For Medical Professionals

"Study Links Bacteria, Long Nails, and Baby Deaths." is the type of headline you would expect to read in a supermarket tabloid. But instead, it was featured in the March 27, 2000 edition of The New York Times as evidence of the fingernail's role in disease transmission increased.

You owe it
to your health to
use freshnails

Prompted by a spike in Pseudomonas Aeruginosa infections in the neonatal intensive care unit (NICU) of a Children's Hospital, a team of investigating epidemiologists in Oklahoma ultimately linked 46 infections of critically ill newborns (sixteen of which would sadly die as a result of those infections) over a 15-month period to the hands of two nurses – one with long natural nails and one with long artificial nails. 

While much of the recent research on the role of fingernails in transmitting disease has examined whether proper hand washing and scrubbing techniques eliminate the germs and bacteria, the simple fact is that studies show that only about 40% of health care workers follow correct hand washing procedures[1Hand Hygiene in Health Care Settings Study, 2002, from Centres for Disease Control and Prevention] in the first place. Even with the proper hand washing techniques, experts still think that long and artificial nails pose a problem in a health care setting. Germs hitchhike, and undernail™ germs that can exceed critical infecting doses can overcome even the strongest immune system.

freshnails™ is the direct result of extensive collaboration with the medical community and will reduce the germ and bacteria count under your nails, lower the risk of common infections, and can help prevent colds, flu, sickness and illness. freshnails™ promotes healthier day care, classroom and hospital environments and can decrease school/work absenteeism rates.

For more information about freshnails™ within the medical field, please contact:

Jason Tetro
The Germ Guy
Chief Health Consultant

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Fingernails can easily harbor infectious agents even when hand hygiene is practiced [1Hedderwick SA, McNeil SA, Lyons MJ, Kauffman CA (2000) Pathogenic organisms associated with artificial fingernails worn by healthcare workers. Infect Control Hosp Epidemiol 21: 505-509. ICHE7153 [pii];10.1086/501794 [doi],2Newman BY (2004) Fingernails hide organisms. Optometry 75: 275.]. For the individual, this could mean the potential for fungal infections including onychomycosis and bacterial infections such as impetigo. These pathogens can evade the handwashing process by hiding in particulate matter residing in the undernail™ space. Upon subsequent disruption of the environment, these organisms are freed and can be transferred through contact.


The impact of fingernails has been linked to several outbreaks including Klebsiella pneumoniae [3Gupta A, Della-Latta P, Todd B, San GP, Haas J, Wu F, Rubenstein D, Saiman L (2004) Outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails. Infect Control Hosp Epidemiol 25: 210-215. ICHE7676 [pii];10.1086/502380 [doi].], Group A Streptococcus [4Dudding BA, Burnett JW, Chapman SS, Wannamaker LW (1970) The role of normal skin in the spread of streptococcal pyoderma. J Hyg (Lond ) 68: 19-28.], Pseudomonas aeruginosa [5Foca M, Jakob K, Whittier S, Della LP, Factor S, Rubenstein D, Saiman L (2000) Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med 343: 695-700. 10.1056/NEJM200009073431004 [doi].], Serratia marcescens [6Passaro DJ, Waring L, Armstrong R, Bolding F, Bouvier B, Rosenberg J, Reingold AW, McQuitty M, Philpott SM, Jarvis WR, Werner SB, Tompkins LS, Vugia DJ (1997) Postoperative Serratia marcescens wound infections traced to an out-of-hospital source. J Infect Dis 175: 992-995.] and fungal infections [7Costa-Orlandi CB, Magalhaes GM, Oliveira MB, Taylor EL, Marques CR, de Resende-Stoianoff MA (2012) Prevalence of dermatomycosis in a Brazilian tertiary care hospital. Mycopathologia 174: 489-497. 10.1007/s11046-012-9576-1 [doi].]. Fingernails have received particular attention in infection control research [8Fagernes M, Lingaas E (2011) Factors interfering with the microflora on hands: a regression analysis of samples from 465 healthcare workers. J Adv Nurs 67: 297-307. 10.1111/j.1365-2648.2010.05462.x [doi].] and the development of infection control guidelines [9Boyce JM, Pittet D (2002) Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 51: 1-45, quiz.]. However, these guidelines are not always met [10Aiello AE, Malinis M, Knapp JK, Mody L (2009) The influence of knowledge, perceptions, and beliefs, on hand hygiene practices in nursing homes. Am J Infect Control 37: 164-167. S0196-6553(08)00686-X [pii];10.1016/j.ajic.2008.04.258 [doi].] and as a result, infection spread through fingernails continues to occur.


