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Handwashing. Washing hands with plain or antimicrobial soap and water. Hand cleansing. Action of performing hand hygiene for the purpose of physically or mechanically removing dirt, organic material or microorganisms. Hand disinfection is extensively used as a term in some parts of the world and can refer to antiseptic handwash, antiseptic handrubbing, hand antisepsis/decontamination/ degerming, handwashing with an antimicrobial soap and water, hygienic hand antisepsis, or hygienic handrub. Disinfection generally refers to inanimate surfaces, but hand disinfection is frequently used in the same sense as hand antisepsis in the literature but not in these Guidelines. Hygienic hand antisepsis. Treatment of hands with either an antiseptic handrub or antiseptic handwash to reduce the transient microbial flora without necessarily affecting the resident skin flora. Hygienic handrub. Treatment of hands with an antiseptic handrub to reduce the transient flora without necessarily affecting the resident skin flora. These preparations are broad spectrum and fast-acting, and persistent activity is not necessary. Hygienic handwash. Treatment of hands with an antiseptic handwash to reduce the transient flora without necessarily affecting the resident skin flora. It is broad spectrum, but is usually less efficacious and acts more slowly than the hygienic handrub. Surgical hand antisepsis/surgical hand preparation. Antiseptic handwash or antiseptic handrub performed pre-operatively by the surgical team to eliminate transient and reduce resident skin flora. Such antiseptics often have persistent antimicrobial activity. Surgical handscrub(bing)/presurgical scrub refer to surgical hand preparation with antimicrobial soap and water. Surgical handrub(bing) refers to surgical hand preparation with a waterless, alcohol-based handrub. ASSOCIATED TERMS Cumulative effect. Increasing antimicrobial effect with repeated applications of a given antiseptic. Substantivity. An attribute of some active ingredients that adhere to the stratum corneum and provide an inhibitory effect on the growth of bacteria by remaining on the skin after rinsing or drying. Persistent activity. The prolonged or extended antimicrobial activity that prevents the growth or survival of microorganisms after application of a given antiseptic; also called “residual”, “sustained” or “remnant” activity. Both substantive and non-substantive active ingredients can show a persistent effect significantly inhibiting the growth of microorganisms after application. Humectant. Ingredient(s) added to hand hygiene products to moisturize the skin. Excipient. Inert substance combined to the product formula to serve as a vehicle for the active substance. Surrogate microorganism. A microorganism used to represent a given type or category of nosocomial pathogen when testing the antimicrobial activity of antiseptics. Surrogates are selected for their safety, ease of handling and relative resistance to antimicrobials. Visibly soiled hands. Hands on which dirt or body fluids are readily visible. Efficacy/efficaceous. The (possible) effect of the application of a hand hygiene formulation when tested in laboratory or in vivo situations.
Effectiveness/effective. The clinical conditions under which hand hygiene products have been tested, such as field trials, where the impact of a hand hygiene formulation is monitored on the rates of cross-transmission of infection or resistance. 2. HISTORICAL PERSPECTIVE ON HAND HYGIENE IN HEALTH CARE For centuries, handwashing with soap and water has been considered a measure of personal hygiene 1,2 but the link between handwashing and the spread of disease has only been established in the last 200 years. In the mid-1800s, studies by Ignaz Semmelweis in Vienna and Oliver Wendell Holmes in Boston established that hospital-acquired diseases, now known to be caused by infectious agents, were transmitted via the hands of HCWs. In the community, hand hygiene has been acknowledged as an important measure to prevent and control infectious diseases 3 and can significantly reduce the burden of disease, in particular among children in developing countries 4,5 . In the health-care setting, a prospective controlled trial conducted in a hospital nursery 6 and investigations conducted during the past 40 years have confirmed the important role that contaminated hands of HCWs play in the transmission of health care-associated pathogens. Currently, hand hygiene is considered the most important measure for preventing the spread of pathogens in health-care settings 7 . The 1980s represented a landmark in the evolution of concepts of hand hygiene in health care. The first national hand hygiene guidelines were published in the 1980s 8,9 ), followed by many others in more recent years. These guidelines were essentially issued in countries in the northern hemisphere, including the United States of America (USA), Canada and some European countries. Therefore, it can be seen that hand hygiene concepts have much evolved over the past two decades 10 . In 1961, the United States public health service produced a training film that demonstrated handwashing techniques recommended for use by HCWs 11 . At that time, it was recommended to wash hands with soap and water for 1 to 2 minutes before and after patient contact. Rinsing hands with an antiseptic agent was believed to be less effective than handwashing and was recommended only in emergencies or in areas where sinks were unavailable. Twenty years later, the United States national guidelines 9 still recommended waterless antiseptic agents (i.e. alcohol-based solutions) only in situations where sinks were not available, and handwashing with soap and water was considered the standard of care. Subsequent hand hygiene guidelines in the USA 12,13 included more detailed discussion of alcohol-based handrubs and supported their use in more clinical settings than what had previously been recommended 13 . In 1995 and 1996, the United States Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended that either antimicrobial soap or a waterless antiseptic agent be used for cleansing hands upon leaving the rooms of patients with multidrug-resistant pathogens such as vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) 14,15 . More recently, the CDC/HICPAC guidelines issued in 2002 defined alcohol-based handrubbing as the standard of care for hand hygiene practices in health-care settings 7 . In central European countries, the use of alcohol-based rubs for hand hygiene has been the method of choice for many years 16 . However, in many other countries, handwashing is
Page 2 and 3: The WHO Guidelines on Hand Hygiene
Page 5 and 6: CONTENTS INTRODUCTION . ...........
