American Journal of Infection Control 44 (2016) 66-70

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

journal homepage: www.ajicjournal.org

Major article

Poor hand hygiene by college students linked to more occurrences

of infectious diseases, medical visits, and absence from classes
Kayla J. Prater, Crystal A. Fortuna, Janis L. McGill, Macey S. Brandeberry BS 1,
Abigail R. Stone BS 2, Xu Lu PhD *
College of Sciences, The University of Findlay, Findlay, OH

Key Words: Background: Proper hand hygiene has been linked to lower susceptibility to infectious diseases in many
Hand hygiene types of communities, but it has not been well established on college campuses. This study investigated
Infectious diseases the hand hygiene statuses of college students and their occurrences in relation to infectious diseases,
College students
medical visits, and absence from classes or work. It also examined the effects of education on hand-
Handwashing education
washing technique to improve hand hygiene.
Methods: College students enrolled at a university in Northwestern Ohio were recruited as study sub-
jects. Microbial samples were collected 3 times from each of the 220 valid volunteers before washing
their hands, after washing with their own procedures, and after washing with a procedure recommended
by the Centers for Disease Control and Prevention (CDC). Each volunteer also answered a survey
including questions on their health conditions, medical visits, and absence from classes or work.
Results: Hands of 57.7% volunteers were colonized by an uncountable number of microbial colonies,
which were significantly linked to more occurrences to infectious diseases (P < .05), medical visits
(P < .05), and arguably more absence from classes or work (P ¼ .09). The handwashing procedure pro-
vided by the CDC significantly improved hand hygiene.
Conclusion: It is critical to promote education on proper handwashing in colleges, in grade schools, and
at home to improve health and learning outcomes.
Copyright Ó 2016 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

Understanding the role of infectious disease in our society is
crucial in the aim to improve public health. Developing and prac-
ticing preventative efforts against infectious diseases may further
in achieving this goal. The Centers for Disease Control and Pre-
vention’s (CDC’s) summary for notifiable diseases is changing every
year with reported updates of emerging or re-emerging diseases.1
Each disease is well characterized, and each has remained a high
priority on disease reports. One important aspect to prevent these
diseases lies in investigating disease transmission.
Infectious diseases can be transmitted from person-to-person
by indirect or, more commonly, direct contact. Among the
different ways of transmission, person-to-person contact via the
* Address correspondence to Xu Lu, PhD, College of Sciences, University of Fin-
dlay, 1000 N Main St, Findlay, OH 45840.
E-mail address: lu@findlay.edu (X. Lu).
Funding/Support: The research was funded by internal funding from the uni-
versity that the authors were affiliated (to the correspondent author).
Conflicts of interest: None to report.
1
Current address: Ohio University Heritage College of Osteopathic Medicine,
Dublin, OH.
2
Current address: Kettering College of Medical Arts, Kettering, OH.
hands is critical in the spread of bacterial infection.2-4 This
demonstrates the importance of basic infection-prevention in-
terventions, with an emphasis on one of the most prevalent sources
of infection transmission, hand hygiene. In fact, it has been shown
multiple times that proper hygiene is the key to reducing occur-
rence of infectious diseases in many different types of communities,
including hospitals, daycare centers, and grade schools.5 However,
interestingly, there were very few previous studies addressing hand
hygiene practice on college campuses.6 There were even fewer
studies addressing whether proper hand hygiene could reduce
occurrence of infectious diseases among college students7,8;
therefore, it should still be considered as an open question.
The CDC and many other organizations (eg, World Health
Organization) have published simple-to-follow handwashing
guidelines.9,10 However, incorrect handwashing practices and low
compliance are prevalent,11-14 even among health care workers.
College campuses are at a high risk for spreading infectious
disease. Students live in close proximity with numerous chances of
close contact and are constantly subjected to environmental and
indoor pathogens as a result of constant traveling among different
areas on campus. However, among the few studies which address

0196-6553/$36.00 - Copyright Ó 2016 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2015.08.012
 K.J. Prater et al. / American Journal of Infection Control 44 (2016) 66-70 67

handwashing among college students, the compliance has been Table 1

found to be low and inadequate15 by unobtrusive observation, Demographic profiles of volunteers (N ¼ 220)

whereas in another study, through self-reporting,16 most students Demographic n (%)

