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and both reduced viral counts on hands to about the same extent as antimicrobial soap containing 4% chlorhexidine gluconate 234 . The same study found that both 70% ethanol and the 62% ethanol foam product demonstrated greater virucidal activity against poliovirus than either non-antimicrobial soap or a 4% chlorhexidine gluconate-containing soap 234 . However, depending on the alcohol concentration, time and viral variant, alcohol may not be effective against hepatitis A and other non-lipophilic viruses. Schurmann concluded that the inactivation of naked (non-enveloped) viruses is influenced by temperature, the ratio of disinfectant to virus volume, and protein load 235 . Various 70% alcohol solutions (ethanol, propan-1-ol, propan-2-ol) were tested against a surrogate of norovirus and ethanol with 30- minute exposure and demonstrated virucidal activity superior to the others 236 . In a recent experimental study, ethyl alcohol-based products showed significant reductions of the tested surrogate for a non-enveloped human virus; however, activity was not superior to non-antimicrobial or tap water controls 237 . In general, ethanol has greater activity against viruses than isopropanol. Further in vitro and in vivo studies of both alcohol-based formulations and antimicrobial soaps are warranted to establish the minimal level of virucidal activity that is required to interrupt direct contact transmission of viruses in health-care settings. Alcohols are not good cleansing agents, and their use is not recommended when hands are dirty or visibly contaminated with proteinaceous materials. However, when relatively small amounts of proteinaceous material (e.g. blood) are present, ethanol and isopropanol may reduce viable bacterial counts on hands 238 , but do not obviate the need for handwashing with water and soap whenever such contamination occurs 117 . A few studies have examined the ability of alcohols to prevent the transfer of health care-associated pathogens by using experimental models of pathogen transmission 30,44,109 . Ehrenkranz and colleagues 44 found that Gram-negative bacilli were transferred from a colonized patient’s skin to a piece of catheter material via the hands of nurses in only 17% of experiments following antiseptic handrub with an alcohol-based hand rinse. In contrast, transfer of the organisms occurred in 92% of experiments following handwashing with plain soap and water. This experimental model suggests that when the hands of HCWs are heavily contaminated, alcohol-based handrubbing can prevent pathogen transmission more effectively than handwashing with plain soap and water. Table I.9.4 summarizes a number of studies that have compared alcohol-based products with plain or antimicrobial soaps to determine which was more effective for standard handwashing or hand antisepsis by HCWs (for details see Part I, Section 9.13) 44,71,82,156,158,199-205,212,239-247 . The efficacy of alcohol-based hand hygiene products is affected by a number of factors, including the type of alcohol used, the concentration of alcohol, the contact time, the volume of alcohol used, and whether the hands are wet when the alcohol is applied. Small volumes (0.2–0.5 ml) of alcohol applied to the hands are not more effective than washing hands with plain soap and water 30,109 . Larson and colleagues 93 documented that 1 ml of alcohol was significantly less effective than 3 ml. The ideal volume of product to apply to the hands is not known, and may vary for different formulations. In general, however, if hands feel dry after being rubbed together for less than 10–15 seconds, it is likely that an insufficient volume of product was applied. Alcohol-impregnated towelettes contain only a small amount of alcohol and are not much more effective than washing with soap and water 30,248,249 . Alcohol-based handrubs intended for use in hospitals are available as solutions (with low viscosity), gels and foams. Few data are available regarding the relative efficacy of various formulations. One small field trial found that an ethanol gel was somewhat less effective than a comparable ethanol solution at reducing bacterial counts on the hands of HCWs 250.
