Why is hygiene and infection control important in schools?

Hygiene is particularly important in the school setting as young school children are recognized as at particular risk of contracting and transmitting enteric (relating to intestines) infection (Finn and Crook, 1998/1999). Children are particularly susceptible because of a number of factors.
  1. They have immature immune systems
  2. They tend to have a higher degree of close contact with other children
  3. They tend to explore with their hands, and germs from hands to mouth can easily cause infection
  4. They share facilities and equipment
  5. They may not have an understanding of hygiene practices
  6. They may have incomplete immunisations (Berg, 1988)

It is recognised that infection control focusing on environmental factors and hygiene practices in schools can reduce the transmission of infection. (Black et al, 1981; Krilov et al, 1996). For example, a study of sanitation facilities in schools in Bloomsbury found inadequate provision of soap, toilet paper and towels and the potential for the spread of infectious diseases. (Jewkes and O’Connor, 1990). Another study in Leeds found faecal bacteria (a micro-organism) on environmental surfaces and children’s hands. (Kaltenthaler et al, 1995) and a sample of children’s hands and the environment found contamination in the classroom, on floors, taps, and surfaces (Holaday et al (1990).

What are the potential benefits for schools?

  • Fewer school days missed – which can have a knock on effect on parents for childcare arrangements together with education lost for children
  • Fewer illness for children especially diarrhoea and vomiting and respiratory illness
  • Less visits to GPs
  • Potentially less use of antibiotics
  • Fewer outbreaks of infectious disease
 A study in America gathered baseline data for a year on infections in children before an infection control intervention. The findings from this study were a significant decrease in total illness, with downward trends in respiratory illness, gastrointestinal illness, visits to the GP, antibiotic use and school days missed. (Krilov et al, 1996). Another study showed how a comprehensive handwashing programme reduced absenteeism (Guinan M et al, 2002).

What are micro-organisms? (adapted from Mims)

Micro-organisms, also known as germs, are small living things that cannot be seen by the naked eye. They can be found in many different places and can cause infectious diseases. The main micro-organisms are bacteria, viruses, fungi and parasites.

Bacteria can live anywhere including in food and water or on surfaces. The majority of them are harmless, in fact many of them live on the human body and protect us from other harmful bacteria. In our stomachs, for example, we have bacteria that protect us when we eat and digest food.

However, other germs can cause us harm and give us infections. Infectious diseases caused by bacteria include scarlet fever, meningitis and certain types of food poisoning such as salmonella. Viruses, which are much smaller than bacteria cause many diseases such as measles, mumps, rubella (German measles), chicken pox and HIV. Fungal infections include ringworm and finally, parasites include head lice and scabies.

How do we catch them? (adapted from Mims)
The mains ways we can catch an infection are:

  1. Through the air – For example, when someone coughs or sneezes in front of you. If the person has an infectious disease you can inhale the tiny droplets and catch an infection e.g. the common cold.
  2. Through direct contact – when someone is infectious and passes their infection directly to you by touch e.g. ringworm. Another method is by blood entering your body through a cut or break in the skin. Diseases such as hepatitis B can be transmitted in this way.
  3. Through indirect contact – when someone transfers their germs via their unwashed hands to other surfaces. Germs can also be passed to food in this way. For example, if someone has a disease like viral gastroenteritis (diarrhoea and vomiting) and they go to the toilet, do not wash their hands and prepare you a sandwich afterwards, the germs are passed to you.
  4. Through insects and animals – animals can transmit infectious diseases including pets. Examples of insects include mosquitos which can pass on the disease malaria.

In other words germs are everywhere! As germs, like us, are living organisms we could never eliminate them completely and in fact we need good germs to protect us against the more sinister variety! However, there are things that we can do to make sure that we don’t spread the harmful germs and make ourselves ill. Good toilet facilities and hand washing facilities are two important factors!

Hand Washing (Adapted from the ICNA)

Hand washing is one of the most important ways of preventing infection. Hands can move germs to other places such as from the toilet to the classroom!

The importance of hand hygiene to prevent the risk of infection is well documented. (Pete J, 1987; May, 1998; Hammond et al, 2000). Education around hand hygiene in schools is very important, along with access to appropriate facilities. (May, 1998; Baxter and Cleary, 2002). Liquid soap and paper towels together with warm and cold water are considered the best practice for hand washing (Gould, 2000; Ward, 2000).

Thorough hand washing with warm water and soap will remove germs along with effective hand drying.

When should children wash their hands?

  • Before eating food especially at lunch time
  • After using the toilet
  • After contact with blood or other body fluids (such as vomit)
  • After touching or picking their nose
  • After handling pets, pet cages, feeding utensils and other pet items such as litter trays
  • After going out to play
  • After being in contact with a contaminated area such as rubbish bins
  • Whenever their hands are dirty

How should children wash their hands?
Ideally liquid soap, warm running water, paper towels and a foot operated bin should be provided.