claimed to wash their hands frequently. Sex
This study seeks to investigate the statuses of hand hygiene to Female 152 (69.1)
evaluate the relationship of proper handwashing and reduced Male 66 (30)
Unanswered 2 (0.9)
occurrences of infectious diseases on a college campus and to
Classification
disseminate the procedures and techniques of proper hand hy- Freshman 39 (17.8)
giene. Study findings argue for a need to better disseminate the Sophomore 42 (19.1)
importance and the correct technique of basic hand hygiene. Junior 36 (16.4)
Senior 66 (30)
Graduate 36 (16.4)
METHODS Unanswered 1 (0.5)
Living
Study subjects On campus 121 (55)
Off campus 99 (45)
Influenza vaccination?
This research was performed according to a procedure approved
No 79 (35.9)
by the institutional review board at the university in which the Yes 141 (64.1)
authors were affiliated (project no. 679). The research was con- Infectious diseases?
ducted anonymously, and the data were stored according to No 165 (75)
guidelines setup by the institutional review board. Student volun- Yes 55 (25.0)
Seek help?
teers were recruited from a campus in Northwestern Ohio to No 24 (43.6)
participate in the study through public announcements across Yes 31 (56.4)
campus. Each volunteer received and signed a written consent and Miss classes?
was assigned an identification number. The volunteers were then No 29 (52.7)
Yes 26 (47.3)
instructed to answer a survey sheet, including questions about their
sex, class classification, living conditions, whether they received an
influenza vaccination, whether they had become sick during the
winter of 2014-2015, and if so, whether they sought help from their various reasons, including incomplete answers on the survey
health care provider, and whether they missed school or work sheets or a major mistake during the experimental process (data
because of the illness. not shown). The demographic data of the 220 valid volunteers are
shown in Table 1. Volunteers were mostly women, consistent with
Data collections the sex distribution of the campus, with a rather even distribution
of student classifications and living conditions. Of the volunteers,
Each volunteer was asked to press the 5 fingertips of their 64.1% received an influenza vaccination during the previous winter,
dominant hand on one side of a Tryptic Soy Agar (TSA) (Sigma- and 25% reported being sick with infectious diseases. Among the 55
Aldrich, St. Louis, MO)17 plate to collect a microbial sample. The volunteers who were sick with infectious diseases, 31 (56.4%)
volunteer was then instructed to wash their hands as they normally sought help from their health care providers, and 26 (47.3%) were
would, and a second sample was collected in the same way on the absent from classes or work for at least 1 day because of the in-
other side of the same TSA plate. They were then instructed a fectious diseases.
proper way of hand sanitation, as suggested by the CDC,9 and were
asked to wash their hands using this procedure. A third bacterial Hand hygiene status
sample was collected. All plates were incubated at 37 C under
aerobic conditions for 24 hours. Six representative samples were All the TSA plates were incubated at 37 C aerobically for
selected, photographed, and used as the standard throughout this 24 hours, and most of which were found to contain too many col-
research. Each sample was then compared with the standard and onies to be counted consistently and accurately (data not shown).
assigned a number by 3 researchers independently. The average of Because of this, an alternative scoring procedure was used to assess
the 3 scores provided by the 3 researchers was used as the score for the samples, as previously described. The hand hygiene status and
that sample. Plates were returned back to the incubator after the effects of handwashing varied among volunteers. Plates of 4
scoring and were scored again another 24 hours later, by comparing representative volunteers are shown in Figure 1B as examples,
with the same standard photograph. The plates were then disposed taken 48 hours after sample collection. In this research, B desig-
as biohazard materials according to campus regulations. nates before washing, A designates after washing, and 2nd desig-
nates the second handwashing (with the CDC procedure,9 which
Statistical analysis was not labeled on the plates). The hands of a small percentage of
volunteers were found to contain higher microbial counts after
Paired t tests and z statistics were chosen to analyze the handwashing, which is consistent with a previous study showing
collected data and were performed using Microsoft Excel (Micro- extensive bacterial contamination in public restrooms.19 It was
soft, Redmond, WA), using standard procedure.18 A cutoff of P ¼ .05 likely that those volunteers inadvertently touched highly contam-
was used to signify statistical significance. inated areas after handwashing.
The average scores of all samples at 24 and 48 hours are shown
RESULTS in Figure 2A. At 24 hours (indicated by 1D), on average, microbial
scores improved after volunteers washed their hands with their
Demographic profiles of volunteers own procedure (A1D/B1D). However, the difference was not sta-
tistically significant with P ¼ .14, according to the paired t test
A total of 226 volunteers were recruited to participate in this (Fig. 2B). A paired t test was chosen here and thereafter because it
research, 6 of which were deemed as invalid data because of was designed and commonly used to compare 2 observations of the
68 K.J. Prater et al. / American Journal of Infection Control 44 (2016) 66-70

Fig 1. (A) Six representative samples were selected and photographed to serve as the standard for microbial scoring. Each sample received a score of 0-5, with 0 being the plate
containing the most microbial colonies. (B) Representative plates of 4 volunteers showing different statuses of hand hygiene and the effects of their handwashing. For each
volunteer, 1 plate contained 2 portions, the samples collected before handwashing and after handwashing, respectively. The other plate (without letter labeling) contained the
sample collected after washing hands with the Centers for Disease Control and Prevention procedure.

