A "SAFE HANDS" HAND WASH PROGRAM

FOR RETAIL FOOD OPERATIONS: A TECHNICAL REVIEW

O. Peter Snyder, Jr., Ph.D.
Hospitality Institute of Technology and Management
For: Florida Environmental Health Association, Inc., May 27, 1999
Introduction
The following comments relate to the overheads used for a presentation at the 51st Annual Education Conference of the Florida Environmental Health
Association, Inc., May 27, 1999, in Orlando, Florida. In this presentation, I have summarized our current knowledge of the critical control points in hand
washing and have recommended solutions to the problem. I have also presented information on our "Safe Hands" program, which a number of large companies
are using in the United States. Other companies have been using our nail brush and hand wash method for over fifteen years. These companies have experienced
virtually zero foodborne illnesses due to fecal pathogens on fingertips.

1. Fecal pathogens on fingertips - a major cause of foodborne illness

Fingertip washing is the only control with a zero defect potential
1. "When you are sick stay home" is an ineffective government control. People are not doctors who can diagnose their illness. There are other causes for feelings
of sickness and diarrhea other than Salmonella typhi, E. coliO157:H7, Shigella spp., Hepatitis A, etc.
2. Pathogens are often shed before there are illness symptoms.
Viral Hepatitis
Campylobacter jejuni
Listeria monocytogenes
Salmonella typhi
Escherichia coli
Shigellaspp.
Salmonella typhimurium
Cryptosporidiumspp.
Giardia lamblia
and other serotypes
3. Pathogens are also shed after people feel well. People can be carriers.
Salmonella typhi
Escherichia coli
Listeria monocytogenes
Shigellaspp.
Vibrio cholera
Salmonella typhimurium
Giardia lamblia
and other serotypes
4. When an employee is ill, the supervisor will be aware of it. It is the supervisor's responsibility to send the employee home.
Conclusion: "When you are sick, stay home" has a high probability of failure for preventing fecal pathogens getting into food and should not be used as a hazard
control method.
******
Explanation: This overhead points out that the government control stating that when an employee is sick, he or she should stay home, is ineffective and should
not be in any food regulation as a control method. Fingertip washing provides for zero defects, as will be pointed out. The principle problem is that before people
have any symptoms and know that they are ill with a pathogen, they are shedding pathogens in their fecal material. It is true that when they have vomiting and
diarrhea, they shed higher levels. However, we have no idea how much leaks through toilet paper and gets onto fingertips, thus creating a hazard. In addition,

after people feel well, they can, and do, become carriers of these pathogens. Again, they will have no symptoms, but if they do not wash their fingertips, they will
cause illness. Finally, it has been my experience in talking to supervisors that when a person is ill, those supervisors are well aware of the situation. Therefore,
the best strategy is simply to leave the problem to the restaurant owner to solve. People who have taken food safety classes know very well that a major cause of
foodborne illness is fecal pathogens on the fingertips. It is up to them to choose the level of risk to which they will expose their customers.

2.

Site
Skin

Hair follicles, sweat glands

Sebum from sebaceous glands
Beneath skin surface

Defenses of skin*
Defenses
Function
Dryness and acidic
Limit bacterial growth
conditions (pH 5)
Sloughing cells
Remove bacteria
Resident bacteria
Compete for nutrients and colonization /
attachment sites
Lysozyme, toxic
Kill bacteria
lipids
Protective film on
Prevents excessive dryness of skin
surface of skin
Skin associated
Kill bacteria; sample antigens on skin
lymphoid tissue
surface.
(SALT)

*References:
Salyers, A.A., and Whitt, D.D. 1994. Chapter 1. Host defenses against bacterial pathogens: Defenses of body surfaces. In Bacterial Pathogenesis.
American Society of Microbiology Press. Washington, D. C.
Prescott, L. M., Harley, J. P., and Klein, D. A. 1996. Microbiology. 3rd edition. Wm. C. Brown. Dubuque, IA.
******
Explanation: Today, many companies sell antibacterial solutions and chemicals for the purpose of making hands safe. In fact, this actually leads to damage of
the skin, which then leads to less hand washing. This overhead points out the defenses of the skin and their function. It identifies the hair follicles, sweat glands,
and other skin defense mechanisms. One must not interfere with these defenses; otherwise, we will have diseases of the skin and less hand washing.

3.

Species isolated from hands of 22 health care personnel*

Category and Species
No. of Isolates
Percent of Category
Gram-positive cocci
Staphylococcus epidermidis
70
39.3
Staphylococcus saprophyticus
35
19.7
Staphylococcus capitus
21
11.8
Streptococcus haemolyticus
16
9.0

Alpha streptococci
Staphylococcus aureus
Staphylococcus simulans
Gram-negative bacilli
Klebsiella-Enterobactersp.
Acinetobacter sp.
Pseudomonassp.
Proteus-providencia sp.
Yeast
Candida parasilosis
Rhodotorula rubra
Candida albicans
Candida guilliermondii
Candida glabrata

11
10
4

6.2
5.6
2.2

15
5
4
3

55.6
18.5
14.8
11.1

10
6
4
4
2
231

38.5
3.1
15.4
15.4
7.7

Total
*Reference:
Adapted from Larson, E., K. J. McGinley, G. L. Grove, J. J. Leyden, and G. H. Talbot. 1986. Physiologic, microbiologic, and seasonal effects of Hand Washing
on the skin of health care personnel. Am. J. Infect. Control. 14(2):51-59.
******
Explanation: Our studies at HITM have shown that when individuals rinse their hands, 1,000 to 100,000 skin microorganisms are released. This overhead lists
some of these organisms and specifically identifies that the only food pathogenic organism on the skin is Staphylococcus aureus. Staphylococcus aureus, one of
the resident bacteria on the hands, is normally not at a high level and poses no threat until food is abused. In this case, 10 organisms from the skin would have to
multiply to 1,000,000--almost 17 multiplications--before this is a problem. Unlike hospital health care workers, there is no need to inactivate the resident S.
aureus in the hands of foodservice workers, since time and temperature to prevent spoilage will control the hazard.

