The Amount of Water used to Wash Hands to Prevent The Spread of Covid-19

Making asthma exacerbations routine: Infrequent outcomes in common conditions through routine data collection

The coronavirus disease 2019 (COVID-19) pandemic has led to an increase in global awareness of relevant public health preventive measures. This awareness can be explored using online search trends from major search engines, such as Google Trends. We investigated the relationship between public awareness of preventative measures and progression of the COVID-19 pandemic. Search data for five queries ('mask', 'hand washing', 'social distancing', 'hand sanitizer', and 'disinfectant') were extracted from Google Trends in the form of relative search volume (RSV). Global incidence data for COVID-19 were obtained from 1 January to 30 June 2020. These data were analysed and illustrated using a global temporal RSV trend diagram, a geographical RSV distribution chart, scatter plots comparing geographical RSV with average number of daily cases, and heat maps comparing temporal trends of RSV with average number of daily cases. Global temporal trends revealed multiple increases in RSV, associated with specific COVID-19-related news events. The geographical distribution showed top regions of interest for various preventive measures. For the queries 'mask', 'hand washing', 'hand sanitizer', and 'disinfectant', heat maps demonstrated patterns of early RSV peaks in regions with lower average number of daily cases, when the temporal element was incorporated into the analysis. Early public awareness of multiple preventive measures was observed in regions with lower average number of daily cases. Our findings indicate optimal public health communication regarding masks, hand washing, hand sanitiser, and disinfectant in the general population during early stages of the COVID-19 pandemic. Early public awareness may facilitate future disease control efforts by public health authorities.

Skin Impact of Alcohol-Based Hand Rubs vs Handwashing.

Hand Hygiene Practices and Risk and Prevention of Hand Eczema during the COVID-19 Pandemic.

There is little question that use of alcohol-based hand rub (ABHR) as the primary mode of hand hygiene in healthcare settings, which is strongly encouraged by the Centers for Dis­ ease Control and Prevention and the World Health Organi­ zation, has increased adherence to recommended hand hy­ giene practices worldwide. Compared with use of soap and water, use of ABHR requires less time, irritates hands less, and is possible at the patient bedside more often. Although ABHR has excellent germicidal activity against a broad spec­ trum of bacteria and viruses, including multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus species, ABHR is not efficacious against spore-forming organisms, such as Clostridium difficile. The 2009 World Health Organization guidelines accommodate this discrepancy in ABHR efficacy by recommending hand washing with soap and water for visibly soiled hands or “if exposure to potential spore-forming organisms is strongly suspected or proven, including out­ breaks of C. difficile [infection]”; for all other situations, the guidelines recommend use of ABHR as the preferred means of routine hand hygiene in healthcare facilities. As C. difficile infection rates increase in the United States, many healthcare facilities have begun encouraging the routine use of soap and water for the care of all patients with active C. difficile–associated diarrhea. However, experts and clinicians have expressed concern about the patientand situation-spe­ cific nature of the recommendations; they fear that incon­ sistency in hand hygiene messaging could potentially dis­ courage ABHR use, which could plausibly decrease the frequency with which healthcare personnel perform hand hy­ giene when indicated. In this issue of the journal, Jabbar et al confirm that hand washing with soap and water demonstrates efficacy superior to that of ABHR use in reducing C. difficile spore counts on hands. Furthermore, the authors report that C. difficile spores were readily transferred through hand-to-hand contact sub­ sequent to hand hygiene with ABHR. The study enlisted 10 volunteers who cleansed their hands with nonmedicated soap and water before inoculation of the palm with a 100-mL C. difficile spore suspension of 500,000 colony-forming units (CFU). Volunteers then performed a 15-second bipalmar hand rub and a 3-minute air dry. A postinoculation stamp for culture was performed before volunteers cleansed their hands with 1 of 5 agents: 5 mL of chlorhexidine gluconate soap (Hibiclens) and water, 2 mL each of 1 of the 3 ABHR products, or water only (control). Immediately after hand hygiene, a post–hand hygiene stamp for culture was per­ formed to assess the log reduction in spore concentration for the 4 hand hygiene products tested relative to the water con­ trol. For chlorhexidine soap and only 1 of the 3 ABHR prod­ ucts, log reductions in residual spore concentrations on hands were significantly greater than log reductions with the water control; chlorhexidine soap and water showed significantly greater log reductions, compared with all 3 ABHR products. The article by Jabbar et al follows a recent article by Ough­ ton et al in which similar conclusions were drawn: use of ABHR did not produce statistically significant log reductions in spore concentration, compared with no hand hygiene at all, and washing with either antimicrobial or plain soap dem­ onstrated significantly greater reductions in spore concentra­ tion than did use of ABHR. The articles by both Oughton et al and Jabbar et al represent in vivo studies that confirm in vitro findings about the superior efficacy of washing with soap and water, compared with the efficacy of using ABHR, for the purpose of eliminating C. difficile spores. These studies relay a clear message: the efficacy of washing with soap and water is superior to that of using ABHR for eliminating C. difficile spores from hands. Hospital admin­ istrators and infection control personnel, however, must set hand hygiene policies that consider C. difficile infections as well as other healthcare-associated infections. Recommending that healthcare personnel use soap and water for patients with

