A century later, a new wave of infectious diseases is rekindling fears, and marketers are responding with antimicrobial products ranging from soap to toys to underwear. The number of new germ-fighting products has risen steadily over the past 5 years, from 36 in 1992 to 123 in 1996, according to Marketing Intelligence Service of Naples, New York.

Some experts question the prudence of spending extra money-up to 50% more in the case of some soaps-for uncertain protection. They say more frequent and thorough hand washing, along with other simple measures, would do more to prevent disease than putting chemicals in household items.

Philip Tierno, PhD, a microbiologist at New York University Medical Center, explained the heightened public concern. Tierno, who is a scientific spokesman for Hasbro of Pawtucket, Rhode Island, a maker of antimicrobial toys, said that the concern began with the Legionella outbreak in 1976. "A few years later came toxic shock syndrome, then Ebola virus, Hantavirus from rat droppings, Cryptosporidium in water, and on and on. People are extremely aware of microorganisms and want to do something," Tiemo explained. Considering the AIDS epidemic, mad-cow disease, antibiotic-resistant bacteria, books called The Hot Zone and The Coming Plague, and the movie Outbreak, the roots of the new microbial awareness are evident.

The germ-fighting revolution in consumer products has been driven largely by innovative uses of triclosan, a broad-spectrum germicide used for 25 years in hospital soaps and dermatologic preparations. The Microban Products Company of Huntersville, North Carolina, developed a way to bond triclosan to plastic polymers, opening the way for such specialty products as surgical drapes, orthopedic cast liners, and hospital mattress covers. More recently, the company has joined makers of consumer goods to introduce germicidal cutting boards, toothbrush holders, and myriad other products-many of which are sold on cable television's QVC shopping channel.

Soaps Go Far Enough

Some infection experts agreed that germicidal soaps probably make sense, but they were skeptical of the value of antimicrobial cutting boards and toys.

"There have been no controlled studies to show that antibacterial soaps work, but in theory they shouldn't hurt, and may very well help," said Benedict DeCicco, PhD, a microbiologist at the Catholic University of America in Washington, D.C. "But all of these other antibacterial things are mainly gimmicks to sell products. As for cutting boards, I don't want any antibacterial stuff getting in my food-it's not necessarily something I want to eat." He is also concerned that antibacterial chemicals on toys could cause allergic reactions in children.

Robyn Gershon, DrPH, of the Johns Hopkins School of Public Health in Baltimore, also called the germ-fighting product trend a "marketing gimmick." Gershon said the products are probably not harmful, although like DeCicco she expressed some uneasiness about introducing antimicrobial chemicals into toys. Both said using a weak bleach solution to disinfect cutting boards and other kitchen surfaces is more likely to be effective than relying on impregnated chemicals.

May Promote Complacency

Gershon also expressed concern that antibacterial sponges and cutting boards might confer a false sense of security, leading people to relax their cleaning efforts. Gail H. Cassell, PhD, chair of the Department of Microbiology at the University of Alabama at Birmingham, agreed. "Just because a toy has this component in it, doesn't mean it's going to maintain efficacy when dropped on the floor or on a dirty diaper. Organisms could still be viable," she explained.

"The awareness that's being created about the need to be more conscientious in the home with respect to germs is important and well justified," Cassell added, "but I think with the [antimicrobial] products, we have a long way to go before we can claim efficacy."

Hasbro has already been admonished by the Environmental Protection Agency (EPA) for its claim that triclosan protects children from germs. The EPA, which registers every antimicrobial product as a form of pesticide, ruled in April that because Hasbro has not presented data to support its claim, the company could only say that the treatment protects the plastic in the toys, not the toys' users.

Tierno said that worry about triclosan, which is molecularly bound into the cutting boards and toy surfaces, is largely misplaced. According to the Microban company, the amount of triclosan that gets into food is well below the U.S. Food and Drug Administration (FDA) limit of 0.5 parts per billion (the FDA regards a higher amount of chemicals as a food additive). Also, Ciba-Geigy of Summit, New Jersey, the maker of triclosan, has completed studies showing that the compound is nontoxic even when ingested at many times the concentration used in Microban products.