Unfortunately, there have been few studies looking at the risk of infection spread through fingernails. The majority of focus has been on the instruments themselves as they have been shown to harbor numerous infectious agents including bacteria, viruses, including HIV, and fungi [16Sekula SA, Havel J, Otillar LJ (2002) Nail salons can be risky business. Arch Dermatol 138: 414-415. dlt0302-4 [pii].] In Brazil [17Oliveira AC, Focaccia R (2010) Survey of hepatitis B and C infection control: procedures at manicure and pedicure facilities in Sao Paulo, Brazil. Braz J Infect Dis 14: 502-507. S1413-86702010000500013 [pii].], a survey of manicurists and pedicurists revealed that most knew of the risks associated with nails and infection although hygiene practices were less than exemplary. This led to a 2011 from the American College of Gastroenterology [18American College of Gastroenterology (2011) Hepatitis Transmission Risk Needs to Be Studied in Nail Salons, Barbershops New Analysis Questions Adequacy of Disinfection Regulations.] which suggested that there was a risk of hepatitis transmission in these salons as a result of improper hygiene practices. Without proper and consistent fingernail cleaning, these pathogens can accumulate under the fingernails and lead to infection spread. There are currently guidelines in the United States that suggest proper handwashing is key [19Occupational Safety and Health Administration (2012) Stay Health and Safe While Giving Manicures and Pedicures. Washington: U.S. Department of Labor. ] although there are no references to fingernails.

Food Industry

Fingernails have proven to be a problem in the food industry for both consumers and the foodhandlers themselves [11Barnham M, Kerby J (1981) Skin sepsis in meat handlers: observations on the causes of injury with special reference to bone. J Hyg (Lond ) 87: 465-476.]. In 2012, several studies in Africa [12Ifeadike CO, Ironkwe OC, Adogu PO, Nnebue CC, Emelumadu OF, Nwabueze SA, Ubajaka CF (2012) Prevalence and pattern of bacteria and intestinal parasites among food handlers in the Federal Capital Territory of Nigeria. Niger Med J 53: 166-171. 10.4103/0300-1652.104389 [doi];NMJ-53-166 [pii].,13Andargie G, Kassu A, Moges F, Tiruneh M, Huruy K (2008) Prevalence of bacteria and intestinal parasites among food-handlers in Gondar town, northwest Ethiopia. J Health Popul Nutr 26: 451-455.] revealed that fingernails were associated with a number of different foodborne pathogens including numerous fecal coliforms and parasites. The obvious cause was inappropriate fingernail care and hygiene. A similar conclusion was made in the US [14llwood PB, Jenkins T, Paulus C, Johnson L, Hedberg CW (2004) Hand washing compliance among retail food establishment workers in Minnesota. J Food Prot 67: 2825-2828.] when food workers were assessed for the potential of contamination. Even in the presence of good hygiene practices [15Dumavibhat B, Tiengpitak B, Srinkapibulaya S, Nilakul C, Tuntimavanich S (1989) Hygienic status of food handlers. J Med Assoc Thai 72: 577-582.], fingernails were shown to have poorer quality and could act as a risk for infection spread.


