Preventing the spread of infectious diseases in the European Union – targeted hygiene as a framework for sustainable hygiene
March 2010
Authors:
Professor Sally F. Bloomfield1, Professor Martin Exner2, Professor Kumar Jyoti Nath3, Mr John Pickup4, Professor Elizabeth A Scott5, Professor Carlo Signorelli6
1London School of Hygiene and Tropical Medicine, London, UK.
2Director, Institute for Hygiene and Public Health, Rheinische Friedrich-Wilhelms-Universität, Bonn, Germany.
3Chairman, Sulabh International Social Service Organization, Calcutta, India.
4Consultant in Scientific Issues, Bridgnorth, Shropshire, UK.
5Director Of Undergraduate Program in Public Health, Co-director Simmons Center for Hygiene and Health in Home and Community, Simmons College, Boston, MA USA.
6Department of Public Health, University of Parma, Italy.
A report by the International Scientific Forum on Home Hygiene
This report was commissioned by Unilever who requested IFH to review the IFH targeted approach to home hygiene as a framework for developing a sustainable approach to hygiene. Most particularly IFH was asked to address the need to balance concerns about environmental and human safety against recognition of the important role of hygiene, and the need to ensure that EU citizens have access to effective codes of hygiene practice, and hygiene products and processes, to protect themselves against infectious disease.
The full report can be downloaded from the IFH website at: http://www.ifh-homehygiene.org/IntegratedCRD.nsf/f5236e2da2822fef8025750b000dc985/62812e8ac19247fe802576c60054693f?OpenDocument
The International Scientific Forum on Home Hygiene (IFH; www.ifh-homehygiene.org) is a not for profit, non governmental organisation which was established in 1997 to meet the need for an independent expert body who could develop and promote a science-based approach to hygiene in home and everyday life settings as a means to reduce the global burden of infectious diseases.
Contents
CONSENSUS STATEMENT 5
REPORT SUMMARY 8
1. Introduction 17
2. The burden of hygiene-related infectious diseases in the European Union 18
2.1 Infectious intestinal diseases 19
2.2 Respiratory infections 21
2.3 Skin infections - Staphylococcus aureus and MRSA 21
2.4 Fungal infections 22
2.5 Antibiotic resistance 23
2.6 Pets and domestic animals as a source of infection in the home 24
2.7 At-risk groups in the home and community 24
2.8 The impact of social determinants on the spread of infectious diseases 25
2.9 The impact of social trends on the spread of infectious diseases 26
2.10 Chronic sequelae of infectious diseases 27
3. Developing a risk-based approach to home hygiene 27
3.1 Identifying critical control points in the chain of infection transmission in the home 28
3.2 Applying hygiene procedures to break the chain of infection in the home 30
3.2.1 Hygiene procedures to prevent cross contamination during food preparation 30
3.2.2 Hygiene procedures to prevent spread of norovirus between family members 33
3.2.3 Hygiene procedures to prevent transmission of MRSA via clothing and household linens 33
4. Establishing the link between targeted hygiene and health benefits 36
5. IFH – Developing and promoting the targeted approach to home hygiene 37
6. Sustainable hygiene – the key factors 38
7. Targeted hygiene – a framework for sustainable hygiene in the home and everyday life 42
8. Conclusions and Recommendations 43
References 46
CONSENSUS STATEMENT
Across Europe, infectious diseases continue to be a significant health and economic burden:
· New pathogens (including antimicrobial resistant strains) such as MRSA, avian and swine influenza and SARS are continually emerging.
· At the same time, social and demographic changes mean that people with reduced immunity to infection, who are more vulnerable to infection, make up an increasing proportion of the population (currently up to 20%).
· Infectious diseases can act as co-factors in other diseases that manifest at a later date, such as cancer and chronic degenerative diseases, or as triggers for development of allergic diseases such as asthma.
These ongoing changes demand new containment strategies, increasingly involving the community as a whole. A number of interrelated factors need consideration. For example:
· Whereas there has been a tendency to assume that common respiratory and foodborne infections circulating in the community are a minor concern, in reality the total burden in terms of absence from work and school is considerable.
