Shelly Mills squirted hand sanitizer into children’s tiny, cupped palms from an economy-sized bottle before serving celery and cream cheese at Country Playhouse Day Care in Middle Township.

The preschoolers have a name for the clear goop: germy gel.

Mills and her business partner, Nancy Ryan, said their day care center is alert to how colds and stomach bugs spread.

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“We try to keep the germs to a minimum,” Ryan said.

Twice a day, staff members use a combination of disinfecting sprays and wipes along with plain soap and water to clean tables, chairs and Mr. Potato Heads.

People typically think about germs during cold and flu season, especially when a co-worker is coughing in the next cubicle. But this year, people have been more preoccupied with germs because of H1N1, or swine flu.

As many as 80 million people in the United States contracted H1N1 between April and December, according to estimates by the federal Centers for Disease Control and Prevention. Of those, 362,000 people were hospitalized by the flu, and as many as 16,460 died.

The seasonal flu kills three times as many people each year. But unlike seasonal flu, which has its biggest effect on the old or chronically ill, swine flu struck down seemingly healthy victims. Nearly 90 percent of the hospitalizations and deaths occurred in people 64 or younger.

Surveillance reports nationwide show cases of swine flu are waning, but state health officials say they are still being vigilant.

“We’re being really careful not to say it’s ebbing,” Deputy Commissioner Susan Walsh said. “Historically, they come in waves. We expect it to rise again.”

And everywhere you go, it seems the flu is not far from people’s minds. Public antibacterial dispensers have become abundant at convenience stores, supermarkets and the building lobbies. Travel bottles are sold next to the well-thumbed magazines that people read in line and other impulse buys at checkout counters.

The fear of the disease has crept into daily routines in tiny ways.

No signs of peace

If cleanliness is next to godliness, the Rev. Christopher Bakey has few worries.

“When you’re in a profession — a doctor or priest — and you deal with shaking hands, you always learn to wash your hands,” he said.

Parishes such as his Church of the Resurrection in Upper Township, Cape May County, have altered what people do during Mass to prevent the spread of sickness.

During the Eucharist, parishioners no longer are offered sacramental wine, Bakey said.

“We haven’t done that for a while. And people don’t shake hands for the kiss of peace,” he said of the ceremonial greeting. “Instead, I see a lot of hugging going on.”

Bakey said the Diocese of Camden directed the changes with the flu in mind.

“People can’t wait to start receiving again from the chalice,” he said. “We’re obedient to our bishop. I concur with him personally. I think it’s a great idea until they fully understand the disease. They have to take necessary precautions.”

Bakey spends a lot of time ministering to the sick and dying. He, too, follows a commonsense approach when it comes to the infectious disease.

“I was just in the hospital all day yesterday,” he said last month. “I used to work with AIDS patients. The hospitals teach you that no matter what room you go into, you ought to wash first.”

A state conference in New Brunswick last year to prepare New Jersey’s response to swine flu had extra-long lines at the bathrooms. The conference attendees made a special point of washing their hands, prompting the hotel to stock extra soap and towels.

Not even doctors are above reproach.

Shore Memorial Hospital in Somers Point encourages patients to remind nurses or physicians to wash their hands before attending to them.

“Hand-washing is really important for the prevention of infection,” said Barbara Juzaitis, the hospital’s administrative director of care management.

“No health care provider — no doctor or nurse — should be offended if they ask that,” she said. “They want to be protected here. Nobody should be afraid to ask.”

Hospitals were especially vigilant about the risks posed by the swine-flu pandemic and until recently limited visiting hours to minimize the risk of infection.

The hospital also has long-standing protocols for disinfecting patient rooms, hallways and operating rooms, and uses antibacterial agents, bleach and other cleansers.

“In the operating rooms, even the walls are cleaned. It’s a standard of practice in health care,” she said.

This practice ensures that all bacteria are killed, preventing any from surviving and mutating into antibacterial-resistant strains.

Prevention in a bottle

Consumers have embraced the idea of killing germs, too.

At Country Playhouse Day Care, Shannon Brunell, of Middle Township, crouched and threw out her arms. Her daughter, 3-year-old Bailey, ran giggling to her as if they had been apart for weeks, not a few hours.

“Did you have a good day?” she asked, all smiles.

Brunell said she is more preoccupied with germs because of her three children. Her younger brother contracted swine flu, which made him sick and miserable for 10 days, she said. Fortunately, he did not need hospitalization, but the illness reinforced Brunell’s belief in the adage about an ounce of prevention.

