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Original Article

A Study on Prevalence of Bacteria in the Hands of Children and

Their Perception on Hand Washing in Two Schools of
Bangalore and Kolkata
*Sandip Kumar Ray1, Ritvik Amarchand2, Jayanthi Srikanth3, Kunal Kanti Majumdar4
1
Professor and Head, 4Associate Professor, Department of Community Medicine, KPC Medical College, Kolkata, 2SRO, Centre for Community
Medicine, AIIMS, New Delhi, 3Associate Professor, Department of Community Medicine, Kempegowda Institute of Medical Sciences (KIMS),
Bangalore, India

Abstract
Background: Contaminated hands play a major role in fecal–oral transmission of diseases. In 1847, Dr Semmelweis
Ignac pointed to the link between infection and unclean hands, and demonstrated that washing hands could
reduce transmission of puerperal fever (child birth fever), a dreaded disease with high mortality in those days.
Materials and Methods: A cross-sectional study was conducted to find out the extent of germs present in hand, and
also the students’ perception on hand washing. This was assessed by questionnaire as well as by collection of swab
from hand and performing bacteriological culture in the laboratory. Results: In regard to students’ perception about
the dirty areas of the hands, it was observed that majority (78%) felt palm was likely to be more dirty while less than
70% felt that web spaces could harbor dirt. Almost 86% reported that they washed hands before eating lunch, but
only 21.3% said they always used soap while 47.3% never used it. Availability of soap all the time in the school was
reported by only 18.4% students. The swabs of 61% children showed potential pathogens. The commonest of these
was Staphylococcus aureus which was seen in 44% samples. Conclusion: The students’ hands were contaminated
before taking food. Although they washed hands before meals, they hardly used soap due to non-availability of soap.
The school authority should be asked to keep soaps in the toilets for hand washing.

Key words: Handwashing, Prevalence of bacteria, Students, Perception

Introduction reduce transmission of puerperal fever (child birth

Contaminated hands play a major role in fecal–oral
transmission of diseases. In 1847, Dr Semmelweis Ignac
pointed out the link between infection and unclean
hands, and demonstrated that washing hands could
*Corresponding Author: Dr. Sandip Kumar Ray,
Professor and Head, Department of Community Medicine,
KPC Medical College, Kolkata, India.
E-mail: sandip89@hotmail.com
Access this article online
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Website: www.ijph.in
DOI: 10.4103/0019-557X.92408
PMID: ***
fever), a dreaded disease with high mortality in those
days.1 Since then, a number of studies have established
that hands can carry different types of pathogenic
organisms. Washing hands is believed to reduce infection
transmission by washing off potential microorganisms
and also by removing the dirt, which could also harbor
microorganisms and allow their survival for longer
periods of time.2 Systemic reviews have pointed the
effectiveness of hand washing in reduction of diarrhea3,4
and acute respiratory illnesses,5,6 the two major childhood
killer diseases. Despite being shown to be effective,
hand washing with soap is not a common practice.
Worldwide, there is a wide variation in the prevalence
of hand washing behavior and the use of soap for hand
washing is not widespread.7 A study8 conducted in West
Bengal among 302 respondents from rural, urban slums
and non-slum areas revealed that in the urban slums,
98% reportedly washed hands with soap after defecation,
while only 69% did so after cleaning child’s bottom. In

