Face touching: A frequent habit that has implications for hand hygiene

Abstract

There is limited literature on the frequency of face-touching behavior as a potential vector for the self-inoculation and transmission of Staphylococcus aureus and other common respiratory infections.
A behavioral observation study was undertaken involving medical students at the University of New South Wales. Their face-touching behavior was observed via videotape recording. Using standardized scoring sheets, the frequency of hand-to-face contacts with mucosal or nonmucosal areas was tallied and analyzed.
On average, each of the 26 observed students touched their face 23 times per hour. Of all face touches, 44% (1,024/2,346) involved contact with a mucous membrane, whereas 56% (1,322/2,346) of contacts involved nonmucosal areas. Of mucous membrane touches observed, 36% (372) involved the mouth, 31% (318) involved the nose, 27% (273) involved the eyes, and 6% (61) were a combination of these regions.
Increasing medical students' awareness of their habituated face-touching behavior and improving their understanding of self-inoculation as a route of transmission may help to improve hand hygiene compliance. Hand hygiene programs aiming to improve compliance with before and after patient contact should include a message that mouth and nose touching is a common practice. Hand hygiene is therefore an essential and inexpensive preventive method to break the colonization and transmission cycle associated with self-inoculation.
Crown Copyright © 2015. Published by Elsevier Inc. All rights reserved.

Full text

Major article
Face touching: A frequent habit that has implications
for hand hygiene
Yen Lee Angela Kwok MBBS, MPH, MHM, PhD, Jan Gralton BSc (Hons), PhD,
Mary-Louise McLaws DipTropPubHlth, MPHlth, PhD *
School of Public Health and Community Medicine, UNSW Medicine, UNSW Australia, Sydney, NSW, Australia
Key Words:
Face touching
Self-inoculation
Medical students
Hand hygiene compliance
Background: There is limited literature on the frequency of face-touching behavior as a potential vector
for the self-inoculation and transmission of Staphylococcus aureus and other common respiratory
infections.
Methods: A behavioral observation study was undertaken involving medical students at the University of
New South Wales. Their face-touching behavior was observed via videotape recording. Using stan-
dardized scoring sheets, the frequency of hand-to-face contacts with mucosal or nonmucosal areas was
tallied and analyzed.
Results: On average, each of the 26 observed students touched their face 23 times per hour. Of all face
touches, 44% (1,024/2,346) involved contact with a mucous membrane, whereas 56% (1,322/2,346) of
contacts involved nonmucosal areas. Of mucous membrane touches observed, 36% (372) involved the
mouth, 31% (318) involved the nose, 27% (273) involved the eyes, and 6% (61) were a combination of
these regions.
Conclusion: Increasing medical students’awareness of their habituated face-touching behavior and
improving their understanding of self-inoculation as a route of transmission may help to improve hand
hygiene compliance. Hand hygiene programs aiming to improve compliance with before and after pa-
tient contact should include a message that mouth and nose touching is a common practice. Hand hy-
giene is therefore an essential and inexpensive preventive method to break the colonization and
transmission cycle associated with self-inoculation.
Crown Copyright Ó2015 Published by Elsevier Inc. on behalf of the Association for Professionals in
Infection Control and Epidemiology, Inc. All rights reserved.
Infections may be transmitted by self-inoculation. Self-inoculation
is a type of contact transmission where a person’scontaminated
hands makes subsequent contact with other body sites on oneself and
introduces contaminated material to those sites.
1,2
Although the
literature on the mechanisms of self-inoculation of common respira-
tory infections (eg, influenza, coronavirus) is limited,
3-5
contaminated
hands have been reported as having potential to disseminate respi-
ratory infections.
6
Staphylococcus aureus is carried in the nasal mucosa
in approximately 25% of the community
7,8
and, may be self-inocu-
lated, via face touching, by individuals who are frequently exposed to
potentialcarriersinboththecommunityandhealthcaresettings.
9,10
During the influenza A (H1N1) pandemic, face-touching behavior in
the community was commonly observed with individuals touching
their faces on average 3.3 times per hour.
11
Inthehealthcaresetting,
frequent face touching, particularly during periods of seasonal ende-
micity or outbreak, has the theoretical potential to be a mechanism of
acquisition and transmission.
1
However, quantifying the role of face
touching in the spread of respiratory infections or S aureus coloniza-
tion is difficult for several reasons. First, such a study would require
enrollment, screening, and prospective follow-up of a large popula-
tion to identify a significant causal link. Second, the study would need
to observe transmission occurring in community settings, rather than
in isolation or under laboratory conditions, which would be ethically
challenging. Finally, there are likely to be confounding factors, such as
virulence of pathogens, varying susceptibility of the study population,
and effects of modes of transmission other than hand to face
contamination, that cannot easily be controlled.
A self-inoculation event may occur if a health care worker
(HCW) fails to comply with hand hygiene after patient contact
* Address correspondence to Mary-Louise McLaws, Level 3, School of Public
Health and Community Medicine, UNSW Medicine, UNSW Australia, Sydney, NSW
2052, Australia.
E-mail address: m.mclaws@unsw.edu.au (M.-L. McLaws).
Conflicts of interest: An unfunded project and the authors declared have no
conflict of interest.
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.ajicjournal.org
American Journal of
Infection Control
0196-6553/$36.00 - Crown Copyright Ó2015 Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2014.10.015
American Journal of Infection Control 43 (2015) 112-4