Alcohol-based hand gels and hand hygiene in hospitals

Affiliations: 1. First Global Patient Safety Challenge, Patient Safety Program, World Health Organization, Geneva, Switzerland; 2. Infection Control Program and World Health Organization Collaborating Center on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland. Received March 5, 2012; accepted March 11, 2012; electronically published April 19, 2012. World Health Organization 2012. All rights reserved. The World Health Organization has granted the publisher permission for the reproduction of this article. 0899-823X/2012/3306-0013$15.00. DOI: 10.1086/665720 Hand hygiene promotion is key to patient safety and a cornerstone of effective healthcare-associated infection prevention efforts. Many healthcare settings worldwide have committed to the implementation of hand hygiene campaigns with set targets for improvement. Evaluation of these strategies, especially by performance monitoring and infrastructure indicators, is a critical element to their success. This provides managers with information on the impact of campaign implementation and healthcare workers with feedback to motivate and sustain behavior change. Several countries have recently taken up this challenge at national level and included hand hygiene in quality improvement goals and indicators. In this issue, Behnke et al present alcohol-based hand rub (ABHR) consumption data collected prospectively on a voluntary basis through the German national nosocomial infection surveillance system since January 2008. Hospitals report data to a centralized system stratified by type of ward (intensive care unit [ICU] and non-ICU) and specialty. The overall objective is to facilitate improvement through both intrahospital (ie, between wards) and interhospital benchmarking. Established in 2008, the national German hand hygiene campaign includes more than 900 healthcare settings and is one of the largest worldwide. In line with the World Health Organization (WHO) hand hygiene improvement strategy, participating facilities are requested to (1) secure the active support of administrators; (2) participate in a 1-day introductory course, national workshops, and a national hand hygiene day; (3) organize training of healthcare workers at least once a year; (4) increase ABHR availability, monitor its consumption, and provide feedback; and (5) implement the WHO’s My 5 Moments for Hand Hygiene model. Considering the broad national scope, these features and organization are exceptional, particularly the nationwide ABHR consumption data collection system. Behnke et al report the 4-year results for a sample of 152 hospitals and show a 40.9% and 27.2% increase in median ABHR consumption per patient-day in ICUs and non-ICUs, respectively. Although such increases may be easily achieved in institutions where ABHR is newly introduced and replaces hand washing, these are astonishing in a context where ABHR was widely available for many years before the start of the national campaign. This dramatic increase strongly supports the effectiveness of the multimodal promotion strategy, particularly the performance feedback provided. However, establishing whether this increase reflects actual hand hygiene compliance improvement remains challenging. ABHR consumption measurement was chosen as a surrogate parameter for hand hygiene performance in Germany because direct observation of compliance was considered resource demanding and unfeasible over long periods. This choice was possible as the vast majority of hand hygiene actions in German hospitals involve ABHR, a crucial prerequisite for the use of its consumption as a surrogate of compliance. On the basis of 2010 ABHR consumption results, the reported estimates of the median number of hand hygiene actions per patient-day are low compared with that reported in the literature and would suggest defective hand hygiene behavior. Although the authors emphasize the existence of a good correlation between ABHR consumption and hand hygiene compliance rates reported elsewhere, their results are controversial and raise concerns about the ultimate outcome of hand hygiene promotion. ABHR consumption as a surrogate marker for hand hygiene compliance has several limitations. First, there is a need for accurate validation of consumption data entered in the system. Second, as recognized by Behnke and colleagues, consumption does not allow estimates of hand hygiene performance according to actual opportunities and is vulnerable to the influence of unnecessary hand hygiene actions by healthcare workers, use for other purposes (eg, surface disinfection), and use by patients and visitors. Hand hygiene compliance

Background: Ebola virus disease (EVD) is highly transmissible and has a high mortality rate. During outbreaks, EVD can spread across international borders. Inadequate hand hygiene places healthcare workers (HCWs) at increased risk for healthcare-associated infections, including EVD. In high-income countries, alcohol-based hand rub (ABHR) can improve hand hygiene compliance among HCWs in healthcare facilities (HCF). We evaluated local production and district-wide distribution of a WHO-recommended ABHR formulation and associations between ABHR availability in HCF and HCW hand hygiene compliance. Methods: The evaluation included 30 HCF in Kabarole District, located in Western Uganda near the border with the Democratic Republic of the Congo, where an EVD outbreak has been ongoing since August 2018. We recorded baseline hand hygiene practices before and after patient contact among 46 healthcare workers across 20 HCFs in August 2018. Subsequently, in late 2018, WHO/UNICEF distributed commercially produced ABHR to all 30 HCFs in Kabarole as part of Ebola preparedness efforts. In February 2019, our crossover evaluation distributed 20 L locally produced ABHR to each of 15 HCFs. From June 24–July 5, 2019, we performed follow-up observations of hand hygiene practices among 68 HCWs across all 30 HCFs. We defined hand hygiene as handwashing with soap or using ABHR. We conducted focus groups with healthcare workers at baseline and follow-up. Results: We observed hand hygiene compliance before and after 203 and 308 patient contacts at baseline and follow-up, respectively. From baseline to follow-up, hand hygiene compliance before patient contact increased for ABHR use (0% to 17%) and handwashing with soap (0% to 5%), for a total increase from 0% to 22% (P < .0001). Similarly, hand hygiene after patient contact increased from baseline to follow-up for ABHR use (from 3% to 55%), and handwashing with soap decreased (from 12% to 7%), yielding a net increase in hand hygiene compliance after patient contact from 15% to 62% (P < .0001). Focus groups found that HCWs prefer ABHR to handwashing because it is faster and more convenient. Conclusions: In an HCF in Kabarole District, the introduction of ABHR appeared to improve hand hygiene compliance. However, the confirmation of 3 EVD cases in Uganda 120 km from Kabarole District 2 weeks before our follow-up hand hygiene observations may have influenced healthcare worker behavior and hand hygiene compliance. Local production and district-wide distribution of ABHR is feasible and may contribute to improved hand hygiene compliance among healthcare workers.Funding: NoneDisclosures: Mohammed Lamorde, Contracted Research - Janssen Pharmaceutica, ViiV, Mylan