· Community and hospital care for vulnerable groups who become seriously ill, or for those who develop ongoing sequelae are an additional healthcare cost.
· Technological and policy changes are being introduced to reduce costs and/or environmental effects without regard to their potential impact on infectious disease risks.
Governments are under considerable pressure to fund the level of healthcare that people expect, and are now looking at disease prevention strategies as a means to reduce health spending. Hygiene is increasingly recognised as a cost effective means to reduce the burden of infectious diseases within the European Union (EU). Increased homecare is one approach to reducing health spending, but, for this to be effective, it must take account of the fact that gains are likely to be undermined by inadequate infection control at home.
Targeted Hygiene & Sustainability
A parallel agenda of global importance is sustainable development, a concept that refers to meeting the needs of society, and improving quality of life, in a way that does not jeopardise the ability of future generations to meet theirs. Protecting health by preventing infection is an intrinsically more sustainable approach than treatment. Hygiene has the potential directly to improve sustainability because its aim is to promote and protect health. However, hygiene measures must themselves be sustainable, which means that issues such as the environment, concerns about antibiotic resistance, and the much publicised notion that “we have become too clean for our own good” need to be assessed and managed.
In response to the need for more emphasis on hygiene promotion in our homes and everyday lives, the International Scientific Forum on Home Hygiene (IFH) has developed a new approach to hygiene in the home and community, which is designed to meet 21st century needs and support new community hygiene promotion programmes. This approach is based on scientific data and risk assessment, and is known as “targeted hygiene”.The aim of this approach is to maximise protection against exposure to infectious microbes (germs) by breaking the chain of infection transmission at critical points, before germs can spread any further. In some situations, this is readily achieved by physical removal alone using cleaning products such as hand soap, and rinsing with clean water. But in some situations, processes that also inactivate germs, using heat or biocidal hygiene products and processes, are needed to ensure effective and reliable results, and protection from infection. The simple principle is that protecting the public from infection is not about unfocussed daily or weekly deep down cleaning, but about acting where and when there is risk of spread of infection.
Whilst targeted hygiene was originally developed by IFH as an effective approach to hygiene practice in the home and community, it also provides an excellent framework for building sustainability into hygiene. Through prudent and focussed use of hygiene products and processes, it intrinsically minimises their life-cycle impacts,maximises safety margins against any hazards and minimises any risks of encouraging the development of antibiotic resistance through low level biocide exposure. It also seeks, as far as possible, to sustain “normal” levels of exposure to the microbial flora of our environment to the extent that is important to build a balanced immune system.
Developing and Promoting Hygiene within the European Union
Governmental bodies both at regional and national level are now working to develop strategies that respond to the need for greater emphasis on hygiene. A key element is the establishment of the European Centre for Disease Control and Prevention (ECDC). The EU-funded “e-Bug” project http://www.e-bug.eu/ is also working to roll out education on antibiotic resistance and hygiene at primary and secondary school level across Europe. Recent years have seen significant investment in food hygiene, handwashing and, most recently, respiratory hygiene campaigns aimed at re-engaging the public and changing behaviour. IFH is working to support hygiene promotion activities by producing home hygiene guidelines, training resources and fact/advice sheets based on the targeted hygiene approach.
The Role of Biocidal Products
Sustainable use of biocidal hygiene products (i.e Biocidal products which act against bacteria, viruses, fungi etc), in terms of life-cycle impacts and human and environmental safety, can be assessed just as for other cleaning products and ingredients. The Biocidal Products Directive (BPD) requires human health and environmental risk assessments to be prepared in the coming years for all biocides in relation to their uses. Individual biocidal products will also require authorisation under BPD. Those not giving satisfactory risk assessments will be restricted or removed from the market.
IFH is concerned that the environmental and safety assurance of hygiene processes and products must not be addressed in isolation: the potential risks must be balanced against EU citizens’ need for effective means of protecting themselves against the real and continuing harm caused by infectious disease, which may require the use of biocidal products or other biocidal processes involving e.g. heat, UV irradiation, etc.
