Name: A Method to Test the Efficacy of Handwashing for the Removal of Emerging Infectious Pathogens (Video) | JoVE Journal
Uploaded: 2017-06-07T14:00:00.000+00:00
Duration: 9 min 2 s
Description: Learn a flexible laboratory method to test handwashing efficacy using surrogate microorganisms like E. coli and Phi6 bacteriophage. This protocol enables quantitative comparison of chlorine, soap, and sanitizer approaches for infectious disease prevention.

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5 minutes

This work was supported by the United States Agency for International Development, Office of Foreign Disaster Assistance (AID-OFDA-A-15-00026). Marlene Wolfe was supported by the National Science Foundation (grant 0966093).

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</ol>

The authors declare that they have no competing financial interests.

The method described here provides an approach for testing handwashing efficacy in a controlled laboratory setting. This method highlights the use of human volunteers and surrogate, non-infectious organisms. Using the method, it was possible to demonstrate differences in: 1) the efficacy of handwashing methods and 2) organism persistence in rinse water. The purpose of presenting this protocol is to provide a general framework that can be adapted to test a wide range of surrogate organisms and handwashing methods relevant...

Handwashing is widely recommended to prevent the spread of disease, particularly those transmitted by the fecal-oral or airborne route, including diarrheal and respiratory diseases1. Surprisingly, there is little comparable evidence on the efficacy of handwashing methods, such as handwashing with soap and water (HWWS) and with alcohol-based hand sanitizer (ABHS), on the removal of organisms from the hands. Initial research has found that the mechanical action of handwashing, as opposed to the handwashing method, may account for most organism removal2,3. Additionally, there is little comparative evidence on which handwashing method is most efficacious. In an informal literature review, 14 studies that compared the efficacy of soap and hand sanitizer on the removal of organisms were identified. Of these studies, five found ABHS to be more efficacious4,5,6,7,8, seven found HWWS to be more efficacious9,10,11,12,13,14,15, and two found no significant difference between the methods16,17. These findings are inconsistent and do not address the ongoing risk of disease from the persistence of organisms in the rinse water after handwashing. Overall, the evidence on the comparative efficacy of handwashing methods for the removal of infectious disease-causing pathogens is limited.
This limited evidence has led to uncertainty about which methods are most appropriate in outbreak settings. For example, during the Ebola Virus Disease (EVD) outbreak in West Africa from 2013 to 2016, several large international responders provided contradictory recommendations for HWWS, ABHS, or 0.05% chlorine solutions. M&#233;decins Sans Fronti&#232;res (MSF) recommends the use of 0.05% chlorine solution for handwashing, while the World Health Organization (WHO) recommends HWWS or ABHS (if the hands are not visibly soiled). The WHO goes so far as to state that chlorine should not be used unless no other options are available, because it is less effective than other methods due to the chlorine demand exerted by the skin18,19,20,21,22. Additionally, the chlorine solutions are commonly produced from four different chlorine compounds, including high-test hypochlorite (HTH), locally-generated and stabilized sodium hypochlorite (NaOCl), and sodium dichloroisocyanurate (NaDCC). A systematic review commissioned by the WHO in response to the EVD outbreak in West Africa recently found only four studies investigating the comparative efficacy of handwashing with chlorine23. These studies also produced conflicting results, and none of these studies used the recommended chlorine concentration of 0.05% for handwashing or investigated microorganisms similar to the Ebola virus10,24,25,26,27. Thus, the recommendations were not found to be evidence-based, and it was unclear which recommendations were most efficacious.
Additional research is needed to compare handwashing approaches to prevent the spread of infectious pathogens, as handwashing interventions are an important tool to prevent epidemic disease transmission. These handwashing recommendations must be based on evidence. Thus, a method for testing handwashing efficacy and rinse water persistence, performed with surrogates or non-infectious pathogens, was developed2,28,29. Sample results, using Phi6 as a surrogate for the Ebola virus and using Escherichia coli as a common indicator organism, are presented here. In this protocol, handwashing efficacy and rinse water persistence tests are presented.

