Handwashing 101

by Donna Walls, RN, BSN, ICCE, IBCLC, ANLC

There have been concerns expressed by many health-related consumer groups about the use and overuse of antibiotics and antibacterials in so many of the products we use everyday. We hear the commercials promoting antibiotic-free meats and dairy, brought on by the research based concerns of the growth of “super-bugs”, or those bacteria which have been able change and become resistant to the antibiotics we presently use to treat infections.

“Back in 2013, the FDA first proposed the ban and called on soap manufacturers to submit data that would show that their products were both harmless and could out compete plain soap in de-germing humans. The agency reports that manufacturers either didn’t bother submitting data or offered up data that wasn’t convincing. In the meantime, many manufacturers have already started phasing out triclosan and other antimicrobial compounds from their products.” (Beth Mole – 9/2/2016)

In July of 2016 the FDA issued a statement expressing concerns over the safety and effectiveness of antibacterial chemicals in soaps and popular hand sanitizers along with this statement:

“Focusing on children and pregnant women, if these ingredients show up in blood or urine after repeated daily use, it could mean the chemicals are hurting reproductive systems or the production of hormones.”

Then, in August of 2016 the FDA took the next step to ban antibacterial soaps with this statement: There is “No scientific evidence” they’re safe, effective. Ban applies to soaps with any of 19 chemicals, including triclosan.

The 19 chemical ingredients included in the ruling are:

  • Cloflucarban
  • Fluorosalan
  • Hexachlorophene
  • Hexylresorcinol
  • Iodophors (Iodine-containing ingredients)
  • Iodine complex (ammonium ether sulfate and polyoxyethylenesorbitanmonolaurate)
  • Iodine complex (phosphate ester of alkylaryloxy polyethylene glycol)
  • Nonylphenoxypoly (ethyleneoxy) ethanoliodine
  • Poloxamer-iodine complex
  • Povidone-iodine 5 to 10 percent
  • Undecoylium chloride iodine complex
  • Methylbenzethonium chloride
  • Phenol (greater than 1.5 percent)
  • Phenol (less than 1.5 percent)
  • Secondary amyltricresols
  • Sodium oxychlorosene
  • Tribromsalan
  • Triclocarban
  • Triclosan
  • Triple dye
  • Antibacterial soaps

This will be a huge change for so many families who have been lead to believe using this short cut hand cleansing method was safe and effective. But, just like our mothers said- go wash your hands! The CDC confirms mother’s words of wisdom:

“Handwashing is like a “do-it-yourself” vaccine—it involves five simple and effective steps (Wet, Lather, Scrub, Rinse, Dry) you can take to reduce the spread of diarrheal and respiratory illness so you can stay healthy. Regular handwashing, particularly before and after certain activities, is one of the best ways to remove germs, avoid getting sick, and prevent the spread of germs to others. It’s quick, it’s simple, and it can keep us all from getting sick. Handwashing is a win for everyone, except the germs.”

The CDC has declared October 15, 2016 as Global Handwashing Day.

Handwashing 101

When to wash hands
  • Before eating
  • Before and after preparing food
  • After using the toilet
  • After changing an infant’s or child’s diaper
  • After sneezing and/or coughing
  • After contact with an ill person
How to wash your hands

Wet hands with warm (not hot) water, lather with non-antibacterial soap and scrub for 20 seconds (about the time it takes to sing Happy Birthday or Twinkle Twinkle Little Star). Rinse well with warm water and dry thoroughly.

What if I am not close to water?

If there is no water source available atemporary, acceptable substitute is an alcohol-base hand cleanser with 60% alcohol. A caution is issued for proper storage of alcohol cleansers to keep out of reach of children!

Another natural option is to make your own with distilled water and pure essential oils: Begin with 1 oz distilled water and add 10 drops each of lavender and lemon pure essential oils (artificial or fragrance oils do not contain antimicrobial properties). Place a dime-sized amount in the palm of the hand and work well into skin. Avoid ingestion by infants and children.

So, armed with good information we can all make safer decisions on keeping our families healthier as we head into the cold and flu season of 2016.