Fig 2. (A) Average microbial scores of all volunteers at 24 and 48 hours after data collections. (B) P values of paired t tests of different comparison groups. (C) Explanations of
abbreviations used. CDC, Centers for Disease Control and Prevention.

same subject.18 The microbial scores were further improved after
volunteers washed their hands using the procedure recommended
by the CDC, with a significance at P ¼ .01 (B1D/2nd1D). Comparing
the scores of 48 hours to 24 hours of the same category (eg, A1D to
A2D), as expected, the score at 48 hours was slightly lower but with
drastically statistical significance by paired t test, indicating more
microbial growth during this period. The difference between B2D/
A2D, B2D/2nd2D, and A2D/2nd2D were all statistically different
(Fig 2B). Because of this, subsequent analysis would focus on the
data at 48 hours.
 K.J. Prater et al. / American Journal of Infection Control 44 (2016) 66-70
Table 2
z statistics of selected groups
Groups Total B2D 3, n (%) z score
Healthy 165 90 (54.5)
Sick 55 37 (67.3) 1.65
Sought help 31 22 (71.0) 1.70
Missed classes 26 18 (69.2) 1.40
NOTE. The microbial scores of B2D were used in this analysis. The z statistical tests
were between the healthy group and the 3 indented groups individually.
B2D, before hand washing, 48 hours before washing.
*Statistical significance is defined as P ¼ .05.
Handwashing and infectious disease
The average B2D score of healthy volunteers was 3.20, whereas
that of its sick counterparts was 3.02, arguing for a positive correla-
tion between hand hygiene and susceptibility to infectious diseases.
However, t test revealed that the difference was not significant
(P ¼ .33, data not shown). A microbial score of 3 could be considered
as containing too many colonies to be counted accurately (Fig 1A);
therefore, a threshold of 3 was used to reanalyze the data.
Out of the entire 220 volunteers, 127 (57.7%) had a B2D score of 3.
Out of 165 healthy volunteers, 90 (54.5%) had a B2D score 3
compared with 37 (67.3%) out of 55 sick volunteers (z score, 1.65;
P < .05) (Table 2). Of the 55 sick volunteers, 31 sought help from their
health care providers; 22 (71.0%) of which had a B2D score 3 (z score,
1.70; P <.05). Of the volunteers, 26 missed classes or work for at least 1
day because of infectious diseases; 18 (69.2%) of which had a B2D score
3 (z score, 1.40; P ¼ .09). The last comparison was not significant to
the selected threshold of P ¼ .05, probably because of the small sample
size. Nevertheless, these data indicated that better hand hygiene
indeed positively correlated with susceptibility to infectious diseases.
Comparison of different methods of handwashing
We next asked whether hand hygiene statuses of our volunteers
improved with handwashing by using the microbial score
threshold of 3. If all volunteers were considered together, hand
hygiene statuses improved, but insignificantly, after volunteers
washed their hands with their own procedures (Fig 3A, compare
B2D with A2D of all volunteers), consistent with the previously
used analysis using numerical scores (Fig 2B). Importantly, the
difference between B2D and 2nd2D was significant, with P < .001.
The data were then divided according to whether the volunteers
became sick because of infectious diseases and if so whether they
sought help from their health care providers and whether they
missed classes or work. In the healthy group, the difference of both
B2D/A2D and B2D/2nd2D was significant, suggesting that at least a
significant portion of the members of this group was able to wash
their hands effectively.
In contrast, in the group sick with infectious diseases, there was
hardly any difference between B2D and A2D, arguing for very
ineffective handwashing by its members. The difference of B2D/
2nd2D (and apparently, A2D/2nd2D) was significant.
None of the differences of B2D/A2D, B2D/2nd2D, and A2D/
2nd2D of the group who sought care from their health care pro-
viders were significant. The group who did not seek help improved
their hand hygiene statuses significantly with the CDC procedure,
along with the group who missed classes or work because of the
illness and the group who did not miss classes or work (Fig 3A).
DISCUSSION
Infectious diseases pose a great threat to communities, partic-
ularly in winter. It has been shown multiple times that proper
69
hygiene is the key to reduce occurrence of infectious diseases in
many different types of communities.5 However, such a link has not
P value been well established on college campuses. Noteworthy, college
students have been found to inadequately wash their hands, which
<.05* would seemingly increase their chances in contracting infectious
<.05* diseases.6
.09
In this research, we intended to investigate whether students on
a college campus washed their hands properly, whether proper
hand hygiene was linked to lower occurrence of infectious diseases,
and whether education on proper handwashing techniques could
improve hand hygiene.
Hand hygiene status
Our data indicate that the hand hygiene status of our volunteers
is poor. Hands of 57.7% of all our volunteers were colonized by too
many microbes to be counted accurately. This number increased to
67.3% for the volunteers who were sick with infectious diseases
during the previous winter and was 54.5% for the healthy group