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294 Ray SK, et al.: Bacteria in Hands and Handwashing among School Children
rural areas, 71% washed hands with soap after defecation
while 26% used mud or ash; however, only 5% used soap
after cleaning child’s feces.
As the practice of hand washing is poor, isolation of
pathogenic microorganisms has been reported in a number
of studies done among children. A study from Greece9
found that 52.9% of children’s hands of the 1956 hand
swab samples were contaminated by fecal streptococci.
A study from Amravati, Maharashtra,10 demonstrated
the presence of bacterial pathogens in the hands of all
of the 400 students whose hand swabs were examined.
Data on hand contamination from India are limited. This
study was designed keeping in mind the need for studies
to look at the prevalence of hand contamination among
school children.
The objectives of the study were as follows:
1. To find out of the prevalence of bacterial contamination
of hands of school children before taking mid-day
meals
2. To understand the perception of school children on
key issues of hand washing
Materials and Methods
The study was conducted by Indian Public Health
Association with the involvement of KPC Medical College
and Hospital, Jadavpur, Kolkata, and Kempegowda
Institute of Medical Sciences, Bangalore. Two urban
schools, one each from Bangalore and Kolkata, were
selected (by convenience), and 100 children and
108 children (total 208 children), respectively, aged
approximately 10–14 years, i.e. in classes 6th to 8th, were
selected for the study from each of the above schools.
Very few were above this age group but studying in these
classes only.
The study was cleared by the ethics committees of the two
participating institutes. Written consent was taken from
the schools as well as from the parents of the students
of the selected classes.
On the pre-decided days (for 3–4 consecutive days), a
visit was paid to the selected classes when the children
had no knowledge about such study. The visit was paid
an hour preceding the mid-day meal time. A station to
take hand swabs as per standard aseptic procedures was
established. Dominant hand of the child was swabbed,
beginning from the flexor aspect of wrist, across palm and
Indian Journal of Public Health, Volume 55, Issue 4, October-December, 2011
up all the five fingers (beginning with thumb) including
the creases and nail beds, ending in the dorsal aspect.
A standardized questionnaire was used to fill some basic
information related to hand washing by paramedical
workers under the supervision of faculty member of
Department of Community Medicine and Microbiology
of the above medical Colleges. The ID number of the swab
was pre-filled on the questionnaire so as to enable linking
the findings, if required. The questionnaire included the
issues like practice of hand washing before meals and
after defecation, material used for washing hands, hand
washing facilities at home and school, availability of
water and soap at such facilities, importance of hand
washing and students’ perception about dirty areas of
the hand.
The swabs were collected in Amies’ Transport Media
swabs (Himedia) and transported to lab within 1–2 hours.
At the lab, inoculation was done on urochrome UTI agar
and blood agar.
After 24 hours of incubation, the following pathogens
were identified:
• Enteric bacteria or coliforms like Escherichia coli,
Klebsiella, Enterobacter, Proteus, enterococci-
(diarrheal diseases) – detection by characteristic
colored colonies on urochrome agar
• Staphylococcus aureus (diarrheal + respiratory +
skin diseases): detection by colonies on urochrome
and blood agar, Gram stain and coagulase test
• Pneumococci, Group A streptococci (respiratory
diseases): detection by colonies on blood agar and
Gram stain morphology
• Subculture on special media + biochemical tests
if suspicion of Salmonella or Shigella (enteric and
diarrheal diseases)
• Usually non-pathogenic commensals like coagulase-
negative staphylococci, viridans streptococci,
diphtheroids, Candida sp. – detection by colonies
on urochrome and blood agar + Gram stain
• Usually non-pathogenic environmental flora like
Micrococcus sp., Bacillus sp., Pseudomonas sp.,
Acinetobacter sp. – detection by colony morphology
on urochrome and/or blood agar and/or Gram stain
Data entry and analysis: Data were entered in Epi-Info
(version 3.4.1) and frequency distribution of the different
variables was noted.
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Ray SK, et al.: Bacteria in Hands and Handwashing among School Children 295

Results used soap. About 97% students said that they had hand
washing facilities near toilets at their homes and 85% of
A total of 208 children were included in the study. Both such facilities were provided with soap.
questionnaires were filled in and swabs were taken.
Among the study participants, 161 (77.4%) were females. Around 99.5% students reported that hand washing
The mean age of the children was 12.8 years, with a facility was present near the toilet of their own schools
range of 9–19 years. and only 18.4% of these toilets were provided with soap
[Figure 1]. It was reported that handkerchief was used
In regard to students’ perception about the dirty areas of by 63% of children for drying hand. It was reported by
the hands, it was observed that majority (78%) felt palm 52.4% of students that they used soap while washing
was likely to be more dirty while less than 70% felt that hands on the last occasion. On the contrary, 46.6% of
web spaces could harbor dirt [Table 1]. the participants said they did not use soap when they last
hand washed [Figure 2].
Almost 86% of children reported that they always washed
their hands before eating lunch. It was interesting to note In regard to the importance of hand washing, about 33.2%
that 47.3% students never used any soap while 30.9% of the children said that it removes dirt and makes the
students used it occasionally and only 21.3% always used hands clean, 40% said it prevents diseases and keeps
soap for hand washing. them healthy, and 51.4% children said that hand washing
should be done as hands have germs and hand washing
Regular hand washing before taking dinner was reported removes the germs. There were multiple answers by each
by 88% children. 52.2% said that they always used soap individual student.
for hand washing before taking dinner.
Hand swabs were taken from all the 208 students. The
It was reported by 97.6% of the students that they always swabs of 127 (61%) children revealed potential pathogens.
wash hand after defecation, while only 72.9% of them The commonest of these was S. aureus which was seen in
44% of samples. This bacterium is associated with skin
Table 1: Students’ perception of the dirty areas of the hands and respiratory diseases as well as food poisoning. The
Contaminated areas of the hands Numbers of Percentage* commonest coliform bacterium noted was Enterococcus
students
Palm 162 77.9
faecalis: in 49 (24%) samples, followed by E. coli in 25
Fingers 158 76.0 (12%) samples and Klebsiella sp. in 14 (7%) samples.
Finger tips 155 74.5 Presence of Group A streptococcus, which is a potential
Nails 149 71.6 respiratory and skin pathogen, was noted in 5 (2.4%)
Web spaces 144 69.2
samples. Commensal flora growth, which is generally
Dorsum of the hand 94 45.2
*
non-pathogenic to immunocompetent individuals,
Multiple responses