The FDA seems to be convinced of the chemical's safety when ingested. In July, it approved for marketing a triclosan-containing toothpaste called Total (Colgate-Palmolive, New York, New York). Total is the first toothpaste that contains this chemical to be sold in the United States. The product has been shown to reduce gingivitis in controlled clinical trials, according to the FDA.

Nothing Replaces Hand Washing

Enthusiasts and skeptics agree that the benefits of antimicrobial products are dwarfed by the potential reduction in disease that could occur if hand-washing habits improved. In a 1996 survey, 94% of adults said they always wash their hands after using public restrooms. But among people observed in such places as New York's Penn Station, the Atlanta Braves' ballpark, and a New Orleans casino, only 74% of women and 61% of men actually did so. And only 33% reported washing their hands after coughing or sneezing. The research was conducted by a market research firm for Operation Clean Hands, * a campaign launched in September 1996 to educate Americans about the risks of poor hand-washing habits. This program is sponsored by the American Society for Microbiology and Bayer Pharmaceutical Division of West Haven, Connecticut. In interviews, several experts confirmed that even among people who wash their hands faithfully, few do it as thoroughly as they should.

The Centers for Disease Control and Prevention (CDC) define "thorough" hand washing as 15 seconds of vigorously rubbing the hands together until a soapy lather appears; scrubbing between fingers, under fingernails, and around the tops and palms of hands; rinsing under warm running water; drying the hands with a clean, disposable towel; and turning off the faucet using the towel as a barrier between the hands and the faucet handle.

The FDA estimates that 81 million Americans develop food-borne illnesses each year, resulting in 9000 deaths. According to the CDC, $4 billion are spent each year to treat infections caused by antibiotic-resistant bacteria, many of which could be prevented by thorough hand washing.

"People have become complacent, starting in the schools and kindergartens, where teachers are not encouraging and enforcing hand washing as they once did," Cassell said. She traced this attitude partly to the many victories over infectious disease that were won by mid-century, when vaccines and antibiotics vanquished once-formidable microbial foes.

Cassell promotes hand washing through Operation Clean Hands, which has been covered by about 50 television stations and prompted a Boston Globe editorial, she said. Lubbock, Texas, sponsored a handwashing day. The campaign has been translated into Spanish for Miami's Latino population.

The Massachusetts Medical Society launched a similar campaign this year, featuring a "Soapy" cartoon character and public-service announcements starring celebrity chef Julia Child.

Can public awareness campaigns create a nation of conscientious hand washers? One historical antecedent is the decline in public spitting witnessed this century. Katherine Ott, PhD, of the National Museum of American History in Washington, D.C., is author of the book Fevered Lives: Tuberculosis in American Culture since 1870 (Harvard Univ Pr; 1996). She said a confluence of circumstances around the turn of the century helped curb spitting, including a decrease in use of chewing tobacco; heightened expectations for cleanliness in public places; and a middle-class reaction to the influx of poor immigrants whose behaviors, including spitting, came to be viewed as repugnant. But Ott said antituberculosis campaigns were also a major factor. Antispitting laws were passed, signs were posted in public places (Figure 1), and leaflets were distributed.

View larger version (92K): [in this window] [in a new window]   Figure 1. A typical disease-prevention poster from the late 1920s. (Courtesy of the American Lung Association.).

No one has suggested mandatory hand-washing laws. But DeCicco drew a parallel to the emerging crisis of antibiotic resistance, dramatized this June by reports from Japan of a vancomycin-resistant strain of Staphylococcus aureus. Early in the century, public health officials "had no treatment for diseases, such as tuberculosis and polio, so they had to focus on prevention," he said. "And now that these drug-resistant organisms are showing up, we may be reaching that point again."

-Tom Reynolds

* Brochures from Operation Clean Hands can be ordered by calling 888-972-2937 (no fee or shipping costs).