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

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S58 Vol. 35 No. 10 Supplement 1 Bloomfield et alTable 20. Increased risk situations in the homeRoutine day-to-day situationsNonroutine situationsIncreased risk from source ofinfection in the homePeople who are otherwisehealthy but at increasedrisk of infectionIncreased risk from infectedfamily membersPeople at increasedrisk of infectionHandling of raw meat, poultry,fish, fruit, and vegetablesFamily members or pets that arecolonized or infected with, forexample, Salmonella, C difficile,MRSAYoung babies, elderly adults,pregnant womenPeople in poor living conditionsFamily members infected withcolds, flu, norovirus,Salmonella, Shigella, and othersPatients home from hospital oroutpatients including peoplewith catheters, wounds, orothersPeople undergoing drugtreatment; people withunderlying illness, eg, diabetes,HIVin coming years, rather than decline. One such factor isthe rising proportion of the population in the communitywho are more vulnerable to infection. An importantpart of current European and US health policy is commitmentto shorter hospital stays. A key requirementis to ensure that the increased health provision at homeis not accompanied by an increase in ID risks; otherwise,the cost savings gained by care in the community arelikely to be overridden by costs of rehospitalization.Even for the ‘‘healthy community,’’ ID represents a significanteconomic burden because of absence fromwork and school and added health care costs. Secondaryinfections can produce complications, and some infectionsmay be associated with the development ofdiseases such as cancer or other chronic conditions,which can manifest at a later date. Those responsiblefor ensuring that the public are protected from infectionin health care facilities are now realizing that their abilityto manage the problem is hampered by spread ofpathogens such as MRSA, C difficile, and norovirus inthe community and the home, and the number of infectedpeople or carriers who come into their facilities,and are looking for ways to address this by engaging thepublic to adopt more rigorous standards of hygiene.One of the things that is apparent from newlyemerging data, and that is reflected in this review, isthe extent to which common infections circulating inthe community are hygiene related. This suggests, inturn, that hygiene promotion could have a significantbenefit in terms of improved public health and well-being;in particular, the data highlight the extent to whichviruses (norovirus, rotavirus, rhinovirus, influenza, andother viruses) are responsible for hygiene-related diseasesnow circulating in the community.The main conclusions from this review are asfollows:dID circulating in the home and community is a seriouspublic health problem in the developed as wellas the developing world.dddddGood hygiene practice is key to reducing the burdenof ID in the home and community.Hand hygiene is a key component of good hygienepractice in the home and community and can producesignificant benefits in terms of reducing the incidenceof infection, most particularly for gastrointestinalinfections but also for respiratory tract and skininfections.Decontamination of hands can be carried out eitherby handwashing with soap or by the use of waterlesshand sanitizers, which achieve a log reduction in bacterialand viral contamination on hands by the removalof contamination or by killing the organismsin situ. The health impact of hand hygiene within agiven community can be increased by using productsand procedures, either alone or in sequence, thatmaximize the log reduction of both bacteria and viruseson hands.The impact of hand hygiene in reducing ID riskscould be increased by convincing people to applyhand hygiene procedures correctly (eg, wash theirhands correctly) and at the correct time.To optimize health benefits, promotion of handhygiene must be accompanied by hygiene educationand should also involve promotion of otheraspects of hygiene, for example, surface and clothhygiene.FURTHER RESEARCHThis report highlights a number of areas in whichadditional data are needed:d Further studies are needed to characterize thefrequency of, and factors associated with, ID transmissionin noninstitutional settings such as thehome.d Further studies are needed to assess the relative efficacyof hand hygiene procedures in reducing handcontamination (handwashing with soap and use of
Bloomfield et al December 2007 S59dddABHS, involving different ‘‘contact/application/rinsing’’times, and others). This includes the following:(1) in vivo panel tests to determine the reduction inbacteria and viruses on hands under controlledconditions. Committee European Normalisation orASTM tests now provide standard test models forcomparing the efficacy of handwashing with theuse of waterless hand sanitizer products, under definedconditions. They provide an economic approach(relative to intervention studies) that canbe used, alone or in combination with QMRA, to informhygiene policy and/or the design of interventionstudies. (2) Field studies to determine logreduction in counts on hands in relation to howpeople actually wash their hands or apply ABHSin their homes.Additional data are needed to understand how, when,and why people practice hand hygiene at home andhow this relates to their understanding of ID transmissionand risks.Intervention studies are needed to determine thehealth impact of hand hygiene promotion