  1. Transcript of the January 22, 1997, Meeting of the Joint Nonprescription

Drugs and Anti-Infective Drugs Advisory Committees, OTC.  Available at


  1. Comment submitted in Docket No. FDA-1975-N-0012, available at

https://www.regulations.gov with Comment No. FDA-1975-N-0012-0081.

  1. Transcript of the March 23, 2005, Nonprescription Drugs Advisory

Committee.  Available at https://www.fda.gov/ohrms/dockets/ac/05/transcripts/2005


  1. Transcript of the October 20, 2005, Meeting of the Nonprescription Drugs

Advisory Committee 2005.  Available at


  1. Summary Minutes of the November 14, 2008, Feedback Meeting with

Personal Care Products Council and Soap and Detergent Association, OTC Vol. 230002.

Available at https://www.regulations.gov/document?D=FDA-1980-N-0006-0031.

  1. Transcript of the September 3, 2014, Meeting of the Nonprescription Drugs

Advisory Committee 2014.  Available at



  1. Part 130-New Drugs, Procedures for Classification of Over-the-Counter

Drugs, 37 FR 9464 (1972).  Available at


  1. Luby, S. P., et al., “Effect of Handwashing on Child Health: A Randomised

Controlled Trial,” Lancet, 366(9481): p. 321-329, 2005.  Available at


  1. Larson, E. L., et al., “Effect of Antibacterial Home Cleaning and

Handwashing Products on Infectious Disease Symptoms:  A Randomized, Double-Blind

Trial,” Annals of Internal Medicine, 140(5): p. 321-9, 2004.  Available at


  1. Webster, J., J. L. Faoagali, and D. Cartwright, “Elimination of Methicillin

Resistant Staphylococcus aureus from a Neonatal Intensive Care Unit After Hand

Washing with Triclosan,” Journal of Paediatrics and Child Health, 30(1): p. 59-64, 1994.

Available at https://www.ncbi.nlm.nih.gov/pubmed/8148192.

  1. Zafar, A. B., et al., “Use of 0.3% Triclosan (Bacti-Stat) to Eradicate an

Outbreak of Methicillin-Resistant Staphylococcus aureus in a Neonatal Nursery,”

American Journal of Infection Control, 23(3): p. 200-8, 1995.  Available at


  1. Schaffner, D. W., et al., “Quantitative Microbial Risk Assessment of

Antibacterial Hand Hygiene Products on Risk of Shigellosis,” Journal of Food Protection,

77(4): p. 574-82, 2014.  Available at



  1. Chen, Y., et al., “Quantification and Variability Analysis of Bacterial Cross

Contamination Rates in Common Food Service Tasks,” Journal of Food Protection,

64(1): p. 72-80, 2001.  Available at


  1. Chen, Y., et al., “FDA-iRISK–A Comparative Risk Assessment System for

Evaluating and Ranking Food-Hazard Pairs:  Case Studies on Microbial Hazards,”

Journal of Food Protection, 76(3): p. 376-85, 2013.  Available at




  1. Ball, R., et al., “Statistical, Epidemiological, and Risk-Assessment

Approaches to Evaluating Safety of Vaccines Throughout The Life Cycle at the Food and

Drug Administration,” Pediatrics, 127 Suppl 1: p. S31-8, 2011.  Available at


  1. Oggioni, M. R., et al., “Recent Advances in the Potential Interconnection

Between Antimicrobial Resistance to Biocides and Antibiotics,” Expert Review of Anti

Infective Therapy, 11(4): p. 363-6, 2013.  Available at


  1. Hansen, L. H., et al., “Substrate Specificity of the OqxAB Multidrug

Resistance Pump in Escherichia coli and Selected Enteric Bacteria,” Journal of

Antimicrobial Chemotherapy, 60(1): p. 145-7, 2007.  Available at


  1. Mavri, A. and S. S. Mozina, “Involvement of Efflux Mechanisms in Biocide

Resistance of Campylobacter jejuni and Campylobacter coli,” Journal of Medical

Microbiology, 61(Pt. 6): p. 800-8, 2012.  Available at



  1. Mavri, A. and S. S. Mozina, “Development of Antimicrobial Resistance in

Campylobacter jejuni and Campylobacter coli Adapted to Biocides,” International

Journal of Food Microbiology, 160(3): p. 304-12, 2013.  Available at


  1. Curiao, T., et al., “Polymorphic Variation in Susceptibility and Metabolism of

Triclosan-Resistant Mutants of Escherichia coli and Klebsiella pneumoniae clinical

