WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE
Shantiparvan, it is explicitly stated that it is not sinful to drink
alcohol for medicinal purposes.
In Buddhism, obstacles to the use of alcohol in health care are
certainly present, but from a completely different perspective.
According to the law of kamma, the act or the intention to kill
living creatures is considered a sinful act. As microorganisms
are living beings, killing them with an alcohol-based handrub
may lead to demerit. According to Expositor (1:128), the five
conditions for the act of killing are: a living being; knowledge
that it is a being; intention of killing; effort; and consequent
death. Nevertheless, considering that HCWs for the most part
have good intentions in their work, namely, to protect patients
from pathogen transmission, the result of this sinful action does
not bear heavy consequences. Therefore, when comparing
a human patient’s life with a bacterium’s life, most people
adhering to the Buddhist kamma agree that a patient’s life is
more valuable. Furthermore, according to Phra Depvethee, a
Thai Buddhist monk and scholar, the consequences of killing
depends on the size and good contribution of that being. 776
The Islamic tradition poses the toughest challenge to alcohol
use. Fortunately, this is also the only context where reflection
on alcohol use in health care has begun. Alcohol is clearly
designated as haram (forbidden) in Islam because it is a
substance leading to sukur, or intoxication leading to an altered
state of mind. For Muslims, any substance or process leading to
a disconnection from a state of awareness or consciousness (to
a state in which she or he may forget her or his Creator) is called
sukur, and this is haram. For this reason, an enormous taboo
has become associated with alcohol for all Muslims. Some
Muslim HCWs may feel ambivalent about using alcohol-based
handrub formulations. However, any substance that man can
manufacture or develop in order to alleviate illness or contribute
to better health is permitted by the Qur’an and this includes
alcohol used as a medical agent. Similarly, cocaine is permitted
as a local anaesthetic (halal, allowed) but is inadmissible as a
recreational drug (haram, forbidden).
To understand Muslim HCWs’ attitudes to alcohol-based
hand cleansers in an Islamic country, the experience
reported by Ahmed and colleagues at the King Abdul Aziz
Medical City (KAAMC) in Riyadh, Kingdom of Saudi Arabia,
is very instructive. 770 At the KAAMC, the policy of using
alcohol handrub is not only permitted, but has been actively
encouraged in the interest of infection control since 2003. No
difficulties or reluctance were encountered in the adoption of
alcohol-containing hand hygiene substances. Though Saudi
Arabia is considered to be the historic epicentre of Islam, no
state policy or permission or fatwa (Islamic religious edict)
were sought for approval of the use of alcohol-containing
handrubs, given that alcohol has long been a component
present in household cleaning agents and other materials for
public use, including perfume, without legislated restriction
within the Kingdom. In all these instances, the alcohol content
is permitted because it is not for ingestion. In 2005, the Saudi
Ministry of Health pledged its commitment to the <strong>WHO</strong> Global
Patient Safety Challenge, and most hospitals across the country
have joined in a national campaign implementing the <strong>WHO</strong>
multimodal Hand Hygiene Improvement Strategy centred on the
use of alcohol-based handrub at the point of care. Given this
high level commitment, <strong>WHO</strong> selected hospitals in Saudi Arabia
in 2007 for the testing of the present <strong>Guidelines</strong>. Preliminary
results indicate a very strong adoption of the strategy, including
a preference for handrubbing instead of handwashing, which
has led to a significant increase of hand hygiene compliance
among HCWs and a reduction of HCAI rates in ICUs. 777 This
example shows that positive attitudes to the medicinal benefits
of alcohol, coupled with a compassionate interpretation of
Qur’anic teachings, have resulted in a readiness to adopt new
hand hygiene policies, even within an Islamic Kingdom which is
legislated by Sharia (Islamic law).
The risk of accidental or intentional ingestion of alcohol-based
preparations is one of the arguments presented by sceptics
concerning the introduction of these products because of
cultural or religious reasons. Even if this is a potential problem,
it is important to highlight that only a few cases have been
reported in the literature. 599,778-781 In specific situations, however,
this unusual complication of hand hygiene should be considered
and security measures planned to be implemented (see Part I,
Section 23.6.2). Another concern regarding the use of handrub
formulations by HCWs is the potential systemic diffusion of
alcohol or its metabolites following skin absorption or airborne
inhalation. Only a few anecdotal and unproven cases of alcohol
skin absorption leading to clinical symptoms are reported in the
literature. 779,780 In contrast, reliable studies on human volunteers
clearly demonstrate that the quantity of alcohol absorbed
following application is minimal and well below toxic levels for
humans. 599,782-784 In a study mimicking use in large quantities and
at a high frequency, 783 the cutaneous absorption of two alcoholbased
handrubs with different alcohol components (ethanol
and isopropanol) was carefully monitored. Whereas insignificant
levels of ethanol were measured in the breath and serum of
a minority of participants, isopropanol was not detected (see
Part I, Section 23.6.2). Finally, alcohol smell on skin may be an
additional barrier to handrubbing, and further research should
be conducted to eliminate this smell from handrub preparations.
17.5 Possible solutions
In addition to targeting areas for further research, possible
solutions may be identified (Table I.17.2). For example, from
childhood, the inherent nature of hand hygiene which is
strongly influenced by religious habits and norms in some
populations could be shaped in favour of an optimal elective
behaviour towards hand hygiene. Indeed, some studies have
demonstrated that it is possible to successfully educate
children of school age to practise optimal hand hygiene for
the prevention of common paediatric community-acquired
infections. 449,454,785
When preparing guidelines, international and local religious
authorities should be consulted and their advice clearly
reported. An example is the statement issued by the Muslim
Scholars’ Board of the Muslim World League during the
Islamic Fiqh Council’s 16th meeting held in Mecca, Saudi
Arabia, in January 2002: “It is allowed to use medicines that
contain alcohol in any percentage that may be necessary for
manufacturing if it cannot be substituted. Alcohol may be used
as an external wound cleanser, to kill germs and in external
creams and ointments. 786
In hand hygiene promotion campaigns in health-care settings
where religious affiliations prohibiting the use of alcohol are
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