(moment 4)
12
or after contact with the contaminated environment
of the patient’s zone (moment 5) (Fig 1) and makes subsequent
physical contact with susceptible sites on their own bodies. To
better understand the dynamic between face touching and the
implications for hand hygiene among clinicians, we explored the
prevalence of face-touching behavior in medical students.
METHODS
In May 2010, a behavioral observation study was undertaken
involving phase 3 medical students at the University of New South
Wales (UNSW). Ethical approval was obtained from the UNSW Hu-
man Research Ethics Committee prior to the commencement of the
study. The student cohort had completed a one 4-hour infection
control course in the previous 12 months. The infection control
course included education on hand hygiene, aseptic technique,
standard precautions, and transmission-based precautions. The
same student cohort attended two 2-hour lectures unrelated
to infection control, on 2 separate occasions. One week before the
2-hour lecture commenced, students were informed that a behav-
ioral observation study was being conducted during the lecture and
required the students to be videotaped while they listened to the
lecture. Students were not informed about which behaviors were
under observation to blind them from the aims of the study; this was
necessary to minimize the potential for a change in behavior as a
result of being observed.
13
To participate in the study, students were
instructed to move to a marked area on the left side of the lecture
theatre and complete a participant consent form. To opt out of the
study, students were instructed to move to the right side of the
lecture theatre outside of the videotape recording range. Students
were also informed that they could withdraw from the study once
recording commenced by simply moving to the other side of the
theatre. All participants consented prior to videotape recording.
A digital videotape recording was made of the consenting
participants and was viewed by investigators to record the face-
touching behavior of every participant. For the purposes of preci-
sion, the digital recording was viewed multiple times after the
lectures had taken place by 1 researcher (Y.L.A.K.). A standardized
scoring sheet was used to tally the frequency of hand-to-face
contacts, the area of the face that was touched, whether a
mucosal area (eyes, nose, mouth) or nonmucosal area (ears, cheeks,
chin, forehead, hair) was touched, and the time in seconds of each
contact. Descriptive statistics were performed to determine the
frequency and duration of touches per hour using SPSS version 21
for Windows (SPSS Inc, Chicago, IL).
RESULTS
A total of 26 students were observed making 2,346 touches to
the face over 240 minutes. Of the face touches, 56% (1,322/2,346)
involved nonmucosal regions, whereas 44% (1,024/2,346) involved
contact with mucosal membranes. Of the 1,322 nonmucosal
membrane touches, most involved the chin (31%; 409/1,322), fol-
lowed by the cheek (29%; 383/1,322), hair (28%; 369/1,322), neck
(8%; 104/1,322), and ear (4%; 57/1,322). Of the 1,024 touches
involving a mucosal membrane region, 36% (372/1,024) involved
the mouth, 31% (318/1,024) involved the nose, 27% (273/1,024)
involved the eyes, and 6% (61/1,024) involved a combination of the
mucosal membranes.
During an average hour participants touched their face 23 times
(median, 29.0 times; LQ (lower quartile), 42.2; UQ, 108.2; range, 4-
153). The average duration of mouth touching was 2 seconds
(median, 1 second; LQ, 3.0; UQ (upper quartile), 24.0; range, 1-
12 seconds), the average nose touching duration was 1 second
(median, <1 second; LQ, 0.09; UQ,1.2; range,1-10 seconds), and the
average eye touching duration was 1 second (median, <1 second;
LQ, 3.0; UQ, 11.5; range, 1-5 seconds).
DISCUSSION
Hands are considered a common vector for the transmission of
health careeassociated infections
7,14,1 5
and have been implicated in
the transmission of respiratory infections.
11,14
Good hand hygiene
before and after patient contact is imperative to prevent trans-
mission of infection. This is particularly so during the symptomatic
or asymptomatic prodromal stages of infections when patients
shed infectious material.
16
In particular, clinicians caring for infec-
tious pediatric patients with high shedding concentrations
17,18
may
be at risk of acquiring an infection if they have a high level of face-
touching behavior.
19
S aureus is a common pathogen prevalent in both community
and health care settings. Colonization of the nasal mucous mem-
branes with S aureus is common and ranges from 20%-30% in health
care and community settings.
7
Nose touching was common among
our participants. This finding supports the importance of hand
hygiene as a means of preventing occupationally acquired coloni-
zation with S aureus from patients or the contaminated environ-
ment.
8,10,20,21
S aureus can survive for up to 5 years on hard surfaces,
and no obvious role has yet been attributed to colonized staff.
7
When mixed with hospital dust, S aureus can still survive for >1
year until it is picked up from the environment.
22,23
Contaminated
hands may act as a vector, transmitting the bacteria from a
contaminated surface to the HCW’s nasopharynx via face touching.
High hand hygiene compliance before and after patient contact
should reduce the likelihood of transferring pathogens through
Fig 1. Average number of face touches observed in a 60-minute period.
Y.L.A. Kwok et al. / American Journal of Infection Control 43 (2015) 112-4 113