At home, fingernails can spread infections at a rapid rate leaving a household suffering. Fingernails have been identified as a route for foodborne agents including fecal coliforms and norovirus [20Dai YC, Xia M, Zhan HC, Liu Y, Li JD, Chen Q, Yu SY, Nie J, Farkas T, Jiang X (2010) Surveillance and risk factors of norovirus gastroenteritis among children in a southern city of China in the fall-winter seasons of 2003-2006. J Paediatr Child Health 46: 45-50. JPC1616 [pii];10.1111/j.1440-1754.2009.01616.x [doi].]. Other infections associated with fingernails include Helicobacter pylori [21Dowsett SA, Archila L, Segreto VA, Gonzalez CR, Silva A, Vastola KA, Bartizek RD, Kowolik MJ (1999) Helicobacter pylori infection in indigenous families of Central America: serostatus and oral and fingernail carriage. J Clin Microbiol 37: 2456-2460.], hepatitis B virus [22Nishiyori A, Fukuda K, Sata M, Tanikawa K (2000) HBV DNA can be detected from nail clippings of HBs Ag positive patients. Kurume Med J 47: 95-96.], and other bloodborne pathogens [23Lohiya GS, Tan-Figueroa L, Lohiya S (2007) Bloodborne pathogens exposure from occupational fingernail scratches. J Natl Med Assoc 99: 1271-1275.].


Since 1999, alcohol hand sanitizers have been used to supplement handwashing practices. In the decade that followed, the use of hand sanitizers in healthcare increased and they are now recommended by the World Health Organization [24Pittet D, Allegranzi B, Boyce J (2009) The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. Infect Control Hosp Epidemiol 30: 611-622. 10.1086/600379 [doi]. ]. Alcohol sanitizers are effective against most vegetative bacteria, many viruses, and fungi including those which cause onchomycosis. They are now considered to be a primary intervention to prevent infection spread in healthcare, food establishments and locations of mass gatherings such as shopping malls.

Concerns with
Alcohol Hand Rubs

The focus of the World Health Organization on the use of sanitizers is hands. However, this does not encompass the undernail™ area. This comes as a result of a trial looking at the need for specific nail contamination in healthcare [25Tanner J, Khan D, Walsh S, Chernova J, Lamont S, Laurent T (2009) Brushes and picks used on nails during the surgical scrub to reduce bacteria: a randomised trial. J Hosp Infect 71: 234-238. S0195-6701(08)00490-8 [pii];10.1016/j.jhin.2008.11.023 [doi].] and found none. However, considering the data on fingernail involvement in infection spread, this conclusion can lead to problems. Studies have looked at the impact of longer (and artificial) fingernails and hand sanitizer use and found that length, adornment and type impact the efficacy of the hand rub as well as the frequency of its use [1Hedderwick SA, McNeil SA, Lyons MJ, Kauffman CA (2000) Pathogenic organisms associated with artificial fingernails worn by healthcare workers. Infect Control Hosp Epidemiol 21: 505-509. ICHE7153 [pii];10.1086/501794 [doi].,26Hautemaniere A, Cunat L, Diguio N, Vernier N, Schall C, Daval MC, Ambrogi V, Tousseul S, Hunter PR, Hartemann P (2010) Factors determining poor practice in alcoholic gel hand rub technique in hospital workers. J Infect Public Health 3: 25-34. S1876-0341(09)00079-3 [pii];10.1016/j.jiph.2009.09.005 [doi].,27McNeil SA, Foster CL, Hedderwick SA, Kauffman CA (2001) Effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers. Clin Infect Dis 32: 367-372. CID000140 [pii];10.1086/318488 [doi].,28Rupp ME, Fitzgerald T, Puumala S, Anderson JR, Craig R, Iwen PC, Jourdan D, Keuchel J, Marion N, Peterson D, Sholtz L, Smith V (2008) Prospective, controlled, cross-over trial of alcohol-based hand gel in critical care units. Infect Control Hosp Epidemiol 29: 8-15. 10.1086/524333 [doi].]. This suggests that while alcohol hand sanitizers are an excellent way to supplement hand hygiene, there is a need for improved fingernail care.

How to Improve
Nail Hygiene

There is little doubt that improved nail hygiene can help to prevent infections in a number of sectors including healthcare, the food industry, personal services, mass gathering locales and the home. The requirements for proper nail hygiene include:

  1. Easy to use and carry
  2. The use of an alcohol that is between 62-70%
  3. The use of an implement that can fit into the subungual region
  4. Provision of enough solution to maintain wetness for 20 seconds
  5. A colour-coded means to identify gross soiling of the implement

By meeting these five criteria, one can be assured that the threat from infection as a result of either self-inoculation or spread to others can be reduced with regular use.