WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...
WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...
WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...
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<str<strong>on</strong>g>WHO</str<strong>on</strong>g> GUIDELINES ON HAND HYGIENE IN HEALTH CARE<br />
8.<br />
Models of hand transmissi<strong>on</strong><br />
8.1 Experimental models<br />
Several <strong>in</strong>vestigators have studied the transmissi<strong>on</strong> of <strong>in</strong>fectious<br />
agents us<strong>in</strong>g different experimental models. Ehrenkranz and<br />
colleagues 88 asked nurses to touch a patient’s gro<strong>in</strong> for 15<br />
sec<strong>on</strong>ds as though they were tak<strong>in</strong>g a femoral pulse. The<br />
patient was known to be heavily col<strong>on</strong>ized with Gram-negative<br />
bacilli. Nurses then cleansed their hands by wash<strong>in</strong>g with<br />
pla<strong>in</strong> soap and water or by us<strong>in</strong>g an alcohol-based handrub.<br />
After cleans<strong>in</strong>g their hands, they touched a piece of ur<strong>in</strong>ary<br />
catheter material with their f<strong>in</strong>gers and the catheter segment<br />
was cultured. The study revealed that touch<strong>in</strong>g <strong>in</strong>tact areas<br />
of moist sk<strong>in</strong> transferred enough organisms to the nurses’<br />
hands to allow subsequent transmissi<strong>on</strong> to catheter material<br />
despite handwash<strong>in</strong>g with pla<strong>in</strong> soap and water; by c<strong>on</strong>trast,<br />
alcohol-based handrubb<strong>in</strong>g was effective and prevented crosstransmissi<strong>on</strong><br />
to the device. Marples and colleagues 74 studied<br />
the transmissi<strong>on</strong> of organisms from artificially c<strong>on</strong>tam<strong>in</strong>ated<br />
“d<strong>on</strong>or” fabrics to clean “recipient” fabrics via hand c<strong>on</strong>tact and<br />
found that the number of organisms transmitted was greater<br />
if the d<strong>on</strong>or fabric or the hands were wet. Overall, <strong>on</strong>ly 0.06%<br />
of the organisms obta<strong>in</strong>ed from the c<strong>on</strong>tam<strong>in</strong>ated d<strong>on</strong>or fabric<br />
were transferred to the recipient fabric via hand c<strong>on</strong>tact. Us<strong>in</strong>g<br />
the same experimental model, Mack<strong>in</strong>tosh and colleagues 169<br />
found that S. saprophyticus, P. aerug<strong>in</strong>osa, and Serratia spp.<br />
were transferred <strong>in</strong> greater numbers than was E. coli from a<br />
c<strong>on</strong>tam<strong>in</strong>ated to a clean fabric follow<strong>in</strong>g hand c<strong>on</strong>tact. Patrick<br />
and colleagues 75 found that organisms were transferred to<br />
various types of surfaces <strong>in</strong> much larger numbers (>10 4 ) from wet<br />
hands than from hands that had been dried carefully. Sattar and<br />
colleagues 170 dem<strong>on</strong>strated that the transfer of S. aureus from<br />
fabrics comm<strong>on</strong>ly used for cloth<strong>in</strong>g and bed l<strong>in</strong>en to f<strong>in</strong>gerpads<br />
occurred more frequently when f<strong>in</strong>gerpads were moist.<br />
8.2 Mathematical models<br />
Mathematical modell<strong>in</strong>g has been used to exam<strong>in</strong>e the<br />
relati<strong>on</strong>ships between the multiple factors that <strong>in</strong>fluence<br />
pathogen transmissi<strong>on</strong> <strong>in</strong> health-care facilities. These factors<br />
<strong>in</strong>clude hand hygiene compliance, nurse staff<strong>in</strong>g levels,<br />
frequency of <strong>in</strong>troducti<strong>on</strong> of col<strong>on</strong>ized or <strong>in</strong>fected patients <strong>on</strong>to<br />
a ward, whether or not cohort<strong>in</strong>g is practised, characteristics of<br />
patients and antibiotic use practices, to name but a few. 171 Most<br />
reports describ<strong>in</strong>g the mathematical modell<strong>in</strong>g of health careassociated<br />
pathogens have attempted to quantify the <strong>in</strong>fluence<br />
of various factors <strong>on</strong> a s<strong>in</strong>gle ward such as an ICU. 172-175 Given<br />
that such units tend to house a relatively small number of<br />
patients at any time, random variati<strong>on</strong>s (stochastic events) such<br />
as the number of patients admitted with a particular pathogen<br />
dur<strong>in</strong>g a short time period can have a significant impact <strong>on</strong><br />
transmissi<strong>on</strong> dynamics. As a result, stochastic models appear<br />
to be the most appropriate for estimat<strong>in</strong>g the impact of various<br />
<strong>in</strong>fecti<strong>on</strong> c<strong>on</strong>trol measures, <strong>in</strong>clud<strong>in</strong>g hand hygiene compliance,<br />
<strong>on</strong> col<strong>on</strong>izati<strong>on</strong> and <strong>in</strong>fecti<strong>on</strong> rates.<br />
In a mathematical model of MRSA <strong>in</strong>fecti<strong>on</strong> <strong>in</strong> an ICU, Sebille<br />