with hygieneeducation, compared with hygiene promotionwithout education. This should also include understandinghow hand hygiene combines with surfacehygiene to influence health outcome.Intervention studies are needed to determine the potentialfor an increase in health impact from promotinguse of ABHS in conjunction with handwashing(ie, handwashing followed by use of ABHS) or as asupplement to handwashing (in situations in whichaccess to water is limited), compared with the promotionof handwashing alone.The authors thank Dr. Michele Pearson, Centers for Disease Control and Prevention,Atlanta, GA, for her very valuable and extensive contributions to the preparation ofthis review.References1. Pinner RW, Teutsch SM, Simonson L, Klug LA, Graber JM, Clarke MJ,et al. Trends in infectious disease mortality in the United States.JAMA 1996;275:189-93.2. Griffith C, Redmond E. Evaluating hygiene behaviour in the domesticsetting and the impact of hygiene behaviour. J Infect 2001;43:70-4.3. Pittet D. Improving adherence to hygiene practice: a multidisciplinaryapproach. Emerg Infect Dis 2001;7:234-40.4. Curtis V. Talking dirty: how to save a million lives. Int J Environ HealthRes 2003;13(Suppl 1):S73-80.5. Kretzer EK, Larson EL. Behavioural interventions to improve infectioncontrol practices. Am J Infect Control 1998;26:245-53.6. Whitby M, Pessoa-Silva CL, McLaws ML, Allegranzi B, Sax H, LarsonE, et al. Behavioural considerations for hand hygiene practices: thebasic building blocks. J Hosp Infect 2007;65:1-8.7. Amato-Gauci A, Ammon A, eds. The First European Communicable DiseaseEpidemiological Report. European Centre for Disease Preventionand Control. Available at: http://www.ecdc.eu.int/pdf/Epi_report_2007.pdf.Accessed 2007.8. Campylobacteriosis overtakes salmonellosis as the most reportedanimal infection transmitted to humans in the EU European FoodStandards Agency. Available at: http://www.efsa.europa.eu/en/press_room/press_release/press_releases_2006/pr_zoonoses_report2005.html. Accessed 2006.9. WHO assesses that up to 40% of food poisoning outbreaks occur inthe home. Several foodborne diseases are increasing in Europe.WHO’s ‘‘five keys to safer food’’ for winter holidays. 2003 PressRelease EURO/16/03. Available at: http://www.euro.who.int/eprise/main/who/mediacentre/PR/2003/20031212_2.10. Food Poisoning Notifications—annual totals England and Wales,1982–2005. Available at: www.hpa.org.uk/infections/topics_az/noids/food_poisoning.htm.11. Food Standards Agency. A report of the study of infectious intestinaldisease in England. London: The Stationary Office; 2000.12. Mead PS, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, et al.Food-related illness and death in the United States. Emerg Infect Dis1999;5:607-25.13. Centers For Disease Control and Surveillance. Outbreak Responseand Surveillance Team. Available at: http://www.cdc.gov/foodborneoutbreaks/outbreak_data.htm.14. Le Baigue S, Long S, Adak GK, O’Brien SJ. Infectious intestinaldisease—it’s not all foodborne! PHLS 25th Annual Scientific Conference,2000.15. Gillespie IA, O’Brien SJ, Adak GK. General outbreaks of infectiousintestinal diseases linked with private residences in England andWales, 1992-1999: questionnaire study. BMJ 2001;323:1097-8.16. Wheeler JG, Sethi D, Cowden JM, Wall PG, Rodrigues LC, TompkinsDS, et al. Study of infectious intestinal disease in England: rates in thecommunity, presenting to general practice and reported to nationalsurveillance. BMJ 1999;318:1046-50.17. de Wit MA, Koopmans MP, Kortbeek LM, van Leeuwen NJ, BarteldsAI, van Duynhoven YT. Gastroenteritis in sentinel general practicesin The Netherlands. Emerg Infect Dis 2001;7:82-91.18. de Wit MA, Koopmans MP, van Duynhoven YT. Risk factors for norovirus,Sapporo-like virus and group A rotavirus gastroenteritis.Emerg Infect Dis 2003;9:1563-9.19. Davis MA, Sheng1 H, Newman J, Hancock D, Hovde J. Comparisonof a waterless hand-hygiene preparation and soap-and-water handwashing to reduce coliforms on hands in animal exhibit settings. EpidemiolInfect 2006;134:1024-8.20. Widdowson MA, Monroe SS, Glass RI. Are noroviruses emerging?Emerg Infect Dis 2005;11:735-7.21. Carter MJ. Enterically infecting viruses: pathogenicity, transmissionand significance for food and waterborne infection. J Appl Microbiol2005;98:1354-80.22. Japan: largest norovirus since 1981. Available at: http://depts.washington.edu/einet/?a5printArticle&print5284.23. Kroneman A, Vennema H, Harris J, Reuter G, von Bonsdorff C-H,Hedlund K-O, et al. Increase in norovirus activity reported inEurope. Eurosurveillance 2006;11(12). Available at:http://wwweurosurveillance.org/ew/2006/061214.asp#1/.24. Shapiro CN, Shaw FE, Mendel EJ, Hadler SC. Epidemiology of hepatitisA in the United States. In: Hollinger FB, Lemon SM, Margolis HS,editors. Viral hepatitis and liver disease. Baltimore: Williams and Wilkins;1991. p. 214.25. Bloomfield SF, Cookson BD, Falkiner FR, Griffith C, Cleary V. Methicillin-resistantStaphylococcus aureus (MRSA), Clostridium difficile, andESBL-producing Escherichia coli in the home and community: assessingthe problem, controlling the spread. International ScientificForum on Home Hygiene 2006. Available at: http://www.ifh-homehygiene.org/2003/2library/MRSA_expert_report.pdf.26. Perry S, de la Luz Sanchez M, Yang S, Haggerty TD, Philip Hurst P,Perez-Perez G, et al. Gastroenteritis and transmission of Helicobacterpylori infection in households. Emerg Infect Dis 2006;12:1701-8.
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