In 1847, with high rates of puerperal fever in Vienna General Hospital's maternity wing, Dr Ignaz Semmelweis (1818–1865) instituted a regimen of handwashing in chlorinated lime prior to medical students undertaking obstetric examinations or deliveries (Gupta et al, 2020). As a result, the mortality rate from puerperal fever fell from 12.2% in May 1847 to 1.9% in August 1847. However:
‘Semmelweis's plea for extension was not granted and the concept of handwashing was not continually implemented after his departure from the obstetric clinic in 1849.’
Hence:
‘The Semmelweis reflex is the tendency to stick to preexisting beliefs and to reject fresh ideas that contradict them (despite adequate evidence).’
Yet, 170 years later, the Semmelweis reflex was apparently operating undiminished, when Vermeil et al (2019) noted that before the 1990s health professionals' handwashing compliance ‘stagnated around 20–30% and never exceeded 40%.’ By 1994, when researchers at the University of Geneva Hospitals showed that time constraint was the most significant risk factor for handwashing non-compliance, the advent of alcohol-based hand rub constituted an important step, with health professionals' compliance improving from 48% to an average of 66% (Vermeil et al, 2019).
During the COVID-19 era, when measures to reduce viral transmission became part of the national conversation, to what extent did implementing mitigation measures in healthcare environments affect health professionals? In their UK study, Burns et al (2021) found that handwashing and facemask use was resulting in skin damage among healthcare workers that was associated with a ‘detriment to wellbeing’. Specifically, in their survey of NHS staff undertaken between April and May 2020, Burns et al (2021) recorded that, of 211 responders, 167 washed their hands more than 10 times per shift, with three quarters of those reporting cracks or fissures on their hands, most often on the back of the hands or in web spaces.
With the recent emergence of new COVID-19 variants, and current reports inviting the inference that society will have to live with – rather than eliminate – COVID-19, it becomes imperative to address the challenges to health professionals posed by them undertaking appropriate infection control measures such as handwashing. In this respect it is of interest that Burns et al (2021) cited two NHS trusts that took the sensible approach of establishing self-referral occupational dermatology clinics whose aim was to support frontline staff during the pandemic. A subsequent questionnaire-based study found that, among those presenting with hand dermatitis, up to 97.1% were diagnosed with irritant contact dermatitis, prompting Burns et al (2021) to observe that
‘If this is confirmed in further studies, it would potentially alter the most appropriate preventative interventions.’
COVID-19 has taught us that while we have naturally acquired focus to address the effects of the pandemic in the UK, we must also cultivate range and look beyond our borders. Thus, noting that there is scant knowledge on the protective effect of handwashing against acute respiratory infections (ARIs), Nasreen and Amin (2023) cited a review of studies conducted in low- and middle-income countries (LMICs), which found that, compared with no handwashing, handwashing interventions reduced ARIs by about 17%, suggesting that
‘even the 17% reduction would translate into substantial reduction in the number of ARI cases and deaths globally.’
Nasreen and Amin (2023) are clear that if innovative interventions were introduced in LMICs to address existing handwashing challenges – such as the simple expedient of providing large liquid soap dispensers to reduce time lost through waiting to refill containers – they
‘could reduce ARIs substantially and save millions of lives.’
Given the life-saving potential of handwashing, Shapiro et al (2021) developed an inexpensive module that connected touchless dispensers of alcohol sanitiser to the automatic doors of a paediatric intensive care unit. Hand hygiene was 46.9% before and 98.5% after the intervention. This is one way of meeting directly the challenge of the Semmelweis reflex, and one which would have earned the approval of Semmelweis himself.