“I always buy everything — the cleaner, the hand sanitizer, the wipes. I even put the small bottles in their backpacks,” she said. “But with the swine flu, you just double up on everything.”

Antibacterial products are hotter than ever, the market-research firm Mintel International Group Limited says.

Companies launched 479 new products boasting “antibacterial” benefits in 2009, up from 435 in 2008 and 336 in 2007 — everything from deodorants and cosmetics to diapers and bed linens. Now, companies are incorporating antibacterial chemicals into fabrics and plastics to make germ-resistant keyboards, telephones and gloves.

Superfresh in Ocean City offers 34 kinds of liquid soap, including several boasting antibacterial properties. Window cleaners, dish soap and detergents also tout their antibacterial message.

“It’s one more thing that plays into fear-based advertising. Get the germs before they get you. Then H1N1 hit, and people were seeking hand sanitizers more than ever,” said Fay Kat, a senior analyst with Mintel.

A Mintel survey last year of American consumers found that 29 percent buy only antibacterial soap and 44 percent use it.

“I find it surprising as well. I thought it would be more of a passing trend,” she said. “I would have expected more ‘free-from’ claims. People are tired of all the chemicals they use.”

But with so many products on the shelves using antibacterial chemicals, Kat said, consumers may have little choice.

“Now we’ve added more fuel to the fear-based fire. People were dying from H1N1. It was a serious outbreak not to be trifled with. But by the same token, as a consumer, I have to step back and think, ‘Are we really gilding the lily here?’ Consumers have to be suspect about being taken advantage of.”

Germ-free overkill

Some researchers want to know if such hypervigilance about germs has unintended consequences.

Long before anyone had heard of H1N1, Dr. Stuart B. Levy, of the Tufts University School of Medicine, wrote a paper warning about the possible dangers of antibacterial household products.

The 2001 study in the journal Emerging Infectious Diseases warned that overuse of antibacterial products could pose the same harm to public health as overuse of antibiotics. The bacteria — like viruses — could become resistant. 

“A cause for concern now is homes, which are becoming end-of-therapy quarters for patients,” he wrote. Without hospital procedures, homes “may be becoming havens for hospital-like bacteria as well.”

Levy wrote in an e-mail that antibacterial cleaners can harm the “good” microbes that protect people from infection.

“Use of antibacterials in household products raises the question of too much hygiene in infants less than 5 years old, which disrupts the maturity of their immune systems — the hygiene hypothesis,” he said.

The active ingredients, including the well-studied triclosan found in some liquid soaps, are now making their way into the environment, even turning up in marine mammals and 60 percent of the country’s freshwater streams.

Triclosan was so effective at killing germs, it was first used by doctors as a surgical scrub.

“The worldwide presence of triclosan is disturbing because it suggests wide use,” Levy said.

The American Medical Association’s Council on Scientific Affairs in 2000 recommended that consumers stop using household products containing antimicrobial agents such as triclosan until studies determine what, if any, effect they were having on bacterial resistance. The federal Environmental Protection Agency plans to examine its use as a crop pesticide in 2013.

But in soaps and detergents, triclosan is regulated by the U.S. Food and Drug Administration.

U.S. Rep. Edward Markey, D-Mass., this year urged federal regulators to take a closer look at potential hazards posed by antibacterial agents used in common consumer products.

“Of course on the national level, they are studying it. But what has come out is the best way to clean hands is using soap and water,” the Health Department’s Walsh said.

Walsh said it is too early to tell whether people’s vigilance about germs will go away when the swine flu does.

“All of these things about washing your hands, covering your cough, staying home when you’re sick have been a public-health message for decades,” she said. “It feels new because people have not taken those messages to heart. It’s difficult to say if this will have made a different impression or become part of our national culture.”

At Country Playhouse Day Care, Eileen Keppel picked up her 4-year-old son, Sammy.

Some parents might worry about their children growing up in a too-sterile world, but Keppel said she is sure Sammy is getting his fair share of germs.

“Sam always has something in his mouth — usually a toy or his fingers. We took a trip to New York, and he was sucking on his fingers after he touched the railings on the subway,” she said.

That grossed her out, she admitted. But she wonders if her own nagging respiratory problems may stem from her limited exposure to a hostile microbial world as a child.

“My mom is a clean freak, and now I’m a terrible asthmatic. Sometimes I wonder if that had anything to do with it,” she said.

“I think people are being a little paranoid. We’re not cultivating any more germs now than before,” she said. “Just wash your hands.”

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