Strains Obtained After Exposure to Biocides and Antibiotics,” Antimicrobial Agents and

Chemotherapy, 59(6): p. 3413-23, 2015.  Available at


  1. Rensch, U., et al., “Salmonella entericaSerovar Typhimurium Multidrug

Efflux Pumps EmrAB and AcrEF Support the Major Efflux System AcrAB in Decreased

Susceptibility to Triclosan,” International Journal of Antimicrobial Agents, 44(2): p. 179

80, 2014.  Available at https://www.ncbi.nlm.nih.gov/pubmed/25059442.

  1. Rensch, U., G. Klein, and C. Kehrenberg, “Analysis of Triclosan-Selected

Salmonella enterica Mutants of Eight Serovars Revealed Increased Aminoglycoside

Susceptibility and Reduced Growth Rates,” PLOS One, 8(10): p. e78310, 2013.

Available at


  1. Fernando, D. M., et al., “Triclosan Can Select for an AdeIJK-Overexpressing

Mutant of Acinetobacter baumannii ATCC 17978 that Displays Reduced Susceptibility to

Multiple Antibiotics,” Antimicrobial Agents and Chemotherapy, 58(11): p. 6424-31,

  1. Available at https://aac.asm.org/content/58/11/6424.full.pdf+html.
  2. Grandgirard, D., et al., “Mutations Upstream of fabI in Triclosan Resistant

Staphylococcus aureus Strains are Associated with Elevated fabI Gene Expression,”

BMC Medical Genomics, 16: p. 345, 2015.  Available at


  1. Buffet-Bataillon, S., et al., “Molecular Mechanisms of Higher MICs of

Antibiotics and Quaternary Ammonium Compounds for Escherichia coli Isolated From

Bacteraemia,” Journal of Antimicrobial Chemotherapy, 67(12): p. 2837-42, 2012.

Available at https://jac.oxfordjournals.org/content/67/12/2837.full.pdf+html.

  1. Guo, W., et al., “Resistant Mechanism Study of Benzalkonium Chloride

Selected Salmonella Typhimurium Mutants,” Microbial Drug Resistance, 20(1): p. 11-6,

  1. Available at https://online.liebertpub.com/doi/abs/10.1089/mdr.2012.0225.
  2. Bore, E., et al., “Adapted Tolerance to Benzalkonium Chloride in Escherichia

coli K-12 Studied by Transcriptome and Proteome Analyses,” Microbiology, 153(Pt. 4):

  1. 935-46, 2007. Available at



  1. Morrissey, I., et al., “Evaluation of Epidemiological Cut-Off Values Indicates

that Biocide Resistant Subpopulations are Uncommon in Natural Isolates of Clinically

Relevant Microorganisms,” PLOS One, 9(1): p. e86669, 2014.  Available at


  1. Copitch, J. L., R. N. Whitehead, and M. A. Webber, “Prevalence of Decreased

Susceptibility to Triclosan in Salmonella enterica Isolates from Animals and Humans and

Association with Multiple Drug Resistance,” International Journal of Antimicrobial

Agents, 36(3): p. 247-51, 2010.  Available at


  1. Skovgaard, S., et al., “Staphylococcus epidermidis Isolated in 1965 Are More

Susceptible to Triclosan than Current Isolates,” PLOS One, 8(4): p. e62197, 2013.

Available at https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0062197.

  1. Cole, E. C. et al., “Investigation of Antibiotic and Antibacterial Susceptibility

and Resistance in Staphylococcus from the Skin of Users and Non-users of Antibacterial

Wash Products in Home Environments,” International Journal of Microbiology Research

3 (2): p 90-96, 2003.  Available at


  1. Lear, J. C., “Chloroxylenol- and Triclosan-Tolerant Bacteria from Industrial

Sources–Susceptibility to Antibiotics and Other Biocides,” International Biodeterioration

and Biodegradation, 2006.  Available at


  1. Lear, J. C., et al., “Chloroxylenol- and Triclosan-Tolerant Bacteria from

Industrial Sources,” Journal of Industrial Microbiology and Biotechnology, 29(5): p. 238

42, 2002.  Available at https://link.springer.com/article/10.1038/sj.jim.7000320#page-1.