<table><tbody><tr><td>Soap bar</td><td>Dove</td><td>White Beauty Bar soap</td><td></td></tr><tr><td>Alcohol-based hand sanitizer</td><td>Purell</td><td>Advanced Instant Hand Sanitizer with 70% Ethyl Alcohol</td><td></td></tr><tr><td>HTH Powder</td><td>Acros Organics</td><td>300340010</td><td></td></tr><tr><td>NaDCC Powder</td><td>Medentech</td><td>Klorsept granules</td><td></td></tr><tr><td>NaOCl Solution</td><td>Acros Organics</td><td>419550010</td><td></td></tr><tr><td>Electrochlorinator</td><td>AquaChlor</td><td></td><td></td></tr><tr><td>Iodometric titrator</td><td>Hach</td><td>1690001</td><td></td></tr><tr><td>Bovine serum albumin</td><td>MP Biomedicals</td><td>NC0117242</td><td></td></tr><tr><td>Tryptone</td><td>Fisher</td><td>BP1421-100</td><td></td></tr><tr><td>Bovine Mucin</td><td>EMD Milipore</td><td>49-964-3500MG</td><td></td></tr><tr><td>0.22 &amp;micro;m Filter</td><td>EMD Milipore</td><td>GVWP04700</td><td></td></tr><tr><td>NaCl</td><td>Fisher</td><td>BP358-1</td><td></td></tr><tr><td>Skin pH probe</td><td>Hanna Instruments</td><td>H199181</td><td></td></tr><tr><td>Large Whirlpak Sample Bag</td><td>Nasco</td><td>B01447WA</td><td></td></tr><tr><td>Small Whirlpak Sample Bag</td><td>Nasco</td><td>B01323WA</td><td></td></tr><tr><td>Funnel bottle</td><td>Thermo Scientific</td><td>3120850001</td><td>You may drill an appropriately sized hole in the lid of a bottle to form a funnel that will dispense water at the appropriate flow rate</td></tr><tr><td>Ethanol</td><td>ThermoScientific</td><td>615090010</td><td>Mix with water to produce 70% ethanol</td></tr><tr><td>Spray bottle</td><td>Qorpak</td><td>PLC06934</td><td></td></tr><tr><td>&lt;em&gt;E. coli&lt;/em&gt;</td><td>ATCC</td><td>25922</td><td></td></tr><tr><td>LB Broth</td><td>Fisher BioReagents</td><td>BP1426-2</td><td></td></tr><tr><td>LB Agar</td><td>Fisher BioReagents</td><td>BP1425-500</td><td></td></tr><tr><td>Sterile loop</td><td>Globe Scientific</td><td>22-170-204</td><td></td></tr><tr><td>Phi6</td><td>HER</td><td>102</td><td></td></tr><tr><td>Nutrient broth</td><td>BD Difco</td><td>BD 247110</td><td></td></tr><tr><td>GeneQuant 100 Spectrophotometer</td><td>General Electric</td><td>28-9182-04</td><td></td></tr><tr><td>Sodium thiosulfate</td><td>Fisher Chemical</td><td>S445-3</td><td></td></tr><tr><td>Membrane filter (47 mm, 0.45 &amp;micro;m)</td><td>EMD Millipore</td><td>HAWP04700</td><td></td></tr><tr><td>m-ColiBlue24 broth media</td><td>EMD Millipore</td><td>M00PMCB24</td><td></td></tr><tr><td>Petri dish with pad (47 mm)</td><td>Fisherbrand</td><td>09-720-500</td><td></td></tr><tr><td>Vacuum Manifold</td><td>Thermo Scientific/Nalgene</td><td>09-752-5</td><td></td></tr><tr><td>Filter funnels</td><td>Thermo Scientific/Nalgene</td><td>09-747</td><td></td></tr><tr><td>Pseudomonas syringae</td><td>HER</td><td>1102</td><td></td></tr><tr><td>Phosphate Buffered Saline</td><td>Thermo Scientific</td><td>10010031</td><td>Solution may also be mixed from source compounds according to any basic recipe</td></tr></tbody></table>

a method to test the efficacy of handwashing for the removal of emerging infectious pathogens

