Daniela Pires

Hand Hygiene With Alcohol-Based Hand Rub: How Long Is Long Enough?

BACKGROUND Hand hygiene is the core element of infection prevention and control. The optimal hand-hygiene gesture, however, remains poorly defined. OBJECTIVE We aimed to evaluate the influence of hand-rubbing duration on the reduction of bacterial counts on the hands of healthcare personnel (HCP). METHODS We performed an experimental study based on the European Norm 1500. Hand rubbing was performed for 10, 15, 20, 30, 45, or 60 seconds, according to the WHO technique using 3 mL alcohol-based hand rub. Hand contamination with E. coli ATCC 10536 was followed by hand rubbing and sampling. A generalized linear mixed model with a random effect on the subject adjusted for hand size and gender was used to analyze the reduction in bacterial counts after each hand-rubbing action. In addition, hand-rubbing durations of 15 and 30 seconds were compared to assert non-inferiority (0.6 log10). RESULTS In total, 32 HCP performed 123 trials. All durations of hand rubbing led to significant reductions in bacterial counts (P<.001). Reductions achieved after 10, 15, or 20 seconds of hand rubbing were not significantly different from those obtained after 30 seconds. The mean bacterial reduction after 15 seconds of hand rubbing was 0.11 log10 lower (95% CI, -0.46 to 0.24) than after 30 seconds, demonstrating non-inferiority. CONCLUSIONS Hand rubbing for 15 seconds was not inferior to 30 seconds in reducing bacterial counts on hands under the described experimental conditions. There was no gain in reducing bacterial counts from hand rubbing longer than 30 seconds. Further studies are needed to assess the clinical significance of our findings. Infect Control Hosp Epidemiol 2017;38:547-552.

Hand hygiene mantra: teach, monitor, improve, and celebrate

Hand hygiene is critical to prevent healthcare-associated infections and reduce the spread of antimicrobial resistance. Compliance with hand hygiene practices has improved over the past two decades, especially in hospitals and healthcare settings where multi-modal promotion has been implemented [1e3]. Practice improvement has been documented across hospital wards and departments, healthcare professions, medical specialties, healthcare settings and systems, as well as across different cultural backgrounds and resource levels [2,4]. Evidence-based guidelines for hand hygiene in healthcare have been produced and are inspirational at local, regional, national, and international levels [1,5]. Improvement in staff knowledge, behaviour and practices relies on the implementation of multi-modal strategies, composed of five main elements: systems change with the preferred recourse to alcohol-based hand rubbing rather than handwashing with soap and water, staff education, compliance monitoring and performance feedback, reminders in the workplace, and safety climate making hand hygiene an institutional priority [6]. Research in hand hygiene has been extremely prolific over the past two decades [7]. In this issue of the Journal, papers presented by authors from Australia, France, Germany, and Switzerland illustrate both the wide cultural diversity and scope of investigative research in today’s hand hygiene agenda, from music in the operating theatre to ‘Big Brother is watching you’ [8e11]. Teaching hand hygiene to medical students, similarly to educating healthcare professionals, is key to successful hand hygiene knowledge and promotion. In a survey on hand hygiene education conducted in 17 medical schools in Australia, students recommended teaching to begin early in medical school and continue at later clinical stages. Furthermore, scenariobased learning was considered the best approach [12]. Kaur et al. evaluated the impact of scenario-based teaching modules on firstand second-year medical students in Sydney and reported a significant improvement in knowledge related to the World Health Organization (WHO) 5 Moment indications, use of hand hygiene material, and rubbing technique [8]. Students’ attitude toward hand hygiene also improved. The effect was partly maintained six months after the intervention. The need for continuous medical education is crucial and scenario-based learning as been promoted since 2009 by WHO (http://www. who.int/gpsc/media/training_film/en/). We welcome new