4.
Type
Hand wash

Hand antisepsis

Types of hand care*

Purpose
Method
Remove soil
Soap or detergent and friction for at least
and transient
10-15 seconds
microorganis
ms
Remove
Antimicrobial soap or detergent or
and/or
alcohol-based hand-rub and friction for at
destroy
least 10-15 seconds
transient and

resident
microorganis
ms to control
infection
transfer from
hands
Remove or
destroy
transient and
resident
microorganis
ms to
control /
prevent
infection in
patients
undergoing
operations

Surgical hand scrub

Antimicrobial soap or detergent

preparation with brush to achieve friction
for at least 120 seconds, or alcohol-based
preparation for at least 20 seconds

*Reference:
Adapted from: Larson, E. 1995. APIC Guidelines for Infection Control Practice. - APIC guideline for hand washing and hand antisepsis in health care settings.
APIC (Association for Professionals in Infection Control and Epidemiology, Inc.). Washington, D. C.,
******
Explanation: There are three basic types of hand care.
1. Hand washing. Removes the soil and transient microorganisms. It can be accomplished in 10 to 15 seconds.
2. Hand antisepsis. Involves some antimicrobial agent. There is a minimum contact time, at least 10 to 15 seconds. Each antimicrobial agent has its own
characteristic. Alcohol works quickly, but other agents might take a minute. This means that people who use antimicrobial agents must make sure that they
follow the minimal antimicrobial agent contact time. This is unlikely in foodservice without extreme training and enforcement.
3. Surgical hand scrub. Destroys transient and resident microorganisms. This is used to prevent the resident bacteria of the skin getting into the patient's body
during surgery or invasive care. In foodservice, the microorganisms that cause illness are typical transient bacteria from fecal material and have no relationship to
the organisms of concern in medical environments.

5.

USDA classification of hand soaps and sanitizers for use in meat processing plants
E1 Compounds: Hand washing compounds for use in all departments
The compounds must be dispensed from adequate dispensers located a sufficient distance from processing lines to prevent accidental product contamination.
- After the use of the compounds, the hands must be thoroughly rinsed with potable water.
- Under conditions of use, there can be no odor or fragrance left on the hands.

E2 Compounds: Hand washing and sanitizing compounds

- The compounds must be dispensed from adequate dispensers located a sufficient distance from processing lines to prevent accidental product contamination.
- The hands need not be washed prior to the use of the compounds.
- The compounds must always be used at dilutions and according to applicable directions provided on the label.
- The compounds have been accepted on the basis of their equivalency to 50 parts per million chlorine.
E3 Compounds: Hand sanitizing compounds (hand dips)
- The compounds must be dispensed from adequate dispensers located a sufficient distance from processing lines to prevent accidental product contamination.
- The hands must be washed and thoroughly rinsed prior to the use of the compounds.
- The compounds may be injected directly into the wash and rinse water.
- The hands need not be rinsed after the use of the compound.
- The compounds have been accepted on the basis of their equivalency to 50 parts per million chlorine.
* Gel-based hand sanitizers are limited to use by employees leaving the plant, unless they meet specific guidelines ensuring that residues remaining on the hands
will not be inappropriate for food handling. Only if such guidelines are met can these hand sanitizers be classified as E3.
E4 Compounds: Hand creams, lotions, and cleaners (including gel-based hand sanitizers not meeting E3 requirements).
- The use of such compounds is limited to toilets and dressing rooms. Employees who handle edible products may use the compounds only when leaving the
plant.
* E classifications of hand soaps and sanitizing compounds apply only to USDA-approved processing plants. Currently, there is no classification system for
hand washing products relating to foodservice establishments.
Reference:
Adapted from: Miller, M. L., James-Davis, L.A. and Milanesi, L.E. 1994. A field study evaluating the effectiveness of different hand soaps and sanitizers.
Dairy Food Envir. Sanit.. 14(3): 155-160.
******
Explanation: The FDA should limit our hand washing compounds to E1 compounds. If we are going to have these ratings, the government must be responsible
for establishing the measurement process. E2 and E3 compounds are a problem in the processing industry, because many employees develop reactions to these
compounds. They dry the skin and cause skin problems such as dermatitis, especially during the winter. If hands are clean, transient microorganisms are gone,
and E2 and E3 compounds serve no purpose. Finally, the E4 compounds (hand creams, lotions) can grow microorganisms if they do not contain antimicrobial
agents in them. This can lead to skin reactions. They must be used with care.

6.

Characteristics of selected antiseptic ingredients*

Antiseptic Ingredient
Action
Negative Effect
Alcohols
- Have no effect on spores
ethyl (ethanol), n-propyl, and isopropyl
Antimicrobi - Alcohol pads are less effective than liquid
al (denature soaps with antiseptic ingredients when
proteins)
used as a brief skin wipe
- Destroy
- Are not good cleaning agents
vegetative
- Have no persistent effect

Chlorhexidine gluconate (CHG)

(cationic bisbiquanide)

bacteria,
fungi, and
viruses
Emollients,
if added,
decrease
skin drying
effect
Antimicrobi
al (disrupts
cell
membranes
and
precipitates
cell
contents)
- Active
against
bacteria,
some
viruses
(HIV,
herpes, flu)
- Good
residual
effect (up to
6 hr.)
- Not
significantly
affected by
organic
matter
- Available
in 2 to 4%
concentratio

- Have drying effect on skin (no more than

70% alcohol / water)
- Are volatile and flammable and must be
stored carefully

- Activity is pH dependent (5.5 to 7.0)

- Can cause damage if instilled in ears or
eyes
- Reports of contact dermatitis, other
allergic manifestations, and anaphylaxis in
sensitive individuals

Hexachlorophene
(Chloronated bisphenol)

Iodine and Iodophores (complex of iodine

with polyvinyl-pyrrolidone (povidone)

ns
- May be
combined
with alcohol
- Disrupts
microbial
cell walls,
precipitates
cell
proteins,
inactivates
cell
enzymes
- Effective
against
grampositive
bacteria
- It is
persistent
Antimicrobi
al (cell wall
penetration,
oxidation,
and
substitution
of microbial
content with
free iodine)
- Active
against
bacteria,
viruses, and
fungi
- Some
activity

