SALLY BLOOMFIELD^1,2, VALÉRIE SÉJOURNɳ
1. London School of Hygiene and Tropical Medicine, United Kingdom
2. International Scientific Forum on Home Hygiene (IFH)
3. A.I.S.E., International Association for Soaps, Detergents and Maintenance Products, Belgium

Abstract

On 7th April 2021, on the occasion of the WHO World Health Day, the International Association for Soaps, Detergents and Maintenance products (A.I.S.E.), and the International Scientific Forum on Home Hygiene (IFH) launched a joint industry/academia report stressing the critical role that hygiene plays to help prevent the spread of infectious diseases and promoting Targeted Hygiene and the appropriate use of cleaning and disinfectants products. The report also shares interesting insights on current consumer understanding of hygiene, based on pan-European data gathered from about 4500 consumers in February and again in June 2020.
The report advocates for good hygiene, i.e. the practices through which people maintain or promote good health and help prevent the spread of infectious diseases. In particular, it promotes the principles of Targeted Hygiene, an approach which argues that, to be effective, hygiene practices need to be focussed at the times and in the places that matter to break the chain of infection and reduce the risk of exposure to harmful microbes, focusing on 9 key moments. In its conclusion, the report sets out a number of actions that need to be taken to maximise effectiveness of hygiene, whilst at the same time addressing sustainability matters.

HYGIENE OVER TIME
During the 19th and early 20th centuries, clean water, safe disposal of human waste and hygiene were key to reducing morbidity and mortality from infectious disease. During the latter half of the 20th century however, once vaccines and antibiotics became freely available, investment in hygiene education and hygiene promotion declined and people became increasingly complacent about practicing hygiene. There was even a suggestion in the 1970s that by the end of the century, infectious disease would be a thing of the past.

Since then, a number of fundamental changes have taken place that have brought hygiene back up the agenda. The first is the emergence of respiratory viruses such as SARS (2003), Avian flu, Swine flu or MERS, prompting concerns about a possible global pandemic, as occurred with COVID-19. Pandemic preparedness plans recognise that public hygiene behaviour is a vital first line of defence before measures such as vaccines or antiviral drugs are put in place.

The second key issue is the global problem of antimicrobial resistance (or AMR) and the need to reduce antibiotic prescribing in order to tackle this. Global action plans began to recognise that public hygiene behaviour has a huge role to play in this respect.

Thirdly, we have seen increasing numbers of people living in our community and caring for themselves who are more vulnerable to infection. This is a very different situation from the 1970s, when it was argued that ‘normal healthy people’ in the community were at little risk of infection.

Given the fundamental nature of these changes, it has become apparent that there is a need for reassessment to ensure that hygiene and public hygiene behaviour is appropriate to the current issues we now face.

TARGETED HYGIENE - AN EFFECTIVE APPROACH TO HYGIENE IN HOME AND EVERYDAY LIFE

In response to these changes, since 1997 the International Scientific Forum on Home Hygiene (IFH) has been developing a novel approach to infection prevention in home and everyday life settings, which is based on risk management and has come to be known as Targeted Hygiene. Risk management approaches have been implemented in many sectors since the 1950s to prevent contamination of foods, pharmaceuticals etc during manufacture. Targeted Hygiene means focusing hygiene practices at specific times (or moments) to break the chain of infection transmission.

This is a very different approach to the 20th century, where the focus was on keeping our homes (visibly) clean as consumers believing that was the main source of harmful microbes, and that keeping the home clean would protect the family against infection. But if COVID-19 has taught us anything, it is that our public perceptions on hygiene are still rooted in the 20th century and there is a crucial need for change.

INTRODUCING THE CHAIN OF INFECTION AND THE 9 MOMENTS FOR HYGIENE
To understand the concept of Targeted Hygiene, it is necessary first to understand the ‘chain of infection’. In the chain of infection, the main sources of harmful microbes are not places that are dirty, but people who are infected and therefore infectious, and raw or contaminated food, and domestic animals that can also carry harmful microbes. During daily life activities, harmful microbes are shed from these sources, and may be transmitted through the environment via surfaces such as our hands and contact surfaces, and via the air. They can only infect us if they can gain entry to a human host through our eyes, nose, mouth etc.

Targeted Hygiene means focusing hygiene practices at the times or moments when harmful microbes are most likely to be spreading to break the chain of infection.

These key moments (see figure below) include during food handling, whilst eating with fingers, using the toilet, coughing, sneezing and nose blowing, touching surfaces frequently touched by other people, handling and laundering clothing and household linens, caring for domestic animals, handling and disposing of refuse and caring for an infected family member. During these ‘moments’, hygiene measures/practices need to focus on critical surfaces or other vectors (e.g the air) most likely to spread harmful microbes to ensure that we do not become exposed and infected.

The nine key moments when hygiene really matters

By examining the nine key moments, it is possible to identify which surfaces are most (and least) often involved as ‘critical control points’ (or CCPs), i.e. surfaces most likely to cause further spread of microbes at that moment. As shown in the graph below, this includes the hands, hand and food contact surfaces and cleaning cloths. For example, after the risk moment of handling raw meat and poultry, pathogens are contained by immediately cleaning and disinfecting food contact surfaces, cleaning, rinsing and drying utensils and cleaning cloths and washing hands.

Surfaces in the home ranked least to most likely to transmit infection at key moments

A JOINT ACADEMIA/INDUSTRY REPORT PROMOTING TARGETED HYGIENE, COMPLEMENTED BY EU CONSUMER DATA ON THE TOPIC

On 7 April 2021, on the occasion of the UN World Health Day, A.I.S.E. (the International Association for Soaps, Detergents and Maintenance Products) and the IFH launched a joint report addressing the critical role that hygiene plays in helping prevent the spread of infectious diseases and tackling the problem of AMR. The report “Developing household hygiene to meet 21st century needs” is the result of a collaboration between experts from the industry and academia.

The report aims at promoting good hygiene, i.e. the practices through which people maintain or promote good health and help prevent the spread of infectious diseases. In particular it evaluates the ways in which household hygiene is changing to meet 21st century needs.

1. In Part One of the report, the Targeted Hygiene concept outlined above and its application in the home is set out in more detail. The report also discusses the key practices which can be used to break the chain of infection.
   It shows how - in many cases - the use of detergent-based cleaning followed by thorough rinsing can be sufficient to reduce contamination to a safe level, but in some cases e.g. for surfaces that cannot be rinsed, then the use of a hand or surface disinfectant may be needed.
2. Part Two of the report shares insights into current consumer understanding of cleaning and hygiene obtained from pan-European online consumer research. The survey gathered data from 4500 consumers across 23 countries. It was carried out in February 2020 before the start of the pandemic in Europe and was then repeated in June of the same year. Based on the research results (published in full on the A.I.S.E. website), a detailed analysis of the key findings is set out in the A.I.S.E./IFH report.

EUROPEAN CONSUMERS’ BELIEFS AND HYGIENE BEHAVIOURS

Whilst 89% of EU consumers do believe that cleaning and hygiene in their home is important because it helps them or the people they live with avoid becoming unwell or getting an infectious disease, this joint industry/academia research highlights that – although consumers’ actions are to some extent guided by their perception of risk – there was limited understanding of what are key risk situations, and when (and where) hygiene is needed. Consumers reported using disinfectants in some situations where experts believe they are needed, whilst in other similarly risky situations, they are only rarely used. The report also shows that a significant proportion of consumers reported using disinfectants in situations normally considered as ‘low risk’.

Despite the fact that the COVID-19 pandemic provided an unprecedented opportunity for hygiene promotion, there was little evidence that this had altered consumers’ perception of risk and hygiene behaviours. Even in June 2020, only 44% of EU citizens felt that not washing their hands with soap after sneezing into them poses a high risk of causing infection, and only 36% claimed that they would always wash them (in contrast to 32% in February 2020).

However, in the February poll 78% of consumers reported that they used disinfectants in their home. This increased to 82% in June indicating they were more concerned about infection risks.

A further barrier to behaviour change highlighted by the survey is a lack of clarity about what the term ‘hygiene’ actually means, suggesting that consumers may interpret product claims and instructions for use differently, based on what they believe these terms mean.

Professor Sally Bloomfield, Chair of the IFH said: “These results are a huge contribution to achieving a better understanding of consumers’ perceptions and behaviours in Europe. They also confirm that, if activities aimed at consumer behaviour change are to be successful, they must be accompanied by consumer education on the basic concepts of Targeted Hygiene, in partnership with all hygiene stakeholders.”

COLLABORATION IS KEY TO CHANGE PUBLIC UNDERSTANDING AND HYGIENE BEHAVIOURS

Overall, the report supports the conclusion of Professor Bloomfield that if hygiene promotion activities aimed at changing people’s hygiene behaviours are to be successful, they must be accompanied by consumer education on the basic concepts of Targeted Hygiene. The report also concludes that, for this to happen, all stakeholders need to work collaboratively with those who communicate directly with the public, including the media, community and public health workers and the private sector, to ensure consistent and responsible messaging about hygiene practices and products.

As such, this joint A.I.S.E./IFH Hygiene Report is a first step in this direction, setting out the concepts and the issues, as well as the actions that need to be taken to maximise effectiveness of hygiene, whilst at the same time addressing sustainability matters.