A Method to Test the Efficacy of Handwashing for the Removal of Emerging Infectious Pathogens

Handwashing is widely recommended to prevent infectious disease transmission. However, little comparable evidence exists on the efficacy of handwashing methods in general. Additionally, little evidence exists comparing handwashing methods to determine which are most efficacious at removing infectious pathogens. Research is needed to provide evidence for the different approaches to handwashing that may be employed during infectious disease outbreaks. Here, a laboratory method to assess the efficacy of handwashing methods at removing microorganisms from hands and their persistence in rinse water is described. Volunteers' hands are first spiked with the test organism and then washed with each handwashing method of interest. Generally, surrogate microorganisms are used to protect human subjects from disease. The number of organisms remaining on volunteers' hands after washing is tested using a modified "glove juice" method: the hands are placed in gloves with an eluent and are scrubbed to suspend the microorganisms and make them available for analysis by membrane filtration (bacteria) or plaque assay (viruses/bacteriophages). Rinse water produced from the handwashing is directly collected for analysis. Handwashing efficacy is quantified by comparing the log reduction value between samples taken after handwashing to samples with no handwashing. Rinse water persistence is quantified by comparing rinse water samples from various handwashing methods to samples collected after handwashing with just water. While this method is limited by the need to use surrogate organisms to preserve the safety of human volunteers, it captures aspects of handwashing that are difficult to replicate in an in vitro study and fills research gaps on handwashing efficacy and the persistence of infectious organisms in rinse water.

Here, the protocol (Figure 1) was completed with 18 volunteers, who were each tested using both E. coli and Phi6. Significant differences were found between handwashing results with E. coli both with and without soil load and Phi6 with soil load (Figure 2 and Figure 3). For E. coli without soil load, handwashing with HTH, NaDCC, and stabilized NaOCl all resulted in signific...

Handwashing is widely recommended to prevent infectious disease transmission. However, there is little evidence on which handwashing methods are most efficacious at removing infectious disease pathogens. We developed a method to assess the efficacy of handwashing methods at removing microorganisms.

Handwashing is widely recommended to prevent infectious disease transmission. However, little comparable evidence exists on the efficacy of handwashing ...