- Not effective against gram-negative

bacteria, tubercle bacillus, fungi, or viruses
- Is not fast acting
- Has been shown to produce neurotoxic
effects
- General use, banned by FDA. Available
by prescription only (3% concentration)
- Should not be used on broken skin or for
bathing

- Neutralized by organic matter

- May cause skin irritation and damage
- Allergic and toxic effects in sensitive
persons

Para-chloro-meta-xylenol
(PCMX or chloroxylenol)

against
bacterial
spores
Antimicrobi
al (cell wall
disruption
and enzyme
inactivation
)
- Active
against
gram
positive
bacteria,
some
viruses, and
fungi
Effectivenes
s increased
with the
addition of
EDTA
- Low
incidence of
skin
sensitivity
- Persistent
effect over a
few hours
- Minimally
affected by
organic
matter
- Used in a
number of

- May be less effective than CHG

- Rapidity of activity is intermediate

Triclosan
5-chloro-2-(2,4-dichlorophenoxyl) phenol

hand
washing
products
(0.5 to
3.75%
concentratio
n)
Antimicrobi
al (cell wall
disruption)
- Active
against
broad
spectrum of
bacteria
- Appears to
be nonallergenic
and nonmutagenic
(short term),
even though
it can be
absorbed
through
intact skin
- Has
excellent
persistent
activity
- Activity is
minimally
affected by
organic
matter
- Has been

- Little information about effect on viruses

- Poor fungicide
- Use of this compound in soaps,
mouthwashes, toothpastes, fabrics, and
plastics may lead to drug resistant
bacteria**

tested in
concentratio
ns from
0.3% to 4%
- Is
commonly
used in
commercial
soaps (1%
concentratio
n) to reduce
body odor
by
inhibiting
the growth
of skin
bacteria
over time
References:
* Larson, E. 1995. APIC Guidelines for Infection Control Practice. - APIC guideline for hand washing and hand antisepsis in health care settings. APIC
(Association for Professionals in Infection Control and Epidemiology, Inc.) Washington, D. C.
**Heath, R.J., Rubin, J.R., Holland, D.R., Zhang, E., Snow, M.E., and Rock, C.O. 1999. Mechanism of triclosan inhibition of bacterial fatty acid synthesis. J.
Biol. Chem. 274 (16): 11110-11114.
******
Explanation: These three overheads list the major antiseptic ingredients used in antimicrobial hand soaps. Their negative effects and limited effectiveness
against spores and viruses are identified. These ingredients, in some cases, are easily neutralized and will effect the skin. The only universal method that removes
the appropriate microorganisms is plain hand washing.

7.

Official test* for hand sanitizers to meet the E2 USDA criterion

Procedure:
1. Grow microbiological cultures to high concentrations (e.g., 108/ml).
2. Make appropriate chemical sanitizer use solutions (e.g., standards for chlorine
are 200, 100, and 50 ppm). The unknown test germicide would be prepared at concentrations expected to be as effective as chlorine.
3. Add 10 mil of 200, 100, and 50 ppm chlorine to 25 x 150 mm medication tubes
and put in a 25 C water bath. Bring to temperature.

4. Starting with the 200 ppm tube, add 0.05 mil of test culture. Shake and return to
the bath. After 1 minute, make a transfer to an appropriate subculture media using
a 4 -mm flamed loop. (The subculture media tube will be used to check for viability.)
5. At 1.5 minutes, add another 0.05 ml of the culture to the 200-ppm solution. Shake
and return to the bath. After an additional 1 minute (2.5 minutes into the test), make
a second subculture. In 30 seconds (3 minutes into the test), add another 0.05 ml. Shake and return to the bath. After 1 minute (4 minutes into the test), make
another subculture. Repeat to give 10 total increments. (This requires a total time of 14.5 minutes and 0.5 ml of culture.)
6. Do the same 10-tube test culture destruction test with the test disinfecting solution.
To be considered equivalent in disinfecting activity, the unknown germicide must show the absence of growth in as many consecutive subculture tubes as the
chlorine standard.
*AOAC method 955.16 (Aoac, Official Methods of Analysis, 1995.
The test organisms are Salmonella typhiATCC 6539 and Staphylococcus aureus ATCC 6538.
******
Explanation: This overhead points out the method used to verify that a sanitizer meets E2 USDA criteria. It is important to point out that none of the hand
sanitizers are required to be tested and validated on hands. This is a laboratory test and has no relationship to in-use effectiveness.

8.

ASTM "glove juice" test method for evaluation of health care personnel handwash formulation
1. Test organism = Serratia marcescens ATCC No. 14756
2. Subjects (12) who have not used topical antimicrobials for at least 1 week; no clinical evidence of dermotosis or other skin disorders.
3. Procedure:
Subjects wash hand for 30 seconds wash using plain soap solution.
Five (5) ml of Serratia marcescens containing at least 10 microorganisms / ml are dispensed onto the hands, then rubbed over the surfaces of the hands
for 45 seconds. The hands are then allowed to air dry for 1 minute.
Baseline Recovery A baseline sample is taken after contamination to determine the number of marker organisms surviving on the hands.
Wash and Rinse Procedure Five (5) ml or amount specified by the manufacturer of the test formulation is place on hands and rubbed over all surfaces..
After the material is spread, a small amount of water is added from the tap, and the hands are lathered for 30 seconds. The lower third of the forearm is also
washed. After completion of the wash, hands and forearms are rinsed under tap water at 40 ( 2 C) for 30 seconds. A total of seven (7) washes with the test
formulation are involved. Bacterial samples are taken following the 1st, 3rd, 5th and 7th washes.
Bacterial Sampling After specified washes, rubber gloves used for sampling are placed on the right and left hand. 75 ml. of sampling solution** is
added to each glove and the glove is secured at the wrist. After the solution is added, the gloved hand is messaged for 1 minute. After messaging, an aeseptic
sample of the fluid within the glove is taken.
4. Enumeration of Bacteria in Sampling Solution is performed using standard microbiological techniques.
5. Determination of Reduction. At each sampling interval, changes from baseline counts obtained with test material are determined.
6. Comparison of Test material with a Control Material. If the test material is compared to a control material, an equivalent number of subjects should be
assigned to the control product on a random basis. All test parameters will be equivalent for products.