Background: Hand hygiene (HH) remains arguably the most effective way to prevent healthcare-associated infections (HAIs) and ultimately improve the prospect of patient safety. Studies have shown that as many as 50%–70% of infections are transmitted through hands due to poor HH practices. HH with use of alcohol-based hand rub (ABHR) is preferred over handwashing with soap and water because of its wide microbial efficacy, time efficiency, and improved skin tolerance. It is also well known that ABHR can be used as an effective prevention measure during disease outbreaks. Before and during the COVID-19 pandemic, health facilities in Sierra Leone have been challenged with HH infrastructural problems such as lack of sinks with constant running water. Before Sierra Leone recorded its first case of COVID-19 in March 2020, the consumption of ABHR in the health facilities was estimated to be 24,000 L per year, which doubled during the COVID-19 pandemic. The demand for commercially available ABHR increased, leading to acute shortages. The estimated cost of the locally produced ABHR ~$2–3 per 500 mL, although it may cost up to $10 for 500 mL when buying imported ABHR products from the local market. Methods: All ingredients were procured locally, and ABHR production was based on WHO formula 1. The production was set for 12 months to cover the estimated annual consumption of ABHR, with periodic monitoring to ensure effective distribution and availability at the point of care. Analysis of assessment results in 12 hospitals from the pre-COVID-19 era (2019) to the COVID-19 era (2021) was performed based on the WHO IPC Assessment Framework (IPCAF) indicator. Results: With an average monthly production of 3,482 L, a total of 41,780 L ABHR was produced and packaged in branded 500-mL containers for distribution to healthcare facilities. This quantity exceeded the estimated demand for ABHR during the COVID-19 pandemic. The data show a considerable increase (from 25% to 44%) in the number of available and functioning HH stations with mainly locally produced ABHR. Results from the monitoring of 575 peripheral health units (PHUs) in 2021 also showed that >67% of PHUs had HH facilities in all clinical areas and that the locally produced ABHR was used in 79% of these HH stations. Conclusions: Locally produced ABHR has shown to be a cost-effective and evidence-based intervention to optimize HH at the point of care. Therefore, localities are encouraged to undertake this realistic and sustainable approach to address issues of acute shortage of ABHR, especially during a global pandemic.Funding: NoneDisclosures: None

Comparative efficacy of commercially available alcohol-based hand rubs and World Health Organization-recommended hand rubs

Can a school-based hand hygiene program reduce asthma exacerbations among elementary school children?

Background Asthma exacerbations are seasonal with the greatest risk in elementary-agestudents occurring shortly after returning to school following summer break. Recentresearch suggests that this seasonality in children is primarily related to viralrespiratory tract infections. Regular hand washing is the most effective method toprevent the spread of viral respiratory infections; unfortunately, achieving handwashing recommendations in schools is difficult. Therefore, we designed a study toevaluate the effect of hand sanitizer use in elementary schools on exacerbationsamong children with asthma.Purpose To describe the process of redesigning the trial in response to changes inthe safety profile of the hand sanitizer as well as changes in hand hygiene practicein the schools.Methods The original trial was a randomized, longitudinal, subject-blinded,placebo-controlled, community-based crossover trial. The primary aim was to evaluatethe incremental effectiveness of hand sanitizer use in addition to usual hand hygienepractices to decrease asthma exacerbations in elementary-age children. Three eventsoccurred that required major modifications to the original study protocol: (1) safetyconcerns arose regarding the hand sanitizer’s active ingredient; (2) no substituteplacebo hand sanitizer was available; and (3) community preferences changed regardinghand hygiene practices in the schools.Results The revised protocol is a randomized, longitudinal, community-based crossovertrial. The primary aim is to evaluate the incremental effectiveness of a two-stephand hygiene process (hand hygiene education plus institutionally providedalcohol-based hand sanitizer) versus usual care to decrease asthma exacerbations.Enrollