3.2.2.2: Handwashing Procedure

Children and staff members should wash their hands using the following method:

1. Check to be sure a clean, disposable paper (or single-use cloth) towel is available.
2. Turn on clean, running water to a comfortable temperature.¹
3. Moisten hands with water and apply liquid or powder soap to hands.
1. Antibacterial soap should not be used.
2. Bar soaps should not be used.
4. Rub hands together vigorously until a soapy lather appears (hands are out of the water stream) and continue for at least 20 seconds (sing “Happy Birthday to You” twice).² Rub areas between fingers, around nail beds, under fingernails and jewelry, and on back of hands. Nails should be kept short; acrylic nails should not be worn.³
5. Rinse hands under clean, running water that is at a comfortable temperature until they are free of soap and dirt. Leave the water running while drying hands.
6. Dry hands with the clean, disposable paper or single-use cloth towel.
7. If faucets do not shut off automatically, turn faucets off with a disposable paper or single-use cloth towel.
8. Throw disposable paper towels into a lined trash container; place single-use cloth towels in the laundry hamper. Use hand lotion to prevent chapping of hands, if desired.

Children and staff who need to open a door to leave a bathroom or diaper-changing area should open the door with a disposable towel to avoid possibly re-contaminating clean hands. If a child cannot open the door or turn off the faucet, he or she should be assisted by an adult.

Use of antimicrobial soap is not recommended in early care and education settings. There are no data to support use of antibacterial soaps over other liquid soaps. Premoistened cleansing towelettes do not effectively clean hands and should not be used as a substitute for washing hands with soap and running water.

When running water is unavailable or impractical, the use of alcohol-based hand sanitizer (Standard 3.2.2.5) is a suitable alternative. The use of alcohol-based hand sanitizers is an alternative to traditional handwashing (with soap and water) if

1. Soap and water are not available and hands are not visibly dirty.^4,5
2. Hands are rubbed together, distributing sanitizer to all hand and finger surfaces, and allowed to air-dry.

Alcohol-based hand sanitizers should contain at least 60% alcohol and be kept out of reach of children. Active supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact with eyes and mucous membranes.^6,7

Single-use towels should be used unless an automatic electric hand dryer is available. The use of cloth roller towels is not recommended because children often use cloth roller towel dispensers improperly, resulting in more than one child using the same section of towel.

Washbasins should not be used as an alternative to running water. Camp sinks and portable commercial sinks with foot or hand pumps dispense water like plumbed sinks and are satisfactory if filled with fresh water daily. The staff should clean and disinfect the water reservoir container and washbasin daily.

RATIONALE

Running clean water over the hands removes visible soil. Wetting the hands before applying soap helps to create a lather that can loosen soil. The soap lather loosens soil and brings it into solution on the surface of the skin. Rinsing the lather off into a sink removes the soil from the hands that the soap brought into solution.
 
Alcohol-based hand sanitizers do not kill norovirus and spore-forming organisms, which are common causes of diarrhea in child care settings.⁴ This is enough reason to limit or even avoid the use of hand sanitizers with infants and toddlers (children younger than 2 years) because they are the age group at greatest risk of spreading diarrheal disease due to frequent diaper changing. Handwashing is the preferred method. However, while hand sanitizers are not recommended for children younger than 2 years, they are not prohibited.

 

Outbreaks of disease have been linked to shared wash water and washbasins.⁸

COMMENTS

Current handwashing procedure states that water remains on throughout the handwashing process. However, there is little research to prove whether a significant number of germs are transferred between hands and the faucet while performing hand hygiene.⁸  Turning off the faucet after wetting and before drying hands saves water for those early care and education programs practicing water conservation.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.5 Hand Sanitizers
5.4.1.10 Handwashing Sinks
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. Centers for Disease Control and Prevention. Handwashing: clean hands save lives. http://www.cdc.gov/handwashing. Reviewed October 9, 2018. Accessed January 28, 2019

2. American Academy of Pediatrics. Isolation precautions. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:148–157

3. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1–45

4. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017

5. Centers for Disease Control and Prevention. Handwashing: clean hands save lives. Show me the science—situations where hand sanitizer can be effective & how to use it in community settings. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html. Reviewed October 15, 2018. Accessed January 28, 2019

6. Centers for Disease Control and Prevention. CDC features. Wash your hands. https://www.cdc.gov/features/handwashing/index.html. Updated December 6, 2018. Accessed January 28, 2019

7. Santos C, Kieszak S, Wang A, Law R, Schier J, Wolkin A. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers—United States, 2011–2014. MMWR Morb Mortal Wkly Rep. 2017;66(8):223–226

8. Ogunsola FT, Adesiji YO. Comparison of four methods of hand washing in situations of inadequate water supply. West Afr J Med. 2008;27(1):24–28

9. Centers for Disease Control and Prevention. Handwashing: clean hands save lives. Show me the science—how to wash your hands. https://www.cdc.gov/handwashing/show-me-the-science-handwashing.html. Reviewed October 2, 2018. Accessed January 28, 2019

NOTES

Content in the STANDARD was modified on 8/9/2017 and 5/17/19.