At each sampling interval, changes from baseline counts obtained with test material are compared to changes obtained with control material.
**0.4 g KH2PO4 and 10.1 g Na2hPO4 and 1.0 g isoactylphenooxypolyethoxyethanol in 1 liter of water. Adjust pH to 7.8 with 0.1N HCL or 0.1 N NaOH. Dispense
in 75-ml volumes and sterilize for 20 minutes at 121 C
Reference:
Adapted from: ASTM. 1987. Standard test method for evaluation of heath care personnel hand wash formulation. Designation E 1174 - 87. Annual Book of
ASTM Standards. 11.04:779-781.
******
Explanation: When in-use effectiveness is measured the glove juice test, as described in this overhead, is used. This is a complex test using a mildly pathogenic
organism, Serratia marcescens, and is not applicable to testing the removal of fecal pathogens from fingertips.

9.

HITM procedure for measuring hand sanitation

The feces of healthy people contains 107 to 109 E. coli / g*. E. coli is uncommon in food.
TEST
Use E. coli as an indicator of inadequate hand washing after using the toilet.
Utilize Coliform / E. Coli Petrifilm .
1. Go into the food production facility / kitchen. Pick the 5 employees with the longest, dirtiest fingernails.
2. Take a small separate Ziplock bag for each employee. Add 10 ml of letheen broth to each bag and have each employee rinse their work hand fingertips in the
broth in their designated bag. These employees should also use a small toothpick to scrape under their fingernails. This scrapping should also be added to the
letheen broth in the Ziplock bag.
3. Plate 1 ml. of the fingertip / letheen broth culture onto Coliform / E. Coli Petrifilm . Incubate Petrifilm for 24 hours at 35 C.
4. Significance of results:
- If < 20 CFU / ml, there is no problem. (Hands have been washed adequately.)
- If > 20 CFU / ml, there is inadequate fingertip washing.
deWit and Rombouts* found:
- Before stool samples 4% of kitchen employees, had >20 CFU E. coli/ ml on their hands
- After defecating 25% of the employees had >20 CFU E. coli/ ml on their hands.
The average was about 200 CFU E. coli after defecation.
Reference:
*de Wit, J.C., and Rombouts, F. M. 1992. Faecal bacteria on the hands of carriers: Escherichia coli as model for Salmonella. Zentralbl Hyg. Umweltmed
193(3):230-6.
******
Explanation: I have provided a method that we have used in retail food operations to measure the effectiveness of the operation's hand washing program. The
test organism is E. coli, which is already naturally present in the employees' fecal material. If the employees are properly washing their hands, one would find,
perhaps, a low level (<20) E. coli on a few of their hands, as the study revealed. On the other hand, if >20 E. coli were recoverable from fingertips, it was found
that the employees were not washing their hands properly after defecating. In the HITM method, we used the Petrifilm&trade; Coliform / E. coli test plate. We

put 10 ml letheen broth in a small, plastic, zipper bag in which the employees rinsed the thumb and first and second fingertips. Each employee then used a
toothpick to clean the dirt from underneath the fingernails. In addition to being a highly effective measurement process, this is a highly effective way to warn
employees that we know how to look for poor or lack of hand washing.

10.

Control of foodborne illness pathogens: HITM hand washing study

1. 0.1 ml of Serratia marcescens was placed on the thumb and first and second fingers of subjects and allowed to air dry. This was a total of 20,000,000 to
100,000,000 bacteria. To test the number of S. marcescensremaining of the fingertips, the thumb, first and second finger were rubbed together in 10 ml. of
letheen broth.
2. Single wash (about 13 seconds): Liquid Ivory hand detergent was put on the hands and fingertips which were washed for 13 seconds under flowing water at 2
gallons per minute. There was a 99.7% reduction.
3. Double wash with fingernail brush (about 20 seconds): A nail brush with about 5 ml. liquid Ivory hand detergent was used on the first wash. Then, the hands
were washed again with 5 ml. more of Ivory detergent, without the nailbrush. A total of 99.999% reduction was obtained.
4. The nailbrush was rinsed in 10 ml of phosphate buffer. Compared to the original starting bacterial counts, there was a 99.9998% reduction on the brush.
5. The normal skin bacteria that come off in a wash are about 1,000 to 100,000 per ml of rinse water. It is critical to use a marker organism to show reduction
because there is little reduction of skin resident bacteria. The brush becomes contaminated with them.
******
Explanation: This overhead summarizes the lab study we did to measure the effectiveness of the nail brush. We put between 20,000,000 and 100,000,000
Serratia marcescens on fingertips. Using the single wash with Ivory soap, we obtained a 99.7% reduction, which is typical for hand washing. Using the double
wash with the nailbrush on the first wash and friction on the second wash, we got a reduction of 99.999%. When we checked the nail brush in 10 ml phosphate
buffer, we found that, based on the original starting counts, there were a few S. marcescens remaining, but there was a reduction of 99.9998% on the brush. The
samples contained a lot of skin bacteria, which points out that one must use a marker organism to separate out the effectiveness of the hand washing. Relating
this to the USDA concept of establishing performance standards, the FDA should set performance standards for hand washing that say that a transient marker
organism (e.g., non-pathogenic E. coli) will be reduced by a minimum of 100,000 to 1 in any hand washing process that is to be approved.

11.

When to use double and single fingertip washing

Policy:
All employees who prepare food in the kitchen or production area and who serve food are responsible for keeping pathogens on fingertips and hands at a safe
level of <10 highly infective pathogens.
When entering the kitchen, the double wash procedure, at the feces wash off sink, will be used to reduce high levels of pathogens (10 6) to a safe level:
Upon beginning a work shift.
After using the toilet and reentering the kitchen or production area.
After cleaning up vomitus or any fecal material.
After touching open sores.