self-inoculation and in turn prevent inoculation of patients.
10,24,25
Pathogens found on stethoscopes have also been recovered from
physician’s hands.
26
Given the habitual face-touching behavior
observed in our study, it is possible that the inoculation of
stethoscopes and other contaminated medical equipment may
have been the result of inoculation from nose touching to hands
and subsequently to the stethoscope. Given the frequency of face-
touching behavior observed in this study, clinicians must practice
hand hygiene before and after using such equipment to ensure that
patient equipment is kept clean prior to use.
Given the highfrequency of mouth and nose touching observed, 4
times perhour on averagefor mouth touching and3 times per hour on
average for nose touching, performing hand hygiene is an essential
and inexpensive preventivemethod for breakingthe colonizationand
transmission cycle. Models of infection transmission and comparison
of transmission efficiency of self-inoculation against other trans-
mission routes are required to further expand our knowledge on the
role of face touching for self-inoculation. Meanwhile, raising aware-
ness thatface-touching behavior is commonand is a possible vectorin
self-inoculation could result in HCWs accepting the message that
hand hygiene before and after patient contact is an effective method
of reducing colonization and infection transmission for themselves
and their patients.
Acknowledgments
We thank Professor Gary Velan for providing us access to the
UNSW medical students prior to his lecture and to Professor Wil-
liam Rawlinson for providing recording equipment.
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