Figure 2: Use of soap for washing hands on the last occasion before the hand
Figure 1: Availability of soap at hand washing facility at school swab was taken

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296 Ray SK, et al.: Bacteria in Hands and Handwashing among School Children

was noted in 76 (36.5%) samples. The findings are Table 2: Distribution of isolates from hand swabs according to
summarized in Table 2. the nature of the organism
Pathogens identified Bangalore Kolkata Total
(N = 108) (N = 100) (N = 208)
Discussion Potential pathogens 62 (57.4) 65 (65) 127 (61)
Staphylococcus aureus 41 (37.96) 51 (51) 92 (44)
The study demonstrated the presence of pathogenic Escherichia coli 20 (18.51) 05 (05) 25 (12)
microorganisms on the hands of 61% of the children Enterococus faecalis 13 (12.03) 36 (36) 49 (24)
studied. The study from Amravati, Maharashtra, had Klebsiella 04 (3.70) 10 (10) 14 (7)
also demonstrated the presence of potential pathogens Commensal flora 48 (44.44) 29 (29) 77 (37)
Sterile culture None 06 (06) 06 (3)
on hands of students between 3 years (Kindergarten) and
Figures in parentheses are given in percentage
24 years (Postgraduates), studying in various educational
institutes. The isolates included Staphylococcus
sp. (23%), E. coli (20%), Klebsiella sp. (10%), Pakistan,13 has demonstrated that regular hand washing
Micrococcus sp. (9%), Proteus sp. (7%), Citrobacter and bathing with soap is effective in preventing both
sp. (7%), Streptococcus sp. (7%), Enterobacter sp. diarrhea and pneumonia. Another study from Kolkata
(6%), Enterococcus sp. (4%), Pseudomonas sp. (3%) slums indicated that hand washing with soap may reduce
and Salmonella sp. (2%). The authors also demonstrated the incidence of dysentery cases in the community.14
reduction in hand contamination after hand washing.10
Conclusion
In the current study, practice of hand washing was
found to be high; however, soap usage was found to be The students’ hands were contaminated before taking
suboptimal, as has been seen in other studies from other food. Although they washed hands before meals, they
countries.7 The present study findings are similar to a hardly used soap due to non-availability of soap at
study11 on knowledge, attitude and practices of school schools. Children are often targeted for hygiene behavior
children conducted in Ethiopia, which found that though as it is felt that habits that develop at their impressionable
most students reported hand washing before meals, i.e. age would continue into their adulthood. However, in
99.0%, only 36.2% reported using soap during hand the absence of infrastructure which includes water and
washing. Availability of soap at handwashing facilities, soap for hand washing, inculcating this habit would not
especially in schools, was low. This study more or less be possible. It was found that the students’ hands were
corroborated with the present study findings. About 50% contaminated before taking food. The schools should
children exhibited the knowledge that hand washing be told to keep soaps in the toilets for hand washing.
removes germs. About 30% children did not know Schools should help in this regard which is not a costly
that nails or web spaces can be dirty areas in hands. affair. However, teachers should tell the students that
Further, the present study also corroborated with the other drying hand after washing with soap should be done by
studies on bacterial content in hands as well as diseases clean dry clothes, otherwise effect of hand washing with
caused by the improper hand washing practices. Ray soap will be lost and students will suffer from diarrhea
et al.,12 observed a decrease in colony count following dysentery and pneumonia even after hand washing.
hand washing with soap in 60% of the samples in a
study conducted in areas around Kolkata. The evidence Acknowledgments
suggested that hand washing with soap reduced the
bacterial count in majority of the respondents. At the Authors deeply acknowledge Lifebuoy of Hindustan Lever
same time, an increase in colony count was seen in 30% limited (HLL) for the support rendered for carrying out the
samples that were either pond water users or food servers study with an intention to improve hand washing practices
from a canteen using dirty clothes for drying hands after among the school children, in collaboration with Indian
washing. Therefore, to have a real impact, particularly Public health Association. The authors also acknowledge with
in reducing the incidence of diseases, three aspects of gratitude the respective Principals of KPC Medical College,
hand washing seem to be important: washing hands with Kolkata, and Kempegowda Institute of Medical Sciences
soap and following all steps diligently, using clean water (KIMS), Bangalore, for permitting them to conduct the study
and drying hands with a clean cloth. A study in Karachi, as well as for ethical clearance.