and colleagues 172 found that the number of patients who<br />
became col<strong>on</strong>ized by stra<strong>in</strong>s transmitted from HCWs was <strong>on</strong>e<br />
of the most important determ<strong>in</strong>ants of transmissi<strong>on</strong> rates. Of<br />
<strong>in</strong>terest, they found that <strong>in</strong>creas<strong>in</strong>g hand hygiene compliance<br />
rates had <strong>on</strong>ly a modest effect <strong>on</strong> the prevalence of MRSA<br />
col<strong>on</strong>izati<strong>on</strong>. Their model estimated that if the prevalence of<br />
MRSA col<strong>on</strong>izati<strong>on</strong> was 30% without any hand hygiene, it would<br />
decrease to <strong>on</strong>ly 22% if hand hygiene compliance <strong>in</strong>creased to<br />
40% and to 20% if hand hygiene compliance <strong>in</strong>creased to 60%.<br />
Antibiotic policies had relatively little impact <strong>in</strong> this model.<br />
Aust<strong>in</strong> and colleagues 173 used daily surveillance cultures<br />
of patients, molecular typ<strong>in</strong>g of isolates, and m<strong>on</strong>itor<strong>in</strong>g<br />
of compliance with <strong>in</strong>fecti<strong>on</strong> c<strong>on</strong>trol practices to study the<br />
transmissi<strong>on</strong> dynamics of VRE <strong>in</strong> an ICU. The study found that<br />
hand hygiene and staff cohort<strong>in</strong>g were predicted to be the most<br />
effective c<strong>on</strong>trol measures. The model predicted that for a given<br />
level of hand hygiene compliance, add<strong>in</strong>g staff cohort<strong>in</strong>g would<br />
lead to the better c<strong>on</strong>trol of VRE transmissi<strong>on</strong>. The rate at which<br />
new VRE cases were admitted to the ICU played an important<br />
role <strong>in</strong> the level of transmissi<strong>on</strong> of VRE <strong>in</strong> the unit.<br />
In a study that used a stochastic model of transmissi<strong>on</strong><br />
dynamics, Cooper and colleagues 176 predicted that improv<strong>in</strong>g<br />
hand hygiene compliance from very low levels to 20% or<br />
40% significantly reduced transmissi<strong>on</strong>, but that improv<strong>in</strong>g<br />
compliance to levels above 40% would have relatively little<br />
impact <strong>on</strong> the prevalence of S. aureus. Grundmann and<br />
colleagues 175 c<strong>on</strong>ducted an <strong>in</strong>vestigati<strong>on</strong> that <strong>in</strong>cluded cultures<br />
of patients at the time of ICU admissi<strong>on</strong> and twice-weekly<br />
observati<strong>on</strong>s of the frequency of c<strong>on</strong>tact between HCWs<br />
and patients, cultures of HCWs’ hands, and molecular typ<strong>in</strong>g<br />
of MRSA isolates. A stochastic model predicted that a 12%<br />
improvement <strong>in</strong> adherence to hand hygiene policies or <strong>in</strong><br />
cohort<strong>in</strong>g levels might have compensated for staff shortages<br />
and prevented transmissi<strong>on</strong> dur<strong>in</strong>g periods of overcrowd<strong>in</strong>g and<br />
high workloads.<br />
A stochastic model by McBryde and colleagues used<br />
surveillance cultures, hand hygiene compliance observati<strong>on</strong>s,<br />
and evaluati<strong>on</strong> of the likelihood of transmissi<strong>on</strong> from a col<strong>on</strong>ized<br />
patient to a HCW, as well as other factors, to estimate the<br />
impact of various <strong>in</strong>terventi<strong>on</strong>s <strong>on</strong> MRSA transmissi<strong>on</strong> <strong>in</strong> an<br />
ICU. 177 They found also that improv<strong>in</strong>g hand hygiene was<br />
predicted to be the most effective <strong>in</strong>terventi<strong>on</strong>. Unlike several<br />
earlier studies, their model suggested that <strong>in</strong>creas<strong>in</strong>g levels of<br />
hand hygiene compliance above 40% to 60% c<strong>on</strong>t<strong>in</strong>ued to have<br />
a beneficial impact <strong>on</strong> reduc<strong>in</strong>g MRSA transmissi<strong>on</strong>. A model<br />
us<strong>in</strong>g M<strong>on</strong>te Carlo simulati<strong>on</strong>s to study the impact of various<br />
c<strong>on</strong>trol measures <strong>on</strong> MRSA transmissi<strong>on</strong> <strong>on</strong> a general medical<br />
ward also suggested that improv<strong>in</strong>g hand hygiene compliance<br />
was likely to be the most effective measure for reduc<strong>in</strong>g<br />
transmissi<strong>on</strong>. 178<br />
While the above-menti<strong>on</strong>ed studies have provided new<br />
<strong>in</strong>sights <strong>in</strong>to the relative c<strong>on</strong>tributi<strong>on</strong> of various <strong>in</strong>fecti<strong>on</strong> c<strong>on</strong>trol<br />
measures, all have been based <strong>on</strong> assumpti<strong>on</strong>s that may not be<br />
valid <strong>in</strong> all situati<strong>on</strong>s. For example, most studies assumed that<br />
transmissi<strong>on</strong> of pathogens occurred <strong>on</strong>ly via the hands of HCWs<br />
22