Hand hygiene.pdf

9.1.3 WATER QUALITY
The physical, chemical and bacteriological characteristics of water used in health-care
institutions must meet local regulations 162 . The institution is responsible for the quality
of water once it enters the building. In Europe, requirements for water quality in public
buildings are regulated by the European Council Directive 98/83/EC of 3 November 1998
“Water for human consumption”. In France, national guidelines for health-care settings have
recently proposed microbiological standards for water quality (Table I.9.2).
If the water is non-drinkable or suspected of being contaminated, steps can be taken to
treat it for medical use through physical or chemical treatments 162 . These include a filtration
process to remove particles including protozoa and a disinfection stage to reduce the
number of pathogens. Disinfectants include chlorine, monochloramine, chlorine dioxide,
ozone and ultraviolet irradiation 162 . Chlorine is the most practical disinfectant to use. Ozone
has high installation costs, and monochloramine acts more slowly against bacteria, protozoa
and viruses than does chlorine. It is usual to apply a residual disinfectant following
primary treatment: first, to prevent or limit regrowth of microorganisms in the distribution
system; and second, to inactivate any microorganisms that may enter the system through
contamination. Materials that come into contact with drinking-water are known to stimulate
microbial growth. Microorganisms may enter the distribution system through cross-connections,
breaks in the pipes or faulty backflow prevention devices. However, conventional
disinfectant residuals are ineffective against massive contamination 175 . Ultraviolet radiation
is one potential alternative to chlorine for disinfecting small water systems. It is suitable for
the disinfection of water which is free of suspended matter, turbidity and colour. However,
the disadvantage of this method is that it does not leave a residue 176 .
Many developing countries do not have drinkable water at the health-care facility for
handwashing. Even if water used for handwashing should ideally be drinkable, it is important
to highlight that there is no evidence to date that washing hands with non-potable water
leads to higher hand contamination. A study was conducted in a rural area of Bangladesh
where, for reasons of limited resources, supplying safer water and improving sanitation were
not possible 177 . In this community setting, education and promotion of handwashing with
plain soap and water significantly reduced the spread of diarrhoeal diseases across all age
groups 177 . In Pakistan, hand hygiene promotion in the community setting also reduced the
infectious disease burden 4 .
Nevertheless, if soap applied on the hands has to be rinsed by flushing with water which
may be contaminated, antibacterial soap alone may not be adequate. Steps may be taken
to reduce the risk of infection caused by washing hands with non-drinkable water. These
include use of antiseptic handrubs, treating the water by filtration or disinfection, and
restricting the use of tap water in high-risk populations 178 . In areas of the world where water
supply is intermittent, water contamination is a greater problem than in areas where supply
is sufficient through piped distribution systems. In these situations, water is usually stored in
containers at the health-care facility. Improperly stored and dispensed water may become
contaminated by a number of human pathogens, including enteric bacteria, staphylococci,
yeasts and parasites, in addition to free-living aquatic organisms. Practical methods to
ensure microbiological safety of water supplied in containers include point-of-use filtration
and disinfection 179 .
In addition, water storage containers should be emptied and cleaned frequently and
inverted to dry. The frequency of cleaning will depend on the size of the container, but
no specific recommendations are available to date. Direct or indirect hand contact with
the stored water should be avoided at all times, and containers should always be covered.