When working in the kitchen, the single wash procedure will be used to remove low levels of pathogens (10 3):
Between handling raw poultry and ready-to-eat foods.
Hand washing is not critical because it is not probable that there are >10 highly infective pathogens:
After touching raw meat, egg shells, dirty plates, mouth, or garbage bags; blowing nose; touching skin, hair, or beard.
******
Explanation: We have always stated that there is a critical difference between the use of the nail brush and plain hand washing. When the toilet paper slips and,
since fecal material can contain up to 109 pathogens per gram, there is the potential for high levels of pathogens on the fingertips. Hence, there is only one time
that people need to use the nail brush--when entering the kitchen from an outside location, assumed to be the toilet. There should only be one hand wash sink
designated as the feces wash-off sink in the kitchen, so that everyone understands the importance of fecal pathogens from fingertips.
Once employees are in the kitchen, their hands become a food contact surface (e.g., cutting board, knife, food utensils) and are cleaned in a similar manner. The
maximum level of pathogens that one could pick up in the kitchen on fingertips is probably 103 Campylobacter jejuni on poultry products. Scientifically
speaking, raw poultry is the only food in the kitchen that requires hand washing after handling it and before touching ready-to-eat food.
The last statement on this overhead relates to the old-fashioned idea that touching raw meat, egg shells, dirty plates, mouth, garbage bags, blowing the nose, or
touching skin, hair, or beard are hazardous practices. A hamburger might contain 100 E. coliO157:H7 in a 100-gram hamburger. That is 1 per gram of hamburger.
Touching the hamburger would result in picking up only a couple of E. coli--not an effective dose. Eggshells have less of a problem, because they are thoroughly
washed and sanitized; there might be 1 Salmonella transferred. Dirty plates have never been shown to be a problem; the food was "clean" when it went to the
customer. Through the research done on the common communion cup, it is apparent that mouth bacteria are not a food safety issue. Eating someone else's saliva
does not represent a real hazard. It happens with the common cup in churches every Sunday. This means that the dish washing area is not a food safety concern.
Garbage bags are full of spoilage microorganisms, but not hazards. Blowing the nose relates to S. aureus, which must multiply to a very high level and is not a
hazard as it comes out of the nose. The same is true with touching hair, picking a pimple, etc. The organism must be given a chance to grow, which will not
happen with the time and temperature controls that exist in the kitchen. In fact, the only critical food, again, is raw poultry in terms of cross-contamination.

12.

Feces wash-off sink


Stainless steel sink, 18" x 12" x 12" deep for washing up to elbows. Light: 100-foot-candles; light turns on with water flow.
Water flows at 2 gallons per minute, non-splash, 95-110F.
Automated knee switch for water.
Water temperature and water flow adjust valves.
A soft, not dense nailbrush (e.g., Anchor Surgeons Scrub 2000) for each food preparation employee. Air-dry between uses.
3 to 5 ml of plain unscented liquid hand soap. Single use soap container. Employees can have their own hand soap. Visual supply. Automated push
button delivery to the faucet outlet and the brush.
Visual towel dispenser, no lever.
Nose tissue.
Waste disposal.
******
Explanation: This figure shows a well-designed feces wash-off sink for the kitchen. The sink is stainless steel. When the water turns on, a light of 100 footcandles turns on over the sink, so that it is obvious that the sink is being used. Water flow is a minimum of 2 gallons per minute, because it is the water that
washes the fecal pathogens off of the fingertips. The water is from 95 to 110F, but there is no scientific evidence to show that water temperature is critical.
While faucet handles have not been shown to be a critical issue, a knee switch and soap switch will make the process go faster. Valves for water temperature and
water flow are included so that the sink has adjustments to it. The nail brush is a soft-bristled brush (Anchor Surgeons Scrub 2000)--not dense--so that there is no
abrasion of the skin on fingertips, and there is no collection of bacteria in the bristles. An unpublished work by Paulsen for Meritech, whereby Meritech is trying
to put a brush in its automated hand washing system, shows that there is no pick-up of microorganisms on brushes. The see-through towel dispenser allows
people to see how many towels are left. Nose tissues are available for people to blow their noses. Each employee has his or her own nail brush, which hangs up
on a nail brush rack to dry.
For the double wash, the employee comes up to the sink; holds the nail brush under the outlet for the soap dispenser, which is immediately by the spout; pushes
the soap switch, which gives 5 ml soap onto the brush; hits the knee switch to turn on the water; the water gently flows over the fingertips while the employee
brushes over the fingertips. Then, the brush is placed back on the rack. Soap is placed on the hands, and the hands are washed once more.
The infrared units do not seem to be fast enough, so, I have chosen a simple, industrial knee switch, as is used frequently in processing plants and works quite
well.

13.

Safe hand washing

******
Explanation: This overhead depicts our colored, laminated hand wash poster, which is displayed over thousands of sinks in the U.S. today. In facilities where
this poster is displayed and where they use the double wash, there is not a fecal pathogen problem. Note that the friction and volume of water are the critical
variables in hand washing.

14.

Double hand washing with a fingernail brush

HAZARD CONTROL POLICIES, PROCEDURES, AND STANDARDS

Dept.: ______________________ Person responsible: ___________________ Effective date: ____________

Process and Output Specifications:To wash fingertips and hands to reduce by 10-5 pathogens from feces and vomit on fingertips and underneath fingernails and
reduce 10-2 pathogens from food when preparing food in the kitchen.
The Hazard:When an employee arrives from home, or after using the toilet, the employee must be assumed to have <106 pathogens on his or her fingertips and
underneath fingernails. This concentration must be reduced to 10 to assure that the transfer of pathogens to the food that the employee handles is at a safe level.
When working in the kitchen, an employee might touch contaminated food such as raw poultry and then, must reduce pathogens by 10 -2 to reduce the pathogens
to a safe level.
STANDARDS AND OPERATING PROCEDURE

Get ready. Check to see that there is an adequate supply of unscented, non-antibacterial hand
detergent, an Anchor Surgeon's Scrub nail brush, and disposable paper towels at the hand sink.

Wet hands. Turn on the water. Let it flow rapidly at 2 gallons per
minute until warm (110 to 120F). It is the water that removes the
pathogens.
Apply detergent to the fingernail brush. Place enough
detergent (1/2 teaspoon or 3 to 5 ml) to build a good lather on the
fingers.

