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UNC-Chapel Hill ENVR 890 - The infection potential in the home and the role of hygiene- historical and current perspectives

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The infection potential in the home and the roleof hygiene: historical and current perspectivesR. STANWELL-SMITHPublic Health Consultant, London, UKThe control of infection through hygiene has a long erratic history. Personal hygiene and handwashing wasless appreciated in the past, since it was not known that invisible organisms could spread from apparentlyclean hands and surfaces. The role of a hygienic home environment received little attention until the 19thcentury. Since then, the modern tradition of hygiene has served us well, with improved water and drainagedeveloping alongside vaccination, antibiotics, water purification, improved food production and hygienicfood preparation and storage. Two major epidemiological trends are relevant to hygiene perspectives: thedecline in the morbidity and mortality from infection, and the transition towards higher levels of chronicor debilitating disease. While mortality from some infections has decreased, communicable disease is noless prevalent. Infectious intestinal disease is still unacceptably high in both developed and developingcountries. The control of infection within the home needs to take account of changing epidemiologicaltrends, emphasis on evidence-based approaches and loss of public awareness of the role of hygiene. Inearlier eras lack of research on the home environment prevented sufficient attention to infectiontransmission in the domestic setting. Recent research has demonstrated how microbial contamination canbe transmitted by activities in the home. Application of this knowledge could significantly reduce thecontinuing impact of infectious diseases in our communities.Keywords: Control of infection; handwashing; morbidity; mortality; communicable disease; home hygiene.IntroductionPhilosophers through the ages have concluded that forgetting the lessons of history can limitprogress or, at worst, lead to a repeat of mistakes made in the past. The historical developmentof attitudes to hygiene provide an understanding of how it is both perceived and practised inour own era, and also provides insights into whether the current focus and guidelines areappropriate.To our ancestors, hygiene had a broader meaning that affected the person’s whole life,incorporating habits, cleanliness, fresh air, exercise and the general regulation of health. Thiswas partly due to a lack of understanding of the causes of infection and other diseases. Instead,there was a general notion that disease was caused by a number of factors, such as bad air or a‘miasma’ – toxic vapours found near rivers or in poor housing. The poor were thought to have ahigher level of disease because they lived in closer proximity to the miasma. Disease was alsobelieved to be caused by an imbalance in ‘humours’ in the body, an idea developed from Arabicand mediaeval medicine.Correspondence: R. Stanwell-Smith, Royal Institute of Public Health, 28 Portland Place, London,W1N 4DE, UK, Tel: + 44 207 794 1063. E-mail: [email protected] Journal ofEnvironmental Health Research 13, S9 – S17 (June 2003)ISSN 0960-3123 printed/ISSN 1369-1619 online/03/S100S9-09#2003 Taylor & Francis LtdDOI: 10.1080/0960312031000102769This archaic idea of the associations of disease persisted for many centuries and elementsof the miasma theory persist today. During the latter half of the 19th century, several of thepioneers of public health and reform, such as Edwin Chadwick, William Farr, FlorenceNightingale and John Simon, were ‘miasmatists’ for all or most of their careers. Chadwickbelieved that intense smells were diagnostic of acute disease, while Simon thought that feversbecame epidemic in ‘unhealthy places and among the sickly classes’ (Porter 1997). Themicrobiological discoveries that established the germ theory gradually, but not entirely,replaced these concepts. Ironically, many of the reforms to sanitation, which made such anenormous impact on infection morbidity and mortality, were prompted by the belief inmiasma.What do people now mean by hygiene?The current dictionary definition of hygiene refers generally to the promotion of health, but thepublic health definition of hygiene is rooted more specifically in cleanliness of water, food andthe environment. The popular perception of hygiene is still, perhaps, seen as the avoidance ofdirt, the killing of germs, or something to do with bathrooms and with hospitals.Complacency about the contemporary role of hygieneIn the developed world, the media portrayal of hygiene to the general public seems often todraw on outdated concepts of excessive use of disinfectants and attempts to create a germ-freeenvironment, possibly influenced by the stringent methods used to control epidemics in thepast, in turn influenced by the fear aroused by infectious diseases such as cholera anddiphtheria. Thus, the contemporary media approach questions the need to be so clean, nowthat pandemics are rare in developed countries, with the underlying assumption that excessivecleanliness is prevalent. People who specialise in hygiene in the home have a different attitude,shaped by an understanding of the continuing prevalence of infection and by observations ofthe efficiency of hygiene practices. Even health professionals, including doctors and nurses, donot always apply hygiene measures correctly. There is a constant need for education and forapplication of behavioural science in understanding the values and motivation required forappropriate hygienic practice.The current complacency towards hygiene in Europe and the USA – that the major dangersare over and measures can be relaxed – is both misplaced and dangerous. While some of theepidemics of the past have been controlled in industrialised countries, new infections haveemerged, accompanied by demographic changes such as ageing populations and a risingproportion of chronic illness that increases the susceptibility to infection. Rapid, cheaptransport has allowed ever greater numbers of people and food products to travel to moredestinations than at any previous time, but the associated globalisation of infection problems israrely considered. These trends challenge a mindset that assumes the battle for hygiene has beenwon, and it will only be a matter of time before all other countries follow suit. This may notnecessarily be the case. Furthermore, society has changed in other ways that affect hygienepractice. Modern life and jobs outside the home leave little time for


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UNC-Chapel Hill ENVR 890 - The infection potential in the home and the role of hygiene- historical and current perspectives

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