Tuesday, March 26, 2013

Wonder Drugs You Can Clap -- Popcorn by The Colonel #37

SPOILER ALERT: no quirky humor in this piece.

No, this is not The Colonel

The Colonel is not a member in good standing of "our culture's paranoia about germs" (Jessica Hertzstein's phrase), but like many, he abhors needless death. Here are some nuggets he found interesting and more or less stole. Hope he did so artfully, for he hates typos with a pageant and avoids misspellings like the plaque. Now the real beginning:

Unclean hands pose a serious health risk and are a main cause of the spread of infections in hospitals.

Infections contracted in hospitals cause or contribute to about twice as many deaths in the U.S. as AIDS and firearms combined.

Hands are frequently biological weapons because they inevitably, repeatedly, and relentlessly ply the notorious "fecal-oral route" of infection.

"Gojo" is the company that makes Purell. All new hires must go through a two-and-a-half-day training regimen aimed at instilling exemplary hand-cleaning skills. Gojo's illness-related absenteeism is well below the national average.

Consumers say they want fragrance-free products, but they don't buy them.

Alcohol has been a well-known antiseptic since Egyptian mummy times. It is the fastest and most broadly effective antimicrobial agent for use on skin. In the proper concentrations -- more on this below -- it rapidly kills many but not all kinds of harmful bacteria and inactivates so-called "enveloped viruses," including influenza and HIV.

Special insert concerning c. diff (clostridium difficile), which is now a major cause of hospital, clinic, and community-acquired infections. Its spores thrive when powerful antibiotics have wiped out the intestinal flora that are c. diff's natural enemy. A major symptom: bad diarrhea. C. diff  (like tuberculosis, which spreads through the air, not just on hands) may be a major exception to the new protocol that alcohol-based hand rubs are better than hand washing with water and antimicrobial soap. C. diff can be deadly, especially to sick hospital patients. The spread of c. diff has been shown to be preventable only by a regimen of gloves, hand washing with soap and water, and room decontamination.

By the way, this column does not give medical advice. If you think anything in today's column may affect you, talk to an appropriate medical professional.

Purell and most other alcohol-based hand rubs contain between 60% and 70% alcohol. Intuition to the contrary notwithstanding, that concentration is more effective than pure alcohol. The remainder is moisturizers.

Until the mid-fifties, surgeons widely used alcohol as a hand disinfectant. Then antimicrobial soaps displaced alcohol almost everywhere.

In 2002, the Center for Disease Control issued a report reviewing a decade's accumulating science and concluded that  alcohol-based products were more effective for standard handwashing or hand antisepsis than soap or antimicrobial soaps and that alcohol-based products were better at killing drug-resistant pathogens than even soaps and detergents containing powerful antibacterial agents.

In 2009, the World Health Organizations followed suit, issuing guidelines to the effect that alcohol rubs should be the preferred cleaning agent for all health workers, including surgeons, whose hands are not visibly soiled.

Vocabulary time: A "fomite" is an object that conveys one or more infectious agents. Examples of fomites are faucets, doorknobs, physicians' neckties, coins and bills, toilet seats, handrails, and tongs.

The previous paragraph is under extreme etymological protest. In Latin, "fomites" (pronounced foe-mee-tase) is the plural of "fomes" (foam-ace). Back-formation accounts for the singular form "fomite," which bred the pronunciation foe-might. The English word "foment" comes from the same Latin root, fovere, "to warm." Think of a fomite as a "hot spot" for germ transmission.

Not all fomites are equally "hot." Smooth fomites, like bread tongs or metal restroom door handles, are hotter than porous ones, like dollar bills, because infectious agents protrude more from smooth surfaces and can be more easily detached from them. Hands are fomites par excellence, because they get into everything.

In Japan, in some circles, the bow, followed by touching right elbows, has replaced the handshake.

Surprise mid-item quiz: which is more sanitary at a buffet: (1) picking up a croissant from the breadbasket with your bare fingers, or (2) using the bread tongs? If you take the croissant barehanded, you touch only what you will eat, but if you use the tongs, you touch what many diners who came before you touched. Note to self: always be the first one to the buffet, before any diners have touched the bread tongs and before the finger-lickin'-good croissants are gone.

Warning: dangerous statement follows: The careless and improper use of disposable medical gloves may promote infection, because those wearing gloves may do things they would never do if they weren't wearing gloves. The gloves can give the wearer false confidence. They can muffle the evolutionary squeal of disgust that would stop certain ungloved behavior.

The Colonel has recently had occasion to ponder the activities of blue-gloved TSA workers at airports. He concludes that in that context, the gloves protect only the wearer, not the public. Don't think about this at mealtimes.

Two years ago, Purell's scientists became concerned that health workers didn't always use enough product, so they reformulated their hand rub to make it effective when applied in smaller quantities. The new formula is called "Purell Advanced." It feels, looks, and smells like the old formula.

Would you hold hands with a lobster? One reason compliance with hospital and clinic hand-washing regimes can be scandalously low (e.g., 20%) is that repeated washing with soap and water can be hard on the hands. Is that outcome any different with alcohol-based hand rubs? A recent Gojo test with nurses who used Purell Advanced a hundred times a day for a month showed their skin in better condition at the end than at the start, with high moisture content and less visible irritation.

A common fear is that improper use of antimicrobial agents promotes the development of drug-resistant "superbugs." Alcohol hand rubs don't worsen the spread of treatment resistant pathogens, because they kill germs by disrupting the cell membrane. People are as likely to develop immunity to being run over by lorries as microbes are to develop immunity to cell-membrane disruption.

Super-intrusive electronic tracking systems are the future of hospital handwashing regimes. Technical means will detect instances of noncompliance with protocol, enabling prompt retraining or other corrective and protective action.

A pill with the potential of alcohol-based hand sanitizers to reduce hospital-infection deaths would be hailed as a wonder drug.

Inquiring within, The Colonel finds mild reluctance to use alcohol-based hand sanitizer because he feels that it dries out the skin a bit and that it's nicer to wash the dead germs down the drain than to leave their sanitized corpses on his hands. Articulated and examined in sunlight, those reasons don't look good.

So in the future, where we will all be spending the rest of our lives, The Colonel will probably use much more alcohol-based hand rub and also avoid hospitals like the plaque, visiting sick friends by Skype or one or more of the angelic messengers with whom he is constantly in touch on high-level business.

This is where the item should end, but The Colonel is so naturally generous, he's throwing in a loosely related postscript on the Hygiene Hypothesis.

P.S. The Hygiene Hypothesis (HH) is dangerously wrong. It holds, roughly, that letting kids be exposed to the pathogens in their environment toughens their immune systems. More exactly, the HH is the idea that early exposure to some kinds of unsanitary environments prompts the immune system to resist certain ailments later on. In reliance on the HH, some parents don't vaccinate their children and pay little attention to pathogens in, say, playgrounds.

Unfortunately, immunity doesn't work like that; the way "populations" acquire resistance to lethal illnesses is the way North and South American indigenous populations acquired immunity to smallpox: by the death of everyone vulnerable to it.

The First World world" would probably have a much healthier, disease-resistant adult population if it had Third-World food handling, water quality, and environmental pathogens. The trade-off would be high infant mortality, as "nature" "selected out" the "maladapted."



Catherine said...

You left out the Romans. I like it best when you talk about the Romans. Or the Greeks. What does Elizabeth Brobrick think?

Two Hands Clapping said...
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