behavior modification and constant reinforcement.  Training is challenging even with a receptive group of trainees, however, adding the extra obstacle of differing cultural and religious attitudes into the mix, makes influencing attitudes and changing behaviors an even tougher task.

According to a 2008 study conducted by the WHO, hand hygiene is strongly influenced by religious faith and potentially affects compliance.  Although this and other published studies focused on healthcare settings, one can assume that religion and culture influences hand hygiene in the foodservice sector in a similar fashion.   With a growing influx of immigrants from India, Pakistan and the Middle East, Muslim religious and cultural traditions must be taken into consideration when formulating best practices in hand hygiene within the foodservice industry.

Islam places great emphasis on physical and spiritual cleanliness.  The Qu’ran offers specific instruction on when and how hand cleansing should occur.  These include before prayer (5 times a day), before and after meals, after using the toilet, after touching a dog, shoes or cadaver, and after handling anything soiled.  Compared to most other religions, these rules are quite specific and stringent.  More importantly, these rules are followed by the majority of Muslims, not just those who consider themselves ardent followers or overtly religious. One reason for such compliance is that hand hygiene patterns are usually established within the first 10 years of life and become ingrained behavior.  With such specific instructions from the Qu’ran and a high rate of compliance, one would assume hand cleanliness among Muslim workers within the healthcare and foodservice setting would not be an issue.  However, although Islam teaches its followers that cleanliness is vitally important, other Muslim practices may increase the risk of cross contamination and illness transmission.

A common popular belief in the Muslim (and Hindu, Jewish and African) culture is that the left hand is considered unclean as it is used for hygienic cleaning, while the right hand is used for eating. Although toilet paper is widely accepted and used, culture dictates that Muslims should clean their private parts after bathroom use with their bare left hand.  This practice is obviously problematic, as even vigorous post-bathroom hand washing often doesn’t remove all potentially illness-causing pathogens.  Additionally, many Muslims don’t like to use utensils to eat and prefer to use their bare hands.  Again, although the Qu’ran instructs individuals to wash before and after eating, it is almost impossible to wash away all risk.  Perhaps the greatest obstacle foodservice and healthcare management may face when trying to ensure compliance with hand hygiene standards within the Muslim workforce, is their reluctance, and often refusal, to use the gold standard in convenient hand disinfection - alcohol based hand sanitizers.

Alcohol hand sanitizers are considered an adjunct to handwashing and are increasingly used in both foodservice and healthcare to maintain hand cleanliness standards between wash cycles. Using hand sanitizer without a preceding handwash, preferably with a nailbrush, is totally unacceptable after defecation or any use of the restroom.

Although the Qu’ran specifically forbids the use of alcohol, it permits the use of any manmade substance to reduce illness or contribute to improved health, including alcohol used for disinfection.  In fact, the Muslim Judicial Council of South Africa has issued written permission regarding the use of alcohol not produced as a result of fermentation for the specific purpose of disinfecting the hands.  In addition, due various health concerns during Hajj (religious pilgrimages to Mecca and Medina), in 2002 the World Muslim League in Mecca issued a fatwa allowing the use of alcohol based hand sanitizers. During this year’s Hajj, Saudi Deputy Health Minister Dr. Ziad Memish reiterated that Saudi senior religious leaders deem alcohol-based sanitizers acceptable. Despite these fatwas and their documented approval of alcohol based hand sanitizers, many Muslims still adhere to their conservative beliefs that all alcohol is unacceptable.  Not only is the smell of alcohol on the skin disturbing, some fear that the alcohol in the sanitizers may be inhaled or absorbed into the skin causing intoxication.

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