Clean your hands on May 5, 2017: Fight antibiotic resistance—it's in your hands

Preventing healthcare-associated infections and reducing their avoidable impact on health systems is critical today to make facilities safer for patients worldwide. In addition, the increasing public health burden of antimicrobial resistance (AMR) urges action. Stronger political commitment in reducing AMR was highlighted at the last United Nations General Assembly in September 2016 in New York. Hand hygiene is at the center of effective infection prevention and control (IPC) to combat AMR spread. The World Health Organization (WHO) recently issued guidelines on the Core Components of effective IPC program. Their implementation will help create strong, resilient health systems in all settings. The guidelines include the application of a multimodal strategy: achieving system change (infrastructure and resources), raising awareness, increasing education and training, monitoring and timely feedback, and creating a patient safety culture that includes visibly committed leadership. This approach improves hand hygiene, reduces infections, and saves lives. Therefore, on the May 5, 2017, Global Annual Hand Hygiene Day, WHO urges policy makers, top-level managers, IPC specialists, and other health professionals to focus on the fight against AMR spread by building everstronger hand hygiene and IPC programs (Table 1). We encourage health facilities worldwide to endorse the May 5, 2017, WHO campaign and to further improve hand hygiene, fight antibiotic resistance, and commit to progressing toward adherence to all core components of the IPC program. Let’s fight antibiotic resistance together; it’s in our hands.

Hand hygiene electronic monitoring: Are we there yet?

Monitoring practices is a crucial element of hand hygiene promotion. It is part of the widely used World Health Organization (WHO) multimodal implementation strategy to improve hand hygiene (Fig 1), proven to be successful in low-/middleand high-income countries.1-3 A recent meta-analysis showed that the increase in hand hygiene compliance and reduction in health care–associated infection (HAI) are significantly higher when all elements of the multimodal strategy are applied together.4 This unique feature is reflected in the recently published WHO guidelines on the core components of infection prevention and control (IPC) programs.5 The use of multimodal strategies to implement IPC activities, improve practices, and reduce HAI is endorsed as one of the 8 core components of IPC programs. Importantly, the evidence for this recommendation comes in great extent from the experience of successful hand hygiene promotion all over the world in the last 2 decades.5 In the current issue of the American Journal of Infection Control, Boyce provides a clear and very detailed review of the advantages and disadvantages of the currently available methods to monitor hand hygiene.6 The promise of automated hand hygiene monitoring has been around for several years.7 However, despite substantial technical progress, it still has not revolutionized hand hygiene. This comes as no surprise because, as it has been highlighted, hand hygiene improvement requires behavioral change, facilitated by a multimodal strategy, of which monitoring is only one of the different components.1,2 Automated systems might certainly bring a valuable contribution to monitoring. To optimize it, let us recall the role of direct observation within the multimodal strategy. First, direct observation yields performance data that permits to adapt and improve the hand hygiene implementation action plan. Second, the method developed at the University Hospitals of Geneva also strongly contributes to education and training of frontline health care workers (HCWs). Importantly, immediate and individual feedback provided during auditing is an inestimable moment to improve HCWs’ understanding of the My 5 Moments for Hand Hygiene (Fig 1) in practice, and contributes to its promotion. Third, it underwrites institutional safety climate through regular feedback of data, target setting, and the regular presence of trained observers in the wards, reinforcing the institutional commitment to hand hygiene.1,2 The shortcomings of the direct observation method are widely known6; data should be interpreted with caution, but they fulfill the necessary requirements of an improvement action plan. In the current, very careful, extensive, complete, and captivating literature review, Boyce concludes that new methods are needed and would be welcomed to complement the WHO direct observation method, and further contribute to HCWs’ hand hygiene compliance improvement.6 Nowadays, one can monitor hand hygiene compliance (number of hand hygiene actions performed when an opportunity exists divided by the number of hand hygiene opportunities), consumption of alcohol-based handrub (ABHR), and the quality of the observed hand hygiene action. The WHO direct observation method is able to monitor hand hygiene compliance and the quality of action.1,2 Automated monitoring systems can accurately monitor frequency and volume of ABHR use. Interestingly, some systems are further optimizing this by estimating the expected number of hand hygiene actions in a scenario of 100% compliance with the My 5 Moments for Hand Hygiene, thus providing a denominator for the number of actions systematically collected in the wards by automated ABHR dispensers.6 Other systems have elegantly combined events recorded by ABHR dispensers with HCWs movements, namely room entrance and exit (taken as surrogate markers of WHO moments 1 and 4/5, respectively) (Fig 1).6 In spite of these and other exciting advances, one should keep in mind that none of the systems available today are able to provide hand hygiene compliance data, simply because it is nearly impossible for an automated system to accurately detect opportunities for hand hygiene. An opportunity occurs when a hand hygiene action potentially interrupts cross-transmission of microorganisms via HCWs’ hands.1,2,8 The My 5 Moments for Hand Hygiene was built on this concept.8,9 Cross-transmission is potentially avoided by a hand hygiene action when HCWs sequentially touch a health care zone and the patient, or vice versa (moments 1, 4, and 5), when HCWs’ hands access a sterile site (moment 2), or after HCWs’ hands move from a contaminated body site (moment 3) (Fig 1). Thus, all the 5 moments are important to avoid cross-transmission between patients, inoculation of microorganisms in critical sites, and to protect HCWs.1,2 * Address correspondence to Didier Pittet MD, MS, Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, 4 Rue Gabrielle-Perret-Gentil, 1211 Geneva, Switzerland. E-mail address: didier.pittet@hcuge.ch (D. Pittet). Funding/support: D.P. is supported by the Swiss National Science Foundation (32003B_163262) for hand hygiene research activities and by the Fundação para a Ciência e a Tecnologia (SFRH/SINT/95317/2013). Conflicts of interest: None to report.