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Ray SK, et al.: Bacteria in Hands and Handwashing among School Children
References
1. Best M, Neuhauser D. Ignaz Semmelweis and the birth of
infection control. Qual Saf Health Care 2004;13:233-4.
2. Lanata CF. Problems in measuring the impact of hygiene
practices on diarrhoea in a hygiene intervention study. In:
Cairncross S, Kochar V, editors. Studying hygiene behaviour
methods, issues and experiences. New Delhi: SAGE; 1994.
p. 127-34.
3. Huttly SR, Morris SS, Pisani V. Prevention of diarrhoea in
young children in developing countries. Bull World Health
Organ 1997;75:163-74.
4. Curtis V, Cairncross S. Effect of washing hands with soap on
diarrhoea risk in the community: A systematic review. Lancet
Infect Dis 2003;3:275-81.
5. Cairncross S. Editorial: Hand washing with soap – A new
way to prevent ARIs? Trop Med Int Health 2003;8:677-9.
6. Jefferson T, Del Mar C, Dooley L, Ferroni E, Al-Ansary LA,
Bawazeer GA, et al. Physical interventions to interrupt or
reduce the spread of respiratory viruses: Systematic review.
BMJ 2009;339:b3675.
7. Curtis V, Danquah LO, Aunger RV. Planned, motivated and
habitual hygiene behaviour: An eleven country review. Health
Educ Res 2009;24:655-73.
8. Ray SK, Dobe M, Maji S, Chakrabarty D, Sinha Roy AK,
Basu SS. A pilot survey on hand washing among some
communities of West Bengal. Indian J Public Health
2006;50:225-30.
Indian Journal of Public Health, Volume 55, Issue 4, October-December, 2011
297
9. Kyriacou A, Drakopoulou S, Georgaki I, Fountoulakis
M, Mitsou E, Lasaridi KE, et al. Screening for faecal
contamination in primary schools in Crete, Greece. Child
Care Health Dev 2009;35:159-63.
10. Tambekar DH, Shirsat SD. Handwashing: A cornerstone to
prevent the transmission of Diarrhoeal Infection. Asian J Med
Sci 2009;1:100-3.
11. Vivas AP, Gelaye B, Aboset N, Kumie A, Berhane Y, Williams
MA. Knowledge, attitudes and practices (KAP) of hygiene
among school children in Angolela, Ethiopia. J Prev Med
Hyg 2010;51:73-9.
12. Ray SK, Dobe M, Lahiri A, Basu SS. Hand washing practices
in urban and rural communities in and around Kolkata, West
Bengal. Indian J Public Health 2009;53:1192-5.
13. Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer
W, Altaf A, et al. Effect of hand washing on child health: A
randomised controlled trial. Lancet 2005;366:225-33.
14. Sircar BK, Sengupta PG, Mondal SK, Gupta DN, Saha NC,
Ghosh S, et al. Effect of hand washing on the incidence
of diarrhoea in a Calcutta slum. J Diarrhoeal Dis Res
1987;5:112-4.
Cite this article as: Ray SK, Amarchand R, Srikanth J, Majumdar KK. A
study on prevalence of bacteria in the hands of children and their perception
on hand washing in two schools of Bangalore and Kolkata. Indian J Public
Health 2011;55:293-7.
Source of Support: Hindustan Lever Ltd., Conflict of Interest: None declared.