Brush and lather, particularly fingertips and

fingernails. Hold the brush with the bristles up, and touch the tips
of the fingers of the hand that held the toilet paper to the tips of the
bristles. Gently brush the tips of the fingers, without bending the
bristles, while water runs over the fingers and washes the pathogens
down the drain. Continue until the brush and the fingers have no lather
(about 12 to 15 seconds). If this is the first fingertip wash when coming
from home, put more detergent on the nail brush and brush the
fingertips on the other hand, because all fingertips could be
contaminated (for example, cleaning up after animals at home). Lay the
nail brush down with bristles up. This allows the water to run off so
that the brush dries, and bacteria cannot multiply.

Second wash for additional toilet/food pathogen

reduction or first wash for reduction of food
pathogens to a safe level. Add 1/2 teaspoon or 3 to 5 ml of
hand detergent to the palm of one hand. This wash without the nail
brush reduces pathogens another 100 to 1. If it follows use of the nail
brush, it gives a total of >100,000-to-1 reduction of pathogens on
fingertips. When working with food, there are only moderately low
levels of pathogens on fingertips, and this 100-to-1 reduction is
sufficient to make the fingers safe from food pathogens.

Lather and wash hands (and arms if you will be

mixing salad or dough). Massage the hands together and
between the fingers. Wash the arms up to the tips of the shirt sleeves, if
appropriate. Thoroughly rinse all of the lather from the fingertips,
hands, and arms in flowing warm water. When the detergent and lather
are gone from the skin, the pathogens are reduced to a safe level.

Dry hands using paper towel(s). Use clean, disposable

paper towel(s) to thoroughly dry hands and arms. This reduces the
microorganisms an estimated, additional 100 to 1.

Copyright 1997 by Hospitality Institute of Technology, 670 Transfer Road, Suite 21A, St. Paul,
MN 55114 USA

******
Explanation: This figure is a HACCP-style diagram of the hand wash process and should be in the FDA code in terms of teaching the principles of effective

removal of fecal pathogens from fingertips. In teaching this method of hand washing, I find it effective to use Glo-Germ in the hand washing demonstration. As a
modification, I have mixed brown fingerpaint with the Glo-Germ powder, rather than use the Glo-Germ oil, as my simulated fecal material. I have no trouble
teaching employees the importance of fingertip washing, once they see the brown mixture on the fingertips of the demonstration volunteers.

15. Importance of drying hands after hand washing

These simple experiments demonstrate that careful hand drying is a critical factor in determining the level of touch-contact-associated bacterial transfer after
hand washing.
The authors* designed an experiment to determine the drying efficiency of cloth towels and "air towels" (blow dryers).
Result: After 10 seconds of drying, single-service cloth towels removed 96% of the water from a subject's hands, whereas when hands and fingertips were dried
with a blow dryer, 45 seconds drying time was needed to achieve the same endpoint.
Another experiment showed that when materials representing skin, food, and utilities were touched with wet hands, high numbers of microorganisms were
transferred from the subjects' fingers to the test material. Microbial numbers on the order of 68,000, 31,000, and 1,900 were found on samples of skin, food, and
utilities, respectively, after touch contact.
A reduction in bacterial transfer was achieved using a simple, 10-second cloth towel or 20-second blow dryer post-wash hand drying procedure. This 10- or 20second drying procedure after hand washing reduced the transfer of numbers of microorganisms to skin, food, and utilities to 140, 655, and 30 respectively and
achieved 99.8, 94, and 99% reductions in bacterial transfer figures associated with wet hands.
Note: Air dryers are known to accumulate fecal pathogens from the air in the toilet, and HITM does not recommend them for hand drying.
Reference:
* Patrick, D.R., Findon, G., and Miller, T.E. 1997. Residual moisture determines the level of touch-contact-associated bacterial transfer following hand
washing. Epidemiol. Infect. 119:319-325.
******
Explanation:This overhead, then, points out the research that drying hands is a critical variable. While I have not included it in my hand washing effectiveness
analysis, hand drying would increase the standard of effectiveness by a factor of 10 to 100 using relatively coarse paper towels. Barry Michaels (Georgia Pacific)
has documented the effectiveness of the paper towel vs. the air dryer for the removal of pathogens.

16.

Keeping hands clean while working in the kitchen

Food Contact Surface Cleaning Sinks

Hands are a food contact surface.
Clean in plain single compartment sinks
(14" x 12" x 12") in the kitchen where other
utensils are cleaned. Only one hand sink is need
for the feces wash-off sink at the entrance to the
kitchen. The equipment sink should have a highvolume water flow, some soap, and paper towels.
Bucket Hand Cleaning
When there is no sink (as on the food preparation
line), use a 1-gallon (4-L) bucket to disinfect
fingers after touching raw chicken and to keep the
counter rinsed.
4 liters (4,000 ml) provides a safe
dilution. [1,000 Campylobacter jejuni is 1
bacteria / 4 ml].

0.5% distilled vinegar water [400 ml of 5%

vinegar in 3,600 ml of water or about 2 cups
vinegar in gallon of water].

******
Explanation:In the kitchen, the serious error has been made in terms of putting hand wash sinks throughout the kitchen. In fact, there is a lack of sinks for
keeping the food contact surfaces clean--to include the hands. Actually, it would be most appropriate to remove current hand wash sinks and install simple,
stainless steel sinks for the purpose of washing hands and food contact surfaces. This is not a food preparation sink, but can be used as described, or to wash out
towels, etc.
The diagram of the food contact surface wash sink shows a bat-handled faucet, an outlet with a water flow of at least 2 gallons per minutes or, perhaps, 4 gallons
per minute, so that rags and towels can be rinsed effectively. There is a scrub brush at the sink for cleaning cutting boards, a soap dispenser, a sanitizer bottle, and
paper towels. This way, one can squirt sanitizer on a surface and wipe with a paper towel, if appropriate, in order to reduce pathogens on the surface to a safe
level. The picture also shows a two-compartment bucket with soap solution on one side and rinse water on the other side.
In the kitchen where there is no sink close at hand, which is typical of the cook's work station, the cook would have a 1-gallon (4-liter) bucket for rinsing fingers
after touching raw poultry. If one put 1,000 C. jejuni into 4 liters of water, that equates to 1 bacteria per 4 ml, which is below an infective level.
We are now doing a study of the effectiveness of vinegar as a disinfectant in this rinse water. I believe that 0.5% vinegar solution should reduce the bacteria at
least 1,000 to 1 in approximately 15 or 20 seconds. The typical quats and chlorines are actually rendered ineffective by organic and soap materials very rapidly.