(Figs 2B and 3). Statistical analysis indicated that such a difference
in percentage positively correlated with occurrences of infectious
diseases (P < .05) (Table 2), echoing with previous studies in
communities other than colleges.5 We also observed that this
percentage was even higher in the group who sought medical help
(P < .05). Although unsurprising, to our knowledge, this represents
the first finding of this kind in any community. The group who
missed classes or work because of these infectious diseases had a
similar percentage to that of the group who sought medical help,
albeit statistically insignificant (P ¼ .09) when compared with the
healthy group, probably because of small sample sizes (Table 2,
Fig. 3B). Therefore, we conclude that improper hand hygiene is
indeed an important contributing factor to contracting infectious
diseases among college students. Meanwhile, there appeared to be
a threshold boundary in hand hygiene (microbial score of 3 in this
case) that would define hands as clean or unclean.
Proper method of handwashing
After collection of the first sample, 2 more samples were
collected, normal handwashing (with students’ own procedure)
and washing with the CDC procedure, taken in that order. In the
healthy group, normal handwashing improved their hand hygiene
status significantly, and the CDC procedure improved further
(Fig 3). However, in the group sick with infectious disease and 3 of
its subgroups, we did not observe improvement of hand hygiene
status after the volunteers washed their hands with their normal
procedures. In fact, in 2 subgroups, hand hygiene status became
worse. We observed significant improvement after they washed
with the CDC procedure. Because the normal washing did not
improve at all (which happened first), the improvement could only
come from the CDC procedure. Because the CDC procedure
improved hand hygiene status of those groups and their normal
procedure did not or even worsened, it is reasonable to conclude
that the CDC procedure is more effective. Interestingly, the biggest
drop in percentage of hands colonized by an uncountable number
of microbes was observed in the group who was sick but did not see
medical help, which went from 66.7% at the second sample
collection to 29.2% at the third sample collection (Fig 3). These data
clearly indicate that students can learn how to wash hands prop-
erly, and a difference may be made with proper education.
Limitations of this study and future prospective
This research relies on a self-reporting survey to collect data
regarding the health conditions of the volunteers, which in many
70 K.J. Prater et al. / American Journal of Infection Control 44 (2016) 66-70
Fig 3. Improvement of hand hygiene after washing hands with the Centers for Disease Control and Prevention procedure. (A) Stacked bar plot of the numbers of volunteers of
different groups with microbial scores 3 and >3. *P < .05; **P < .01; ***P < .001. (B) Stacked bar plot of the percentage of volunteers of different groups with microbial scores 3
and >3, with percentages of volunteers within indicated groups used to create the plot. A, after handwashing with volunteers’ own procedures; B, before handwashing; D, day (or 24
hours after sample collection); 2nd, after handwashing with the Centers for Disease Control and Prevention procedure.
cases could be self-diagnosed and might be inaccurate. The scoring
method used in this research is unrefined and may carry large
experimental errors. However, our data show that even with such
caveats, the positive correlation between hand hygiene and sus-
ceptibility to infectious diseases was strong and significant, favor-
ably arguing for a correlation of such on college campuses. We also
observed that inadequate hand hygiene is linked to significantly
more visits to medical facilities and arguably more absences from
classes or work, suggesting that it is critical to promote education
on proper handwashing, which should provide a link to reduction
in medical cost and better student performance. The handwashing
technique suggested by the CDC,9 which significantly improved
hand hygiene, took <30 seconds to instruct to each volunteer,
indicating that education on proper handwashing can be simple,
quick, and inexpensive but at the same time effective.
This study was performed only on the campus of 1 college, but
the phenomena could be universal. Therefore, it is important for all
colleges to teach students how to wash their hands properly. In fact,
it is reasonable to suggest that such education should start much
earlier than college; therefore, it may be critical for parents and
grade school teachers to perform this education.
CONCLUSION
This study investigated hand hygiene of college students on a
campus and the potential links between hand hygiene and sus-
ceptibility to infectious diseases, medical visits, and absence from
classes or work. We discovered that the links were all positive, and
most students inadequately washed their hands. We further found
that hand hygiene could be significantly improved by practicing the
procedure recommended by the CDC; therefore, we recommend
that schools, teachers, and parents should increase their efforts on
education in proper handwashing to improve students’ health
conditions and learning outcomes and to reduce medical cost.
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