Recent studies found similar results demonstrating that solutions reduced bacterial counts on the hands to a significantly greater extent than the tested gels 140,251 . Most gels showed results closer to a 1-minute simple handwash than to a 1-minute reference antisepsis 252 . New generations of gel formulations with higher antibacterial efficacy than previous editions have since been proposed 252 . Further studies are warranted to determine the relative efficacy of alcohol-based solutions and gels in reducing transmission of health care-associated pathogens. Furthermore, it is worth considering that compliance is probably of higher importance, thus if a gel with lower in vitro activity is more frequently used, the overall outcome is still expected to be better. Frequent use of alcohol-based formulations for hand antisepsis tends to cause drying of the skin unless humectants or other skin conditioning agents are added to the formulations. For example, the drying effect of alcohol can be reduced or eliminated by adding 1–3% glycerol or other skin conditioning agents 154,156,193,194,199,227,239,253,254 . Moreover, in prospective trials, alcohol-based solutions or gels containing humectants caused significantly less skin irritation and dryness than the soaps or antimicrobial detergents tested 188,190,255,256 . These studies, which were conducted in clinical settings, used a variety of subjective and objective methods for assessing skin irritation and dryness. Further studies of this type are warranted to establish if products with different formulations yield similar results. Even well-tolerated alcohol-based handrubs containing humectants may cause a transient stinging sensation at the site of any broken skin (cuts, abrasions). Alcohol-based handrub preparations with strong fragrances may be poorly tolerated by a few HCWs with respiratory allergies. Allergic contact dermatitis or contact urticaria syndrome caused by hypersensitivity to alcohol, or to various additives present in some alcohol-based handrubs, occurs rarely (see also Part I, Section 11) 257-259 . A recent systematic review of publications between 1992 and 2002 with an adequate methodological quality on the effectiveness of alcohol-based solutions for hand hygiene showed that alcohol-based handrubs remove organisms more effectively, require less time and irritate skin less often than handwashing with soap or other antiseptic agents and water 260 . The availability of bedside alcohol-based solutions increased compliance with hand hygiene among HCWs 260-263 . Alcohols are flammable, and HCWs handling alcohol-based preparations should respect safety standards (see Part I, Section 9.14). Because alcohols are volatile, containers should be designed so that evaporation is minimized and initial concentration is preserved. Contamination of alcohol-based solutions has seldom been reported. One report documented a pseudo-epidemic of infections resulting from contamination of ethyl alcohol by Bacillus cereus spores 264 and in-use contamination by Bacillus spp. has been reported 265 . 9.4 CHLORHEXIDINE Chlorhexidine gluconate, a cationic bisbiguanide, was developed in the United Kingdom in the early 1950s and introduced into the USA in the 1970s 13,266 . Chlorhexidine base is barely soluble in water, but the digluconate form is water-soluble. The antimicrobial activity of chlorhexidine appears to be attributable to the attachment to, and subsequent disruption of cytoplasmic membranes, resulting in precipitation of cellular contents 1,13. Chlorhexidine’s immediate antimicrobial activity is slower than that of alcohols. It has good activity against Gram-positive bacteria, somewhat less activity against Gram-negative bacteria and fungi, and minimal activity against mycobacteria 1,13,266 . Chlorhexidine is not sporicidal 1,266 . It has in vitro activity against enveloped viruses such as herpes simplex virus, HIV, cytomegalovirus, influenza and RSV, but significantly less activity against non-enveloped viruses such as rotavirus, adenovirus and enteroviruses 223,224,267 . The antimicrobial
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 14 and 15: Handwashing. Washing hands with pla
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 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
Page 60 and 61: particularly when resources are lim
Page 62 and 63: Handrubs are available as gels, sol
Page 64 and 65: 14. HAND HYGIENE PRACTICES AMONG HE
Page 66 and 67: quantified in observational studies
Page 68 and 69: According to behavioural theories (
Page 70 and 71: of water with special leaves) outsi
Page 72 and 73: Furthermore, according to Phra Depv
Page 74 and 75: 16. BEHAVIOURAL CONSIDERATIONS 16.1
Page 76 and 77: and community factors must be consi
Page 78 and 79: i. ii. iii. iv. v. vi. a) b) Educat
Page 80 and 81: tion precautions 580 . There are al
Page 82 and 83: follow the intent 588 . Studies hav
Page 84 and 85: 18. FORMULATING STRATEGIES FOR HAND
Page 86 and 87:
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
Page 211 and 212:
AUTHORS: John Boyce Saint Raphael H
Page 213 and 214:
Garance Upham People’s Health Mov
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