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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 fecaloral 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
Contaminated hands play a major role in fecaloral
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

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DOI: 10.4103/0019-557X.92408
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reduce transmission of puerperal fever (child birth

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 childs bottom. In

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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 childs 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 childrens 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 1014 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 34 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

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 12 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 coagulasenegative 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

Results
A total of 208 children were included in the study. Both
questionnaires were filled in and swabs were taken.
Among the study participants, 161 (77.4%) were females.
The mean age of the children was 12.8 years, with a
range of 919 years.
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 [Table 1].
Almost 86% of children reported that they always washed
their hands before eating lunch. It was interesting to note
that 47.3% students never used any soap while 30.9%
students used it occasionally and only 21.3% always used
soap for hand washing.
Regular hand washing before taking dinner was reported
by 88% children. 52.2% said that they always used soap
for hand washing before taking dinner.
It was reported by 97.6% of the students that they always
wash hand after defecation, while only 72.9% of them
Table 1: Students perception of the dirty areas of the hands
Contaminated areas of the hands
Palm
Fingers
Finger tips
Nails
Web spaces
Dorsum of the hand

Numbers of
students

Percentage*

162
158
155
149
144
94

77.9
76.0
74.5
71.6
69.2
45.2

Multiple responses

Figure 1: Availability of soap at hand washing facility at school

295

used soap. About 97% students said that they had hand
washing facilities near toilets at their homes and 85% of
such facilities were provided with soap.
Around 99.5% students reported that hand washing
facility was present near the toilet of their own schools
and only 18.4% of these toilets were provided with soap
[Figure 1]. It was reported that handkerchief was used
by 63% of children for drying hand. It was reported by
52.4% of students that they used soap while washing
hands on the last occasion. On the contrary, 46.6% of
the participants said they did not use soap when they last
hand washed [Figure 2].
In regard to the importance of hand washing, about 33.2%
of the children said that it removes dirt and makes the
hands clean, 40% said it prevents diseases and keeps
them healthy, and 51.4% children said that hand washing
should be done as hands have germs and hand washing
removes the germs. There were multiple answers by each
individual student.
Hand swabs were taken from all the 208 students. The
swabs of 127 (61%) children revealed potential pathogens.
The commonest of these was S. aureus which was seen in
44% of samples. This bacterium is associated with skin
and respiratory diseases as well as food poisoning. The
commonest coliform bacterium noted was Enterococcus
faecalis: in 49 (24%) samples, followed by E. coli in 25
(12%) samples and Klebsiella sp. in 14 (7%) samples.
Presence of Group A streptococcus, which is a potential
respiratory and skin pathogen, was noted in 5 (2.4%)
samples. Commensal flora growth, which is generally
non-pathogenic to immunocompetent individuals,

Figure 2: Use of soap for washing hands on the last occasion before the hand
swab was taken

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

was noted in 76 (36.5%) samples. The findings are

summarized in Table 2.

Discussion
The study demonstrated the presence of pathogenic
microorganisms on the hands of 61% of the children
studied. The study from Amravati, Maharashtra, had
also demonstrated the presence of potential pathogens
on hands of students between 3 years (Kindergarten) and
24 years (Postgraduates), studying in various educational
institutes. The isolates included Staphylococcus
sp. (23%), E. coli (20%), Klebsiella sp. (10%),
Micrococcus sp. (9%), Proteus sp. (7%), Citrobacter
sp. (7%), Streptococcus sp. (7%), Enterobacter sp.
(6%), Enterococcus sp. (4%), Pseudomonas sp. (3%)
and Salmonella sp. (2%). The authors also demonstrated
reduction in hand contamination after hand washing.10
In the current study, practice of hand washing was
found to be high; however, soap usage was found to be
suboptimal, as has been seen in other studies from other
countries.7 The present study findings are similar to a
study11 on knowledge, attitude and practices of school
children conducted in Ethiopia, which found that though
most students reported hand washing before meals, i.e.
99.0%, only 36.2% reported using soap during hand
washing. Availability of soap at handwashing facilities,
especially in schools, was low. This study more or less
corroborated with the present study findings. About 50%
children exhibited the knowledge that hand washing
removes germs. About 30% children did not know
that nails or web spaces can be dirty areas in hands.
Further, the present study also corroborated with the other
studies on bacterial content in hands as well as diseases
caused by the improper hand washing practices. Ray
et al.,12 observed a decrease in colony count following
hand washing with soap in 60% of the samples in a
study conducted in areas around Kolkata. The evidence
suggested that hand washing with soap reduced the
bacterial count in majority of the respondents. At the
same time, an increase in colony count was seen in 30%
samples that were either pond water users or food servers
from a canteen using dirty clothes for drying hands after
washing. Therefore, to have a real impact, particularly
in reducing the incidence of diseases, three aspects of
hand washing seem to be important: washing hands with
soap and following all steps diligently, using clean water
and drying hands with a clean cloth. A study in Karachi,

Table 2: Distribution of isolates from hand swabs according to

the nature of the organism
Pathogens identied

Bangalore
(N = 108)

Kolkata
(N = 100)

Total
(N = 208)

Potential pathogens
Staphylococcus aureus
Escherichia coli
Enterococus faecalis
Klebsiella
Commensal ora
Sterile culture

62 (57.4)
41 (37.96)
20 (18.51)
13 (12.03)
04 (3.70)
48 (44.44)
None

65 (65)
51 (51)
05 (05)
36 (36)
10 (10)
29 (29)
06 (06)

127 (61)
92 (44)
25 (12)
49 (24)
14 (7)
77 (37)
06 (3)

Figures in parentheses are given in percentage

Pakistan,13 has demonstrated that regular hand washing

and bathing with soap is effective in preventing both
diarrhea and pneumonia. Another study from Kolkata
slums indicated that hand washing with soap may reduce
the incidence of dysentery cases in the community.14

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 at
schools. Children are often targeted for hygiene behavior
as it is felt that habits that develop at their impressionable
age would continue into their adulthood. However, in
the absence of infrastructure which includes water and
soap for hand washing, inculcating this habit would not
be possible. It was found that the students hands were
contaminated before taking food. The schools should
be told to keep soaps in the toilets for hand washing.
Schools should help in this regard which is not a costly
affair. However, teachers should tell the students that
drying hand after washing with soap should be done by
clean dry clothes, otherwise effect of hand washing with
soap will be lost and students will suffer from diarrhea
dysentery and pneumonia even after hand washing.

Acknowledgments
Authors deeply acknowledge Lifebuoy of Hindustan Lever
limited (HLL) for the support rendered for carrying out the
study with an intention to improve hand washing practices
among the school children, in collaboration with Indian
Public health Association. The authors also acknowledge with
gratitude the respective Principals of KPC Medical College,
Kolkata, and Kempegowda Institute of Medical Sciences
(KIMS), Bangalore, for permitting them to conduct the study
as well as for ethical clearance.

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

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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.

Indian Journal of Public Health, Volume 55, Issue 4, October-December, 2011