17. ABC cycle example for failure to correctly wash hands

Antecedent

Inconvenient location of sink

Lack of, or incorrect supplies
Employee under time pressure
Lack of adequate training
Procedure not yet habitual with
employee
Lack of enforcement by owner/manager
Weak government enforcement

Beh
avio
r

FAILU
RE
TO
WAS
H
HAN
DS
COR
RECT
LY

Cons
eque
nce
Indivi
dual
Abilit
y to
get
task
done
more
quickl
y/prod
uce
more
items
than if
having
to stop
to

Consequence
System
More products being produced, and thus
sold
Customers served in a timely manner;
more customers served within a given
period of time
Customers pleased with company's
speedy service
No zero-defect performance in terms of
correct hand washing
Possible customer dissatisfaction if
customer sees employee not washing
hands
Possible customer illness resulting in loss
of business, liability suit, or bankruptcy

wash
hands,
and
feeling
good
about
the
progre
ss
Abilit
y to
serve
custo
mer
more
quickl
y and
feeling
good
about
it
Possib
le
praise
from
owner/
manag
er for
servin
g
custo
mers
in a
timely
manne
r
Possib

le
negati
ve,
noninstruc
tive
feedba
ck
from
owner/
manag
er
******
Explanation:Management is probably the "root cause" of the hand washing problem today, because the attitude is that there is no time to train employees. The
correct approach to evaluating a hand washing system is to use the ABC (antecedent-behavior-consequence) diagram. This overhead illustrates the ABC cycle
when the behavior is failure to wash hands correctly.

18.

ABC cycle example for correct hand and fingertip washing in a behaviorcontrolled TQM system
Anteceden
Conseque
Behavior
Consequence
t
nce
Individual
System
Automated
Ability to
Appropriate number of products being produced, and thus
top-quality,
get task
sold
well-lit
done and
Customers served in a timely manner
hand and
CORRECT to serve
Customers pleased with attention paid to food safety
fingertip
HAND
customer,
Zero-defect performance in terms of liability costs
washing
AND
and feeling Possible customer dissatisfaction if customer is in a hurry and
station at
FINGERTI good about needs immediate service, but easy to assuage by employee
the
P
knowing
saying, "I did not want to take the chance of making you ill."
employee
WASHING that the
entrance to
100
customer
the kitchen PERCENT will be
Adequate
OF THE
served safe
supplies
TIME
food as a
present;
result of

back-up
readily
available
Employee
under time
pressure,
but time to
wash hands
and
fingertips
is insisted
upon by
manageme
nt
Customers
are aware
of
manageme
nt's
attention to
food safety
Adequate
training in
correct
hand and
fingertip
washing
procedure
Procedure
is habitual
with
employee
Immediate,
certain
enforceme
nt of
behavior

hand and
fingertip
washing
Positive
feedback
from
owner/man
ager for
following
this critical
safety
procedure
Job is
retained

by
owner/man
ager is
expected;
employee
is fired
upon
failure to
wash hands
and
fingertips
******
Explanation:This cycle shows the antecedents and consequences for correct hand and fingertip washing. Note that it is very important that the consequences be
positive and rewarding in order to instill in employees the desire to wash fingertips correctly when they enter the kitchen.

19.

Industry checklist of an effective government program

1. The head of state food safety program writes a semi-annual fact sheet on safe hand washing.
2. The state has an up-to-date file of the latest research reports on safe hand washing.
3. All food safety inspectors can validate safe hand washing with the E. coli test.
4. All food safety inspectors can demonstrate safe hand washing (the official state method).
5. All food safety inspectors can verify a unit's safe hands program.
6. Inspectors give all employees a 10-minute written knowledge test during an inspection.
7. There is an annual industry / government meeting to improve the state safe hands program. Ten (10) government and ten (10) industry people are randomly
selected each year and are required to meet and review the program.
8. The state keeps statistics, which are updated monthly, on percent of food employees checked that month that could correctly demonstrate safe hand washing.
9. The government must have epidemiological proof of cause of illness for every requirement they have in the state code, to include hand washing.
******
Explanation:A major problem nationwide is that there is no initiative to lead a hand washing program in the states. The sanitarians have different ideas for what
they want, and there is no knowledge. Hence, the first step in an effective national program is to tell the industry that the state has the responsibility for correct
knowledge. The nine factors shown in the overhead are critical elements that I teach the foodservice industry to require of the state food safety leaders so that the
state is held accountable for providing correct knowledge.

20.

Government risk assessmentof the probability of safe fingertip washing in a retail food operation

1. The manager has an up-to-date file of semi-annual fact sheets from the state on hand washing. The manager can demonstrate the correct procedure for
fingertip washing.
2. The manager has a signed written test for hand wash mastery for all employees that show the employees:
- Were trained in safe hand washing.
- Viewed the state hand wash video.
- Demonstrated to the manager that they could double-wash their hands.
3. The manager has a monitoring and reward program for hand washing
4. Five (5) employees, chosen at random, can correctly demonstrate the double-hand wash. Some are tested for E. coli under the fingernails.
5. Employees are retrained and tested every 6 months.
******
Explanation: The question is, then, how does one correctly evaluate the probability of correct hand washing in a retail food operation. The five items in this
overhead explain the critical variables that should be examined during a government risk assessment of a hand washing program. It begins with a state-mandated
program that managers must follow, and all employees must know. That program must have been validated as being effective in actual operation.

21.

Unit HACCP hand wash policy

Safe Hand Washing Policy
Our establishment is committed to the well-being of our employees and our customers. To prevent
foodborne illness, a critical part of that commitment is frequent and proper hand washing, including
proper use of the fingernail brush.
All employees will be trained and certified in safe hand washing before being allowed to work with food.
Employees will be constantly positively reinforced for following correct procedures.
An employee who has difficulty remembering will be retrained.
An employee who does not wish to practice safe hand washing will not be employed.
We will expect nothing less than total compliance with this policy, since our jobs depend on it. We have
the tools to prevent
________________
__________________________
Date
******
Explanation:A part of the evaluation of the unit program is management commitment. This overhead shows a simple commitment statement that should be
posted by the cash register at the front of the restaurant. It states management's commitment to employees and customers alike in terms of serving safe food.