Page 7 and 8: 17. Organizing an education program
Page 11: INTRODUCTION The WHO Advanced Draft
Page 16 and 17: still considered the standard of ca
Page 18 and 19: treatment selectively removes glyce
Page 20 and 21: of the organism on their hands. Mak
Page 22 and 23: 6. MODELS OF HAND TRANSMISSION 6.1
Page 24 and 25: In the 1960s, a prospective, contro
Page 26 and 27: for its ability to reduce the relea
Page 28 and 29: 8.2 SHORTCOMINGS OF TRADITIONAL TES
Page 30 and 31: tions of short-chain aliphatic alco
Page 32 and 33: 9.1.3 WATER QUALITY The physical, c
Page 34 and 35: Case study: experience of Egypt The
Page 36 and 37: and both reduced viral counts on ha
Page 38 and 39: activity of chlorhexidine is not se
Page 40 and 41: protein synthesis and alteration of
Page 42 and 43: in micelle structures formed by sur
Page 44 and 45: In all the studies that included pl
Page 46 and 47: isopropyl alcohol) were applied to
Page 48 and 49: 3) Glycerol is added using a measur
Page 50 and 51: in 2005 the costs of an alcohol-bas
Page 52 and 53: infection, risk factors that are la
Page 54 and 55: 11.4.4 SIDE-EFFECTS OF THE SURGICAL
Page 56 and 57: • Repeat the process on the other
Page 58 and 59: 12.2 ALLERGIC CONTACT DERMATITIS RE
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Page 62 and 63: Handrubs are available as gels, sol
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14. HAND HYGIENE PRACTICES AMONG HE
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quantified in observational studies
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According to behavioural theories (
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of water with special leaves) outsi
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Furthermore, according to Phra Depv
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16. BEHAVIOURAL CONSIDERATIONS 16.1
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and community factors must be consi
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i. ii. iii. iv. v. vi. a) b) Educat
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tion precautions 580 . There are al
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follow the intent 588 . Studies hav
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18. FORMULATING STRATEGIES FOR HAND
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18.2 DEVELOPING A STRATEGY FOR GUID
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1998 (P
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HCWs routinely to wear vinyl gloves
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quality gloves, reuse, shortage of
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• To test for holes, gloves shoul
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Figure l.20.2: Blood safety: crucia
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Consensus recommendations are that
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D. Wash hands with either plain or
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5. SKIN CARE A. B. C. Include infor
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PART III. OUTCOME MEASUREMENTS 1. M
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2. HAND HYGIENE AS A QUALITY INDICA
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can be seen during routine work. Da
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Case study: United Kingdom national
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PART IV. PROMOTING HAND HYGIENE ON
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ated to reinforce its principles (t
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6. PRINCIPLES OF COUNTRYWIDE HAND H
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As many international and national
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debate that resulted in increasing
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23. Lee YL et al. Colonization by S
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Interscience Conference on Antimicr
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122. Vicca AF. Nursing staff worklo
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171. Kauppinen J et al. Hospital wa
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224. Krilov LR et al. Inactivation
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276. Thomas L et al. Development of
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326. Johnson S et al. Prospective,
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34th Interscience Conference on Ant
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423. Kampf G, et al. Influence of a
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474. West DP et al. Evaluation of a
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524. Muto C et al. Hand hygiene rat
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578. Babcock HM et al. An education
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Interscience Conference on Antimicr
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679. Hirschmann H et al. The influe
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729. Martin LS, McDougal JS, Loskos
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Table I.8.1: Basic experimental des
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Table I.9.1: Waterborne pathogens a
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Table I.9.3: Virucidal activity of
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Table I.9.4: Studies comparing the
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Table I.9.6: Studies comparing the
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Table I.14.1: Hand hygiene frequenc
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Table I.14.2: Hand hygiene adherenc
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Table I.15.1: Hand hygiene indicati
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Table I.18.1: Strategies for succes
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Table l.20.1: Possible problems and
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Table I.21.1. Hand hygiene research
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Table I.21.1: Hand hygiene research
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Table I.21.2: Unsolved issues for r
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Table III.2.1: Quality indicators r
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Table V.3.1: Examples of public inf
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Table V.4.1: Examples of national p
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Table V.5.1: The public information
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APPENDIX 1. DEFINITIONS OF HEALTH-C
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APPENDIX 2. HAND AND SKIN SELF-ASSE
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Data in coloured cells can be chang
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NHS NICU n-P NPSA NA NS OPD PACU PA
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AUTHORS: John Boyce Saint Raphael H
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Garance Upham People’s Health Mov
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