The effectiveness of hand hygiene procedures in reducing the risks ...

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S52 Vol. 35 No. 10 Supplement 1 Bloomfield et alTable 18. Effectiveness of alcohol-based hand sanitizers on infectious illnesses in the community settingInterventionControlSetting,countryOutcomemeasuredResult, % reduction(95% CI)StatisticalsignificanceReferenceHEPHP: HW 1 use ofNo HEP or HP Child care,United StatesABHS assupplementHEP No HEP or HP Child care,HP: HW 1 use ofUnited StatesABHS whereno alternativeHEP No HEP or HP Child care,HP: ‘‘intensified’’Finlandhandwashing,use of alcoholbasedoilydisinfectant plusother measuresNo HEPHP: maintainnormalMaintain normalhandwashingElementaryschool,United Stateshandwashing,use of ABHS atspecified timesadditionally also, eg,after sneezingHEP No HEP or HP ElementaryHP: normalschool,HW 1 useUnited Statesof ABHS inclassroomsHEP No HEP or HP University,HP: HW 1 regularUnited Statesuse of ABHS assupplementHEP HEP Elementary school,HP: HW 1 regularUnited Statesuse of ABHS assupplementHEP No intervention Home,HP: ABHS suppliedUnited StatesEnteric disease 29 (0.07-0.45) Enteric: Yes Butz et al 209Runny nose 25 (20.16-0.05) Runny nose: NoDiarrhea 16 (20.06-0.33) No Kotch et al 210Respiratory 26 (20.21-0.06)Enteric disease Age #3: 20(0.09-0.30)Enteric #3: Yes Uhari andMottonen 211Age .3: 0Enteric .3: No(20.22-0.18)Cold Age #3: 13Cold #3: Yes(0.07-0.18)Age .3: 4Cold .3: No(20.04-0.11)Any infectious Age #3: 9Any #3: Yesillness(0.05-0.13)Age .3: 8Any .3: Yes(0.02-0.13)Illness-related 20 (0.17-0.22) Yes Hammond et al 186absenteeismIllness-relatedabsenteeismRespiratory illnessrates andabsenteeismIllness-relatedabsenteeism50 (0.38-0.59) Yes Guinan et al 21226 (0.17-0.35) Yes White et al 21344 (0.16-0.62) Yes Morton andSchultz 214Gastrointestinal 59 (0.10-0.81) Gastrointestinal:Yesfor use in the home Respiratory 3 (20.3-0.28) Respiratory: NoSandora et al 215Ages are in years.HEP, hygiene education program, eg, chain of infection explained; HP, hygiene promotion, eg, promotion of handwashing and/or use of ABHS plus other measures; CI, confidenceinterval.residence halls. 213 However, this study suffered fromseveral methodologic shortcomings, including lack ofcontrol for clustered units, no randomization, no masking,and no monitoring of product use.All but one of the intervention studies included a hygieneeducation component, but, in 7 of these studies,this was only provided in the intervention arm. The levelof education varied widely, ranging from basic informationon when to use the ABHS (ie, after sneezingand coughing, after use in the restroom, before lunch)to in-depth education programs 214 and biweeklyinstructional material designed to educate families onhand hygiene and infection transmission. 215 In all studies,ABHS was promoted as a supplement to handwashing,or as an alternative to handwashing when soap wasunavailable, and it is likely that the hygiene educationwould have had the effect of encouraging more frequenthandwashing as well as use of ABHS. Although almostall studies indicated that hygiene education combinedwith promotion of ABHS can reduce the risks of GI orRT illness, only 2 studies allowed any assessment ofthe independent effect of the ABHS. Of these 2 studies,
Bloomfield et al December 2007 S53the study by Hammond et al 186 did not provide any educationalcomponent to either arm, and the study byMorton and Schultz 214 provided education to both interventionand control arms. Both studies showed a significantreduction in illness-related absences (20% and44%, respectively), but it is not clear whether the illnesseswere predominantly GI or RT because these studiesused a loose definition of absence-related illnesses.Sandora et al 215 was the only study carried out in thehousehold setting and, of all the studies, reported thehighest reduction for GI illness. The trial involved 292families with children enrolled in 26 child care centers.Intervention families received a supply of ABHS andbiweekly hand hygiene educational materials for 5months; control families received only materials promotinggood nutrition. A total of 252 GI illnesses occurredduring the study; 11% were secondaryillnesses. The secondary GI illness rate was significantlylower (59%) in intervention families comparedwith control families (see Table 18). A total of 1802RT illnesses occurred during the study; 25% were secondaryillnesses. Although RT