22.
Planning and Pre-control
____Owner sets the example.

Safe hand washing checklist

____Owner checks on and reinforces performance.

____Employees participate in control.
____Hand sink is maintained and stocked.
____Fingernail brush is replaced when worn.
____There are written hand washing procedures that are kept current and used for training.
____No one is allowed to handle food until trained and certified in safe hand washing.
____There is an effective punishment for not washing hands when returning from the toilet.
____The hand sink produces water at 110 to 120F in 5 seconds. The water flows at
2 gallons / 8 liters per minute.
____The soap lathers well, and effectively and speedily removes filth from the hands and fingertips.
____There are nose tissues by the sink. Handkerchiefs are banned. If a person must sneeze or cough, he or she does so away from the food, into a shoulder, but
never into hands.
____There are good-quality, non-latex gloves available if an employee needs them.
Organization and Training
____Responsibility for training and employee safe hand washing certification is clearly defined.
____Every employee has seen the safe hand washing video tape and has been performance certified using Glo-Germ.
____Every six months, employees receive hand washing refresher training.
Operation and Control
____The sink is always restocked before any supply is less than 1/4. There are back-up supplies near the sink, and employees can restock the sink supplies if
necessary.
____Employees check each other and provide team reinforcement in correct fingertip and hand washing.
____All employees can properly demonstrate safe hand washing.
____There is control of cuts on hands.
____Employees wearing gloves wash or change the gloves frequently.
____Fingernails are kept very short.
Measuring and Feedback
____Supplies never run out.
____Employees participate in improving the system.
____Safe hand washing is continuously positively reinforced by management.
******
Explanation: This overhead shows a list that I have developed and use to evaluate the effectiveness of a hand wash program in a retail food operation. It is quite
thorough, and if a facility follows even a part of what is listed, there will be no food safety issue in terms of hand washing.

23.

Summary

1. How to achieve safe hands is no mystery. It is being done most of the time.
2. The state must have one basic procedure, on videotape, for removal of fecal pathogens on fingertips, and everyone in retail food operations must do the
procedure. There must be verifiable research data that proves the procedure does reduce pathogens on hands and fingertips to a safe level. It must be shown that
this is the minimum effective procedure.
3. In the kitchen, the raw food and ready-to-eat food must be separated and employees must clean-as-they-go. They must clean hands between handling raw
chicken and ready-to-eat food.
4. The percent of correct performance by employees must be measured and recorded by the manager and at the state level.
5. Good performance behavior must be rewarding, not punishing.
6. The government must inform the consumer what actions do not warrant immediate hand washing. These are:
- putting fingers to mouth
- tying shoes
- blowing nose
- bussing dishes
- touching dirty rags, etc.
It is the industry's responsibility to provide quality and customer satisfaction.
******
Explanation:This presentation points out that there is no mystery to achieving safe hands. A number of my clients who have used nail brushes for 20 years do
not have foodborne illness incidents caused by inadequate hand washing. They represent about 5,000 food establishments of various types. The process begins
with correct knowledge, which, today, should be provided by the state. Everyone in the state should use the same method. The state is responsible for validating
in a kitchen that the process achieves a 100,000-to-1 reduction of pathogens on fingertips. Both the state and management, then, measure correct performance by
testing employees periodically to find out how they are doing. their performance must be rewarded by the state. It is up to the government to tell consumers that
putting fingers in the mouth, tying shoes, blowing the nose, bussing dishes, and touching dirty rags are not a food safety issue, that fecal pathogens on fingertips
are the critical problem, and the hand washing procedure takes of it.

24.

HITM's national "Safe Hands" program components

Starter kit.
1. Manager's Information on Safe Hand Washing
2. Employee Safe Hand Washing Policies, Procedures, and Standards
3. Video tape: Safe Hand Washing (English or English / Spanish)
4. Safe Hand Washing Policy
5. Employee Safe Hand Washing Test and Record
6. Safe Hand Washing Checklist
7. Safe hand washing poster for above the hand sink
8. Anchor surgeon's brush: Super Scrub #2000B
9. Glo-Germ kit: orange fluorescent powder in mineral oil for hand washing training; white tracking powder to show what people touch and how they transfer

germs; fluorescent light to cause the powder to "glow" in a darkened room

10. "Safe Hands" Certification Sheet
11. "Safe Hands" Recertification Sheet
12. "Safe Hands" Employee Certification Pin (10 pins for initial training)
Upon completing your initial "Safe Hands" training, contact HITM to receive the following.
1. "Safe Hands" Customer Brochure (packet of 25 for customer distribution and original for photocopying)
2. "Safe Hands" Dated Wall Certificate
For each retraining, contact HITM to receive recertification materials.
1. Personalized "Safe Hands" Wallet-size Employee Recertification Certificate (for each recertified employee)
2. "Safe Hands" Dated Wall Certificate (for recertification, showing ongoing commitment to "Safe Hands")
3. "Safe Hands" Customer Brochure (packet of 25 for customer distribution)
******
Explanation:This overhead is a table of contents for our national "Safe Hands" program, which we have provided for approximately three years. We can provide
it to anyone--including the FDA.

25.

Hand washing on the HITM website

A "Safe Hands" hand wash program for retail food operations.
(http://www.hi-tm.com/Documents/Safehands.html ):
If hand and fingertip washing is to be enforced, there must be agreement on the actual method and then, retail foodservice training and enforcement. This
document sets forth a national initiative for safe hands in the USA and the world.
Double hand washing with a fingernail brush.
(http://www.hi-tm.com/Documents/Handflow.html ):
Illustrated with step-by-step photographs, this 1-page document shows the standards and operating procedure for safe hand washing using the double hand
washing procedure with a fingernail brush. The hazard and process and output specifications are described.
Hand washing.
(http://www.hi-tm.com/Documents/handwash.html):
This is a listing of abstracts from over 130 articles dealing with the problem of washing hands.
******
Explanation: This overhead lists three major resources on our website, which anyone can download and use.

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