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particularly when resources are limited, cannot be recommended at present. Whether the use of basic, oil-containing products, not specifically manufactured for hand skin protection, would have similar efficacy as currently available manufactured agents remains to be determined. Frequent wearing of gloves can increase the risk of skin problems. In a study among healthy volunteers, when a moisturizer was applied prior to wearing occlusive gloves there was a statistically significant improvement in skin hydration 473 . More recently, an examination glove coated with aloe vera resulted in improved skin integrity and decreased erythema in 30 women with occupational dry skin 474 . Nevertheless, such products cannot yet be recommended because field trials, larger sample sizes and cost analyses are needed. In addition to evaluating the efficacy and acceptability of hand-care products, product selection committees should inquire about potential deleterious effects that oil-containing products may have on the integrity of rubber gloves and on the efficacy of antiseptic agents used in the facility 13,417 , as well as the fact that, as previously mentioned, most of these products are not sterile and can easily become contaminated. 13. FACTORS TO CONSIDER WHEN SELECTING HAND HYGIENE PRODUCTS To achieve a high rate of hand hygiene adherence, HCWs need education, clear guidelines, and some understanding of infectious disease risk, and acceptable hand hygiene products 134,262,454,455,459,475-477 . The selection of hand cleansing agents is a key component of hand hygiene promotion, and at the same time a difficult task. The selection strategy requires the presence of a multidisciplinary team (e.g. infection control professionals, administrative staff, pharmacists and behavioural scientists) and efforts to evaluate factors related to hand cleansing agents and to conduct clinical pilot projects to test these factors 1,7,16,277,456,478 The major determinants for product selection are antimicrobial profile and user acceptance. The antimicrobial efficacy of hand hygiene agents is provided by in vitro and in vivo studies (see Part I, Section 8) which are reproducible and can be generalized. Pilot studies aiming to help select products at the local level should mainly concentrate on user acceptability issues. Other aspects such as tolerance, availability, storage and costs should also be addressed on a local basis to guarantee feasibility and sustainability. 13.1 PILOT TESTING Pilot testing to assess acceptability is strongly recommended before final selection. Characteristics that can affect HCWs’ acceptance of a hand hygiene product include dermal tolerance and skin reactions to the product, and its fragrance, consistency and colour 155,445,456 . Structured self-administered questionnaires may be useful tools to assess HCWs’ acceptability of hand hygiene products. Such tools should be adapted to the local setting because of differences in sociocultural backgrounds, climate and environmental conditions, and clinical practices among users. For an efficient comparison, each product should be tested by different users for at least two to three weeks. Skin reactions to hand hygiene products may be increased by low relative humidity. Therefore, dry weather, e.g. during winter months in the northern hemisphere, should be taken into account during pilot testing; the introduction of new products during dry periods, with low relative humidity, should be avoided. Dryness and irritation should be assessed with sufficient numbers of HCWs to ensure that the results
can be generalized. Test products should be compared with products already in use. If more than one new product is to be tested, a period with the routine product should be observed between test periods. When considering the replacement of a product, the new product should be at least as good as the previous one. An inferior product could be responsible for a decrease in hand hygiene compliance. After careful evaluation of suitable hand hygiene agents, HCWs should be given the option to choose themselves the product for use at their institution. Freedom of choice at an institutional level was rated the second most important feature reported by HCWs to improve hand hygiene compliance in the audit of a successful promotion programme in Victoria, Australia. Prior to product pilot testing, the appropriate administrative decision-makers in the institution should determine which products have demonstrated efficacy and which ones can be purchased at the best cost. Only products that have already been identified as efficacious and affordable should be tested by HCWs. 13.2 SELECTION FACTORS Factors to be taken into consideration during user acceptability testing include: • dermal tolerance and skin reactions; • aesthetic preferences of HCWs and patients such as fragrance, colour, texture and ease of use; • practical considerations such as availability, convenience and functioning of dispenser, and ability to prevent contamination; • cost issues; • global policy for the use of soap and alcohol-based handrubs; • relative efficacy of antiseptic agents (Part I, Section 9.13) and consideration for selection of products for hygienic hand antisepsis and surgical hand preparation; • freedom of choice by HCWs at an institutional level after consideration of the above-mentioned factors. 13.2.1 DERMAL TOLERANCE AND SKIN REACTIONS Several studies have published methods to evaluate dermal tolerance such as dryness or irritation 155,430 , either by self-assessment or by expert clinical evaluation 134,156,190,253,254,256,321,454,456,459,478,479 . Some studies have confirmed that these assessment techniques correlate well with other physiological measures such as transepidermal water loss or desquamation, tests which are not practical to use in clinical settings 190,253,321,430,459,478,479 . An example of a self-assessment tool for use in the clinical setting is included in Appendix 2 155,426 . 13.2.2 AESTHETIC PREFERENCES Products with a strong fragrance may occasionally lead to discomfort and respiratory symptoms in some HCWs allergic to perfume or fragrances. Many patients complain about perfumed products, especially in oncology. Therefore, consideration should be given to selecting a product with mild or no added fragrances.
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The WHO Guidelines on Hand Hygiene
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CONTENTS INTRODUCTION . ...........
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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 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
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
Page 88 and 89: 1998 (P
Page 90 and 91: HCWs routinely to wear vinyl gloves
Page 92 and 93: quality gloves, reuse, shortage of
Page 94 and 95: • To test for holes, gloves shoul
Page 96 and 97: Figure l.20.2: Blood safety: crucia
Page 98 and 99: Consensus recommendations are that
Page 100 and 101: D. Wash hands with either plain or
Page 102 and 103: 5. SKIN CARE A. B. C. Include infor
Page 107 and 108: PART III. OUTCOME MEASUREMENTS 1. M
Page 109 and 110: 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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