There is also in the EU an increasing focus on how to control antibiotic resistance, and protect health with less reliance on antibiotics. As antibiotic resistance continues to reduce our ability to treat infections, infection prevention through effective hygiene becomes of even greater importance. By reducing the number of infections through good hygiene, which in some cases requires the use of a biocidal hygiene product, the number of courses of antibiotic treatment can be reduced, which can in turn reduce the impact of antibiotic resistance.
Conclusions and Recommendations
One thing that is increasingly obvious is that if the burden of infectious diseases is to be reduced in an economically sustainable manner, the responsibility must be shared by the public. The key question is how do we achieve this? One problem that hinders progress is that the responsibility for public health within Europe is structured such that the separate aspects of home hygiene – food hygiene, hand washing, pandemic flu preparedness, etc – are dealt with by separate agencies. If hygiene promotion is to be successful in changing behaviour, we need an integrated family-centred (rather than agency-convenient) approach to ensure a basic understanding of infectious disease agents and how they spread , together with an understanding of which people can adapt to meet changing needs. Hygiene needs to be repositioned alongside other values of healthy living such as good diet and exercise rather than something that is old fashioned, unnatural and potentially unhealthy.
IFH concludes that if we are to sustain a high level of protection for EU citizens against infectious disease, in the face of changing demographics and microbial evolution, and at the same time derive real health benefits from investment in hygiene promotion, the various stakeholders (public health bodies and health professionals, environmentalists, immunologists, regulatory bodies and the private sector) need to work together to develop an integrated approach to public hygiene and hygiene promotion that takes account of and balances all of these issues. We must build a more family-centred approach to hygiene that recognises the importance of infectious disease prevention as a public health measure and ensures the people of the EU have effective, safe and sustainable means of achieving this.
2
Professor SF Bloomfield
London School of Hygiene and Tropical Medicine, London, UK
Professor M Exner
Institute for Hygiene and Public Health, Rheinische Friedrich-Wilhelms-Universität, Bonn, Germany
Professor KJ Nath
Sulabh International Social Service Organization, Calcutta, India
Mr J Pickup
Consultant in Scientific Issues, Bridgnorth, Shropshire, UK
Professor EA Scott
Simmons College, Boston, MA, USA
Professor C Signorelli
Dept of Public Health, University of Parma, Parma, Italy
2
International Scientific Forum on Home Hygiene. February 2010.
REPORT SUMMARY
In the late 1960s, the Surgeon General of the United States of America is alleged to have said “it is time to close the book on infectious diseases, declare the war against pestilence won, and shift national resources to such chronic problems as cancer and heart disease". The last 40 years have shown that this optimism was misplaced; infectious diseases are a continuing and significant burden on the health and prosperity of the global community, not only in the developing world, but also in developed world areas such as the European Union (EU).
Across the world, governments now recognise the need for more investment in infectious disease surveillance and prevention strategies involving measures such as immunisation and hygiene. Increasingly, this includes strategies to reduce the spread of infection within the family at home, and in their everyday lives; there is a realisation that, if the global burden of hygiene-related disease is to be reduced in a manner that is economically sustainable it has to be a responsibility that is shared by the public. A key response in Europe has been the establishment of the European Centre for Disease Control and Prevention (ECDC).
A parallel agenda of global importance is sustainable development. Health is at the heart of social sustainability, whilst poor health is a major drain on economic sustainability. Hygiene seeks to promote and protect health by preventing infection and is intrinsically a more sustainable approach than treatment. Of equal importance is that hygiene measures must themselves be sustainable; hygiene needs to be delivered in a way that is effective and efficient in social, economic and environmental terms. In developing and promoting public hygiene strategies, various potential impacts need to be assessed and managed appropriately:
· Life-cycle environmental impacts of hygiene procedures and products, including the assurance of safety.
· Concerns that use of certain biocidal products could encourage the development and spread of antibiotic resistance, and that widespread use of certain biocides may lead to resistance to those biocides.
· The notion that lack of “exposure to infection” may be contributing to the increased incidence of allergic diseases such as asthma and hay fever etc.