The overall goal of this experiment is to test the comparative efficacy of handwashing options on hands that have been experimentally inoculated with an organism of interest. This method can provide information on key questions to help prevent of infectious diseases. By allowing researchers to investigate the efficacy of handwashing for particular organisms of interest.The main advantage of this technique is that it is flexible and can be adapted to allow for investigation of many different organisms. We first had the idea for this method when we realized chlorine solutions were being used for handwashing in Ebola contexts and there was no evidence for the efficacy of this at the time. After recruiting eligible subjects and preparing handwashing solutions according to the text protocol, prepare bacteria by streaking a non-pathogenic strand of E.Coli onto LB agar plates and incubate the cultures at 37 degrees celsius for 24 hours to obtain single colonies.One day before the start of the experiment, use a sterile lube to grab a single colony from the plate and inoculate 10 milliliters of LB broth. Incubate the cultures at 37 degree celsius, with shaking, overnight. On the morning of the experiment, add one milliliter of the overnight culture to 20 milliliters of fresh LB broth.Incubate the cultures for approximately two and half hours to achieve a salt density greater than 10 to the eighth CFU per milliliter. Then, use a spectrophotometer to estimate the concentration of the culture. Immediately prior to testing, prepare an inoculum composed of 68%bacteria or viral suspension and 32%sodium chloride or soil load.Swirl or gently vortex to mix. After preparing the volunteers according to the text protocol, test the pH of each volunteer's skin by placing a flat tip skin pH probe in the webbed space between the pointer and the middle fingers. Ensure that the electrode is flat against the skin and record the pH reading.Next, have the volunteer cup both hands together. Then, carefully pipette 750 microliters of the inoculate into each palm to spike the hands. When spiking volunteers'hands, it is important none of the inoculum is spilled.Remind volunteers this is important and give them the opportunity to practice with water before beginning the procedure. Have the volunteers gently rub their hands together until all surfaces of the hand are coded with the inoculate, while subjecting the hands to as little friction as possible. Instruct the volunteers to hold their hands still and away from their body for an additional 30 seconds to allow the inoculate to dry.Then wash the hands using one of the methods described in the text protocol. For hand washing with soap, use 10 milliliters of Ultrapure water to wet the hands. Have the volunteers lather their hands with soap and then rub their hands together for an additional 20 seconds.Rinse the volunteer's hands by pouring 500 milliliters of Ultrapure water at room temperature through a funnel at a flow rate of 1.5 liters per minute into a large sample collection bag and process the sample within two hours. For all chlorine solutions, pour 200 milliliters of chlorine solution over the volunteer's hands through a funnel at a flow rate of 1.5 liters per minute and have the volunteers rub their hands thoroughly. As another hand washing method, have the volunteers use hand sanitizer to wash their hands.It's important all surfaces of the hand are gently rubbed, instruct participants to focus on each part, palms, fingernails, in between fingers as they rub and then ensure the entire hand has been rinsed. For control A, after inoculation, do not perform a handwashing step. For control B, use only Ultrapure water at room temperature to perform handwashing through a funnel with a known flow rate.After handwashing, immediately place each volunteer's hand selected for testing, into a sample bag containing 75 milliliters of Leeuwin up to the wrist. Hold the top of the bag tightly around the wrist. Have the volunteers gently rub their hand in the solution for 30 seconds, taking care to reach in between the fingers and underneath the fingernails.Gently massage the hand from outside the bag for 30 seconds to ensure that the entire hand is thoroughly rinsed in the Leeuwin, all the way up to the wrist. Seal the bag and process it according to the appropriate essay. Before repeating the process with each handwashing method, have the volunteers use soap in warm water to thoroughly wash their hands in the sink.Finally, use 70%ethanol to spray the volunteer's hands until they are coated on both sides, and allow them to dry. To analyze the samples, set up a flame and a filtration manifold with sterile filtration funnels and a vacuum connection. Sterilize forceps by dipping them in ethanol and flaming them.Use the forceps to place a 0.45 micron filter onto the filtration manifold with the grid facing up. Then use a small amount of sterile PBS to wet the filter. Place the funnel on the base and pipette or pour the sample directly onto the filter.Engage the vacuum until the entire sample has passed through the membrane. Then, use sterile PBS to rinse the sides of the funnel and engage the vacuum again. Next, remove the funnel, flame sterilize the forceps and lift the filter from the base.Then place the filter gently on the medium in a petri dish with the grid facing up, ensuring that the filter lies flush against the surface. Invert the plates and incubate at 37 degrees celsius for 24 hours. Following the incubation, count the E.Coli colonies and record the data.Carry out data analysis according to the text protocol. The protocol described in this video was completed with 18 volunteers tested with E.Coli and Phi6, for E.Coli without soil load, handwashing with HTH, NaDCC and stabilized NaOCl, all resulted in significantly greater log reductions than handwashing with water only. With soil load, HTH resulted in a significantly greater log reduction of E.Coli than water only handwashing with soap and ABHS.There was no significant difference between methods for Phi6 without soil load. However, for Phi6 with soil load, water alone resulted in a greater log reduction than ABHS or stabilized NaOCl, and handwashing with soap in a greater log reduction than ABHS, stabilized NaOCl and generated NaOCl. HTH also had a greater log reduction than ABHS and stabilized NaOCl and NaDCC resulted in a greater log reduction than stabilized NaOCl and ABHS.As demonstrated in these graphs, chlorine resulted in a significantly greater log reduction of E.Coli persisting in the rinse water than handwashing with soap. Finally, the same pattern was found in Phi6 without soil load with all chlorine solutions resulting in a significantly greater reduction of Phi6 in rinse water than handwashing with soap. There were no significant decreases in rinse water with Phi6 and soil load.While attempting this procedure, it's important to remember efficacy results for each condition are calculated by comparing the results for the two controls. This means it is very important to perform the steps consistently for each handwashing option.

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A Method to Test the Efficacy of Handwashing for the Removal of Emerging Infectious Pathogens

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