Ethanol-based handrubs: Safe for patients and health care workers

a Infection Control Programme and World Health Organization (WHO) Collaborating Centre on Patient Safety, Infection Control & Improving Practices, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland b Department of Infectious Diseases, Centro Hospitalar Lisboa Norte and Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal c Social Medicine Department, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil

‘It’s in your hands – prevent sepsis in health care’: 5 th May 2018, World Health Organization (WHO) SAVE LIVES: Clean Your Hands campaign

This announcement has also been submitted for publication in American Journal of Infection Control, Antimicrobial Resistance and Infection Control, Clinical Microbiology and Infection, Critical Care Medicine, Infection Control and Hospital Epidemiology, Infection Disease & Health, Journal of Hospital Infection, International Journal of Infection Control, and American Journal of Obstetrics and Gynecology on the occasion of 5th May 2018 World Hand Hygiene Day in order to improve awareness of the role of hand hygiene on preventing sepsis. Klimik Dergisi 2018; 31(1): 2-3.

Assessing the Likelihood of Hand-to-Hand Cross-Transmission of Bacteria: An Experimental Study

BACKGROUND Although the hands of healthcare workers (HCWs) are implicated in most episodes of healthcare-associated infections, the correlation between hand contamination and the likelihood of cross-transmission remains unknown. METHODS We conducted a laboratory-based study involving pairs of HCWs. The hands of a HCW (transmitter) were contaminated with Escherichia coli ATCC 10536 before holding hands with another HCW (host) for 1 minute. Meanwhile, the unheld hand of the transmitter was sampled. Afterward, the hosts held hand was also sampled. Each experiment consisted of 4 trials with increasing concentrations of E. coli (103-106 colony-forming units [cfu]/mL). The primary outcome was the likelihood of transmission of at least 1 cfu from transmitter to host. We used a mixed logistic regression model with a random effect on the subject to assess the association between transmission and bacterial count on the transmitters hands. RESULTS In total, 6 HCWs performed 30 experiments and 120 trials. The bacterial counts recovered from host hands were directly associated with the bacterial counts on transmitter hands (P1 and ≤3 log10 cfu compared to ≤1 log10. When transmitter contamination was <1 log10 cfu, no cross-transmission was detected. CONCLUSION There is a direct relationship between the bacterial burden on HCWs hands and the likelihood of cross-transmission. Under the described conditions, at least 1 log10 cfu must be present on HCW hands to be potentially transmitted. Further studies are needed at the low contamination range. Infect Control Hosp Epidemiol 2017;38:553-558.

