Ignác Semmelweis anniversary: what does Semmelweis teach us today in the “age of Ebola”?

This year we remember the heritage of Ignác Semmelweis, the great scientist who died 150 years ago. His discoveries and achievements brought a new paradigm to infection control and his messages are just as valid today as in the 1840s. 

Semmelweis introduced antisepsis procedures to control infections in hospital practice, even though no-one really knew anything at that time about bacteria and pathogens. It is therefore quite amazing to note how a young assistant, 3–4 years after graduating from university, could discover and understand the importance of antisepsis.

Semmelweis travelled to Venice in 1847, when he got the news that his friend and colleague from Vienna, Jacob Kolletschka, had died from blood poisoning (septicaemia) contracted while performing an autopsy.

The painful news made Semmelweis think profoundly about the issue, as he had already been continuously struggling with the high mortality rate in maternity wards in Vienna, where many women contracted child-bed fever (puerperal fever) after delivery.

Semmelweis realized that both Kolletschka and the women suffering child-bed fever died of the same cause.

Being a keen observer, experienced clinician and skilled analyst, he came to the conclusion that decomposed organic substances, including the ones on the hands of people who performed autopsies, dirty hands in general, bed linen impregnated with body fluids and the dirt in the hospital rooms could all play their role in septicaemia.

Semmelweis published his discovery in May 1847. He also took a number of measures in Vienna, in the maternity ward that he was leading, and in 1851 he introduced the same measures at the maternity ward of Saint Rokus Hospital in Budapest. Among these measures, the following should be pointed out: compulsory hand washing with calcium hypochlorite for physicians and medical students who carried out autopsies, before entering the maternity wards. The same rule was imposed on nurses and other health and auxiliary personnel. The results were spectacular, so Semmelweis made hand washing obligatory between the examinations of patients in October the same year.

Statistical analysis brought clear-cut theoretical underpinning to Semmelweis' ideas. There was a significant difference in mortality rates seen between Vienna maternity wards 1 and 2 (due primarily to deaths caused by child-bed fever after delivery). Semmelweis explained this as a difference in practice, as medical students carrying out autopsies during pathology studies went only to Maternity Ward 1, and not Maternity Ward 2, for maternity practice. 

That is how it all started: washing hands, infection control through asepsis and antisepsis interpreted by Semmelweis became gradually known over the world, even though people knew little if anything about the bacteria and pathogens causing the diseases at the time of his discovery. It was only many years later that the microscope was invented and then Louis Pasteur and Joseph Lister (1865) confirmed the genius of Semmelweis. 

Nevertheless, this brilliant Semmelweis was not popular at all! Staff from his division did not welcome the measures he introduced, particularly not the regular use of calcium hypochlorite in hand washing. Semmelweis was also adamant about the maintenance of perfect cleanliness of wards. Fresh air, regular change of bed linen, and bed linen put out in the sun were among the measures he required so zealously. According to historical documents, he even fired one staff member who reused the same bed linen without washing it – just to save costs.

His publications and findings were also criticized by his fellow professors who considered them unfounded. Even the very obvious fact that at Saint Rokus Hospital Semmelweis succeeded in reducing the incidence of puerperal fever below 1% at the maternity ward that he ran for six years was rejected. The worst thing was that his methods were not put into practice at the time, causing the deaths of many thousands of young mothers.

Semmelweis was a difficult person to deal with and he lacked diplomatic skills, but his genius and strong commitment to save human lives stand as an amazing example to people of today. He also took part in the March 1848 uprising in Vienna, as a member of the National Guard, which is also a fine example of his openness to change and any new initiatives. 

In 1858, Lajos Markusovszky (the founder and editor-in-chief of the Hungarian Medical Weekly) supported his friend Semmelweis in publishing an article entitled "The etiology of puerperal fever", which was later published in German. This served as the foundation of Semmelweis' open letter of some 100 pages, addressed to obstetricians in 1862. In spite of all his efforts, the medical society of his time never accepted and recognized Semmelweis! Ironically, the Hungarian Academy of Sciences never accepted him as a member. 

We need to answer two questions 150 years after Semmelweis' death: firstly, how his work achieved recognition and, secondly, what its message is to us. The past 150 years brought full confirmation of the work and genius of Semmelweis: virtually all of his ideas were confirmed by modern-day bacteriology, infectology and epidemiology. The United Nations Educational, Scientific and Cultural Organization (UNESCO) acknowledged his achievements in 2013 and recognized him as "the Saviour of Mothers" for his puerperal-fever discovery, and his primary documents dated 1847–1861 were included on the World Heritage list.

The work of Semmelweis has clear and evidence-based messages. The importance of asepsis and antisepsis is growing these days, as WHO warns of serious threats to which patients are exposed. An old proverb says, "Prevention is better than cure". Even in the era of modern medicine, this statement is as true as before. Numerous studies have concluded that the hands of health-care practitioners and caregivers are a common source of hospital-acquired infections. Clean hands are indeed our best measure against the spread of infections, which are increasingly and disturbingly resistant to antibiotics. Every infection prevented is one that needs no treatment. 

This is one of the reasons why in October 2005, WHO launched the "Clean Care is Safer Care" campaign as the first global patient safety challenge. Following Semmelweis' legacy, WHO invested the first four years of the challenge in developing recommendations and implementation strategies to improve hand hygiene practices in any situation in which health care is delivered and in all settings where health care is permanently or occasionally given. As a natural extension of WHO's first global patient safety challenge, the "SAVE LIVES: Clean Your Hands" annual global campaign was launched in 2009, also known as World Hand Hygiene Day, which is celebrated each year on 5 May.

Despite steady progress during the past 10 years of the campaign, data show that hand washing/disinfection between patient examinations is still not done properly everywhere, and that antibiotics are used to compensate for poor infection prevention and control. Hospital linen and patients' objects also pose a risk of infection transmission. Hospital-acquired infections are fought in many ways: several hand disinfectants are on the market; and there are the strict (Semmelweis) rules of hygiene, asepsis and their enforcement, and antiseptic procedures such as silver-impregnated curtains, floors and dressings, just to name a few. As antimicrobial resistance is nowadays considered as a global public health threat, the findings of Ignác Semmelweis are very significant to preventing and controlling its further spread. 

The Ebola epidemic provided a number of lessons: it seems that history repeated itself as people behaved exactly as the medical students attending pathology classes back in the 19th century. Following the start of the Ebola outbreak, WHO specialists were struck by the large numbers of health care practitioners attending Ebola patients who were affected by the disease. It soon became clear that some practitioners were not properly trained, and did not know much about how to remove their protective garments. This caused practitioners to get Ebola patients' body fluids and excretions on their hands, and reach different parts of their bodies, such as the nose or mouth. Ebola virus disease started to affect fewer health care professionals only after this fact had become evident, and the wide training prevented the further spread of the infection. The same was true for the community at large, where the most difficult problem was to change cultural traditions, such as funeral practices. 

Now we honour the "Saviour of Mothers", and fully acknowledge his genius with the firm conviction of the continuing value of his discoveries.