  • Put hands under warm running water
  • Apply soap
  • Rub hands together paying particular attention to finger tips, thumbs and between fingers
  • Rinse hands under warm running water
  • Dry hands thoroughly with a paper towel

Toilets

Studies on toilet facilities have shown children are reluctant to use toilets because of poor sanitary conditions and avoid drinking water in order not to go to the toilet. Low fluid intake has been associated with health problems in children e.g. incontinence, constipation, urinary tract infection and kidney stones (Haines et al, 2000).

One study showed that due to restricted access to toilets (which were also poorly maintained) and restricted access to toilet paper, children did not open their bowels at school, leading to chronic constipation. (Barnes and Maddocks, 2002). Other key research in Sweden and England has addressed the physical and psychological health of children’s experiences of school toilets including bladder dysfunction, urinary tract infection and bullying. (Vernon S, et al 2003).

These studies show the wider implication of poor toilet facilities in schools as well as the potential spread of infectious diseases (Cleary V, et al 2003).

Good toilet facilities and hand washing facilities are considered to be important for infection control.

  • Toilets should be clean, in good repair and monitored regularly. For example, an audit checklist should be located in the toilets, dated and signed at regular intervals.
  • All toilet areas should have hand washing facilities including warm and cold running water, soap and towels
  • Liquid soap and paper towels are recognized as the most effective hand washing method. Liquid soap, unlike bar soap, is less likely to become contaminated.
  • Ideally liquid soap should be wall mounted and disposable cartridges are considered to be the ‘gold standard’. Liquid soap that is “topped up” can become contaminated.
  • Some schools use roller towels or hand dryers. Ideally paper towels should be used. However, if roller towels or hand dryers are provided they should be regularly maintained, changed or cleaned.
  • Water fountains and other drinking outlets should not be located in the toilets (Waters and Cram, 2002).
  • General bins (for paper towels etc) in toilets should be foot operated.

References:

Barnes P M and Maddocks A (2002) Standards in school toilets – a questionnaire survey. Journal of Public Health Medicine 24(2), 85-87.

Baxter A and Cleary V (2002). Hand hygiene in local primary school children – an infection control and health promotion initiative. BJIC. 3(2) 14-17.

Berg R (1988). Day care for children in the APIC curriculum for infection control practice. Kendall Hunt, Iowa, 1310-1324.

Black R E, Dykes AC Anderson KE et al. (1981). Handwashing to prevent diarrhea in day-care centers. Am J Epidemiology. 113: 445-51.

Cleary, V, Slaughter, R and Heathcock R (2003). Infection Control in primary schools and the wider public health impact. BJIC 4(5) 11-15.

Finn L and Crook S. (1998/1999) Handwashing – Starting off on the right foot? Health Trends 30(4): 94-6

Guinan M, McGuckin M, Dr ScEd, MT (ASCP), Ali, Yusuf (2002). The effect of a comprehensive handwashing program on absenteeism in elementary schools. Am J Infect Control. 2002; 30: 217-20.

Haines L, Rogers J and Dobson P (2000). A study of drinking facilities in schools. Ntplus 96(40) 2-4.

Hammond B, Ali Y, Fendler E, Dolan M, Donovan S (2000) Effect of Hand Sanitiser Use on Elementary School Absenteeism. American Journal Of infection Control: 28 (5): 340-6

Holaday B, Pantell R H, Lewis C C, Gillis C L (1990) Patterns of faecal coliform contamination in day care centres. Public Health Nursing 7(4): 224-227.

ICNA (2002). Hand Decontamination Guidelines. ICNA

Jewkes R K, O’Connor B H (1990) Crisis in our schools: Survey of sanitation facilities in schools in Bloomsbury Health District. Brit Med Journal 301: 1085-1087.

Kaltenhaler EC, Elsworth A, Schweiger M, Mara D Braunholz D (1995) Faecal contamination on Children’s Hands and Environmental Surfaces in Primary Schools in Leeds. Epidemiol. Infect (1995) 115: 527-534

Krilov, LR, Barone, SR, Mandel FS, Cusack, TM, Gaber DJ, Rubino JR (1996). Impact of an infection control program in a specialized preschool. AJIC AM J of Infection Control. 24(3): 167-173


May H (1998) Now Wash your hands … Nursing Times 94(4) 63-6

Mims, C, Playfair, J, Roitt, I, Wakelin D and Williams R (1998) Medical Microbiology, Second Edition. Mosby Publishers Ltd, London.

Pete J (1987) Handwashing Practices Amoung Various School Age Students. Health Education December 1986 – January 1987. 37-39

Vernon S, Barbro L and Hellstrom A L (2003) Children’s experiences of school toilets present a risk to their physical and psychological health. Journal of Child: Care, Health & Development. 29(1), 45-53.

Walters K and Cram G (2002) Drinking water in schools: hygiene standards at fountains. Nutrition & Food Science 32(1); 9-12

Ward D (2000) Handwashing facilities in the clinical area: a literature review. British Journal of Nursing. 9(2): 82-6