illness rates were not significantlydifferent between groups, families withhigher ABHS usage had marginally lower RT illnessrate than those with less usage (19% reduction). Sandoraet al 215 suggested that the difference may be dueto heightened diligence associated with using ABHS aftera GI-related incident compared with an RT incident,such as sneezing.Overall, based on relatively limited data available,the results in Table 18 suggest that the impact ofABHS promotion, as part of a hygiene education andpromotion program in reducing the incidence of GI infectionsin young children, is similar to that observedfor promotion of handwashing with soap. Promotionof ABHS in this manner also produced some reductionin the incidence of RT infections, which was less thanthat associated with promotion of handwashing alone.Assessing whether there might be an added health benefitof using ABHS above and beyond the effect of hygieneeducation is hampered by the fact that moststudies used hygiene education and ABHS in the interventionarm but did not provide an educational componentto the control arm.Several important methodologic issues were evident,although more recent studies have improved designsand conduct. In most studies, either parents or schoolpersonnel provided information on ID among childrenin the study populations. In all but one study, 34 the parents,participants, or personnel monitoring and reportinginfections were not masked as to their own ortheir child’s intervention status. Although masking ofparticipants and interviewers to the intervention statusis important, because it might influence reporting, it isoften difficult to conduct masked hygiene interventionsand may not be ethical. Sandora et al determined that itwas neither feasible nor ethical to mask subjects or interviewersbecause it is difficult to devise a formulationthat could act as a ‘‘placebo’’ for ABHS, and using a placeboABHS product might endanger the control groupvia inadequate hand hygiene. 215In many of the ABHS studies, especially the recentones, efforts were made to control for potential confoundingfactors. However, many of the studies didnot collect information on baseline hand hygiene practices(nor methods and frequency of cleaning/disinfectingsoiled/contaminated environmental surfaces inhomes) as well as ABHS use. The studies also excludedparticipants who reported current ABHS use in thehome. Furthermore, participants were asked to refrainfrom using ABHS in settings outside the home. Theseare all important design strategies minimizing bias associatedwith noncompliance or differential usage. Twoof the 8 intervention studies failed to use systematicmonitoring for hygiene practices, such as frequencyof hand-sanitizing episodes, frequency of handwashing,or duration of handwashing. 212,213 This is especiallyconcerning because the study by Sandora et alsuggests that the quantity of ABHS influences the riskof infection in a dose-response manner. 215 Moreover,if frequency of handwashing and ABHS use is not recorded,it is impossible to isolate the independent effectsof ABHS from that of handwashing on infectionrates. In these studies of ABHS use, surveillance measuresincluded calculating use from monthly demand,total amount supplied, observation by research assistants,participant report, and reported use by primarycaregivers in households. 186,209,212,214,215THE HEALTH IMPACT OF HAND HYGIENEOverall, the microbiologic data, together with the interventionstudy data (both those involving ABHS aswell as those involving handwashing) as presented inthis review, provide consistent evidence of a strongcausal link between hygiene and the spread of infectionin the home and community, and suggest thatprobably the single most important route for thespread of infection is the hands. If the data from interventionstudies (summarized in Table 19) are an accuratereflection of the true picture, it is suggested that,for up to 60% of GI illnesses, the hands are the ‘‘sufficient,’’or a ‘‘component’’ (see earlier for definitions),cause of spread of infection. This correlates with microbiologicand other data reviewed in this report,which suggest that, although there is a tendency to assumethat GI infections are mostly foodborne and resultfrom inadequate cooking and inadequate storageof food, in reality, most GI infections in the home resultfrom person-to-person spread or contamination of
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