  1. Aiello, A. E., et al., “Relationship Between Triclosan and Susceptibilities of

Bacteria Isolated from Hands in the Community,” Antimicrobial Agents and

Chemotherapy, 48(8): p. 2973-9, 2004.  Available at


  1. Aiello, A. E., et al., “Antibacterial Cleaning Products and Drug Resistance,”

Emerging Infectious Diseases, 11(10): p. 1565-70, 2005.  Available at


  1. Cole, E. C., et al., “Investigation of Antibiotic and Antibacterial Agent Cross

Resistance in Target Bacteria From Homes of Antibacterial Product Users and

Nonusers,” Journal of Applied Microbiology, 95(4): p. 664-676, 2003.  Available at


  1. Marshall, B. M., et al., “The Frequency of Antibiotic-Resistant Bacteria in

Homes Differing in Their Use of Surface Antibacterial Agents,” Current Microbiology,

65(4): p. 407-15, 2012.  Available at https://www.ncbi.nlm.nih.gov/pubmed/22752336.

  1. Carson, R. T., et al., “Use of Antibacterial Consumer Products Containing

Quaternary Ammonium Compounds and Drug Resistance in the Community,” Journal of

Antimicrobial Chemotherapy, 62(5): p. 1160-2, 2008.  Available at



  1. Coelho, J. R., et al., “The Use of Machine Learning Methodologies to Analyse

Antibiotic and Biocide Susceptibility in Staphylococcus aureus,” PLOS One, 8(2): p.

e55582, 2013.  Available at




  1. Braoudaki, M. and A. C. Hilton, “Adaptive Resistance to Biocides in

Salmonella enterica and Escherichia coli O157 and Cross-Resistance to Antimicrobial

Agents,” Journal of Clinical Microbiology, 42(1): p. 73-8, 2004.  Available at


  1. Brenwald, N. P. and A. P. Fraise, “Triclosan Resistance in Methicillin

Resistant Staphylococcus aureus (MRSA),” Journal of Hospital Infections, 55(2): p. 141

4, 2003.  Available at https://www.ncbi.nlm.nih.gov/pubmed/14529640.

  1. Langsrud, S., G. Sundheim, and A. L. Holck, “Cross-Resistance to Antibiotics

of Escherichia coli Adapted to Benzalkonium Chloride or Exposed to Stress-Inducers,”

Journal of Applied Microbiology, 96(1): p. 201-8, 2004.  Available at


  1. Birosova, L. and M. Mikulasova, “Development of Triclosan and Antibiotic

Resistance in Salmonella entericaserovar Typhimurium,” Journal of Medical

Microbiology, 58(Pt. 4): p. 436-41, 2009.  Available at


  1. Joynson, J. A., B. Forbes, and R. J. Lambert, “Adaptive Resistance to

Benzalkonium Chloride, Amikacin and Tobramycin:  The Effect on Susceptibility to

Other Antimicrobials,” Journal of Applied Microbiology, 93(1): p. 96-107, 2002.

Available at



  1. International Conference on Harmonization S1B. Available at



  1. Guidance for IndustryS1B Testing for Carcinogenicity of Pharmaceuticals.

Available at



  1. Citizen Petition submitted by Comprehensive Technology Center, FDA

Docket No. 1996-P-0205-005, Aug. 9, 1996.  Available at


  1. “NTP Toxicology and Carcinogenesis Studies of 4-Hexylresorcinol (CAS No.

136-77-6) in F344/N Rats and B6C3F1 Mice (Gavage Studies),” National Toxicology

Program Technical Rep Series, 330: p. 1-166, 1988.  Available at



  1. Schreier, H., et al., “Molecular Effects of Povidone-Iodine on Relevant

Microorganisms:  An Electron-Microscopic and Biochemical Study,” Dermatology, 195

Suppl 2: p. 111-6, 1997.  Available at https://www.ncbi.nlm.nih.gov/pubmed/9403268.

  1. Reimer, K., et al., “Antimicrobial effectiveness of povidone-iodine and

consequences for new application areas,” Dermatology, 204 Suppl 1: p. 114-20, 2002.

Available at https://www.ncbi.nlm.nih.gov/pubmed/12011534.

  1. Durani, P. and D. Leaper, “Povidone-Iodine: Use in Hand Disinfection, Skin

Preparation and Antiseptic Irrigation,” International Wound Journal, 5(3): p. 376-87,

  1. Available at https://www.ncbi.nlm.nih.gov/pubmed/18593388.
  2. Barabas, E. G. and H. G. Brittain., “Povidone-Iodine in 25 Analytical Profiles

and Excipients–Volume 25,” Academic Press, Inc., 25: p. 341-387, 1998.  Available at









  1. Michel, D. and G. A. Zach, “Antiseptic Efficacy of Disinfecting Solutions in

Suspension Test in vitro Against Methicillin-Resistant Staphylococcus aureus,

Pseudomonas aeruginosa and Escherichia coli in Pressure Sore Wounds After Spinal

Cord Injury,” Dermatology, 195 Suppl 2: p. 36-41, 1997.  Available at


  1. Block, C., et al., “Evaluation of Chlorhexidine and Povidone Iodine Activity

Against Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant

Enterococcus faecalis Using a Surface Test,” Journal of Hospital Infections, 46(2): p.

147-52, 2000.  Available at





  1. Block, S. S., “Disinfection, Sterilization, and Preservation,” Philadelphia:

Lippincott Williams & Wilkins, 2001.  Available at.  Available at





  1. Houang, E. T., et al., “Absence of Bacterial Resistance to Povidone Iodine,”

Journal of Clinical Pathology, 29(8): p. 752-5, 1976.  Available at


  1. Prince, H. N., et al., “Drug resistance studies with topical antiseptics,” Journal

of Pharmaceutical Sciences, 67(11): p. 1629-31, 1978.  Available at


  1. Panlilio, A. L., et al., “Infections and pseudoinfections due to povidone-iodine

solution contaminated with Pseudomonas cepacia,” Clinical Infectious Diseases, 14(5): p.

1078-83, 1992.  Available at


  1. Jarvis, W. R., “Nosocomial Outbreaks: The Centers for Disease Control’s

Hospital Infections Program Experience, 1980-1990.  Epidemiology Branch, Hospital

Infections Program,” American Journal of Medicine, 91(3B): p. 101S-106S, 1991.

Available at https://www.ncbi.nlm.nih.gov/pubmed/1656744.

  1. Prevention, CDC, “Contaminated Povidone-Iodine Solution–Texas,” in

Morbidity and Mortality Weekly Report, p. 133-4, 1989.  Available at


  1. Berkelman, R. L., et al., “Pseudobacteremia Attributed to Contamination of

Povidone-Iodine with Pseudomonas cepacia,” Annals of Internal Medicine, 95(1): p. 32

6, 1981.  Available at https://annals.org/article.aspx?articleid=694897.

  1. Craven, D. E., et al., “Pseudobacteremia Caused by Povidone-Iodine Solution

Contaminated with Pseudomonas cepacia,” New England Journal of Medicine, 305(11):

  1. 621-3, 1981. Available at


  1. Triclocarban (TCC) Consortium, Soap and Detergent Association. IUCLID

Data Set: Triclocarban.  December 12, 2002.  Available at


  1. Sutherland, V., “NTP Research Concept: Triclocarban.” Available at


  1. Scientific Committee on Consumer Products (SCCP) opinion on Triclosan

COLIPA n° P32.  Available at


  1. Addendum to the SCCP Opinion on Triclosan. Available at


  1. Registered substances. Available at


  1. Fang, J. L., et al., “Absorption and Metabolism of Triclosan After Application

to the Skin of B6C3F1 Mice,” Environmental Toxicology, 2014.  Avilable at



  1. Crofton, K. M., et al., “Short-Term in vivo Exposure to the Water

Contaminant Triclosan:  Evidence for Disruption of Thyroxine, ” Environmental

Toxicology and Pharmacology, 24(2): p. 194-7, 2007.  Available at




  1. European Commission Scientific Committee on Consumer Safety, Final

Opinion on Triclosan (Antimicrobial Resistance), cited March 24, 2016, available at


List of Subjects in 21 CFR Part 310