Why language matters: a tour through hand hygiene literature

BackgroundHand hygiene has evolved over the last decades and many terminologies emerged. We aimed to analyse the evolution in the frequency of utilization of key hand hygiene terms in the literature along the years.MethodsWe identified keywords and Medical Subject Headings (MeSH) used in MEDLINE® indexation related to hand hygiene by searching international guidelines and the MeSH database. We performed a MEDLINE® search combining the selected keywords and MeSH and analysed the number of publications retrieved yearly.ResultsThe literature search yielded 9019 publications when all hand hygiene related search terms were combined, between 1921 and November 2016. The total number of publications per year increased from a median of 4 (IQR 3, 6) in the 1950’s to 554 (IQR 478, 583) between 2011 and 2015. The most frequently used keywords are hand disinfection, hand hygiene, hand washing, handrub, hand sanitizer and alcohol-based hand rub (ABHR). Until the 1990s, hand disinfection and hand washing were the most frequently used terms. Whilst the last decade has seen a remarkable increase in publications mentioning hand disinfection and hand hygiene and for the first time handrub, hand sanitizers and ABHR were introduced in the literature. Hand disinfection, hand hygiene and hand sanitizers are the main MeSH used by MEDLINE®. Since 2013 hand hygiene is the most frequently used MeSH and keyword.ConclusionsThe change seen in literature in the last two decades, from hand washing and hand disinfection to hand hygiene, most probably reflect the paradigm shift favouring use of ABHR over soap and water promoted by international guidelines in the early 2000s.

“It’s in Your Hands—Prevent Sepsis in Health Care”: 5 May 2018, World Health Organization (WHO) SAVE LIVES: Clean Your Hands Campaign

To the Editor—Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It is estimated to affect more than 30 million people worldwide every year with high mortality and morbidity. Sepsis was reported as a key global health issue at the 70th World Health Assembly (WHA) in 2017, where a resolution on sepsis was adopted by member states. Sepsis can result from care practices and complicates healthcare-associated infections. Hand hygiene, a core of infection prevention and control (IPC), plays a critical role in preventing such avoidable events. Each year, the World Health Organization (WHO) “SAVE LIVES: Clean Your Hands” campaign aims to bring people together in support of hand hygiene improvement globally on or around May 5. In 2018, the campaign focuses on supporting the prevention of sepsis in health care. The WHO urges ministries of health, health facility leaders, IPC leaders, health workers, and patient advocacy groups to take action on hand hygiene to prevent sepsis in health care (Figure 1 and Supplemental Table 1). The WHO also invites health facilities to join the global campaign to demonstrate ongoing commitment to hand hygiene and IPC (http://www.who.int/infection-prevention/campaigns/ clean-hands/register/en/). Each hand hygiene action contributes to preventing sepsis in health care: Let’s act together, “It’s in Your Hands—Prevent Sepsis in Health Care.”

Promoting and sustaining a historical and global effort to prevent sepsis: the 2018 World Health Organization SAVE LIVES: Clean Your Hands campaign

Sepsis is estimated to affect more than 30 million patients with potentially five million deaths every year worldwide. Prevention of sepsis, as well as early recognition, diagnosis and treatment, can’t be overlooked to mitigate this global public health threat. World Health Organization (WHO) promotes hand hygiene in health care through its annual global campaign, SAVE LIVES: Clean Your Hands campaign on 5 May every year. The 2018 campaign targets sepsis with the overall theme “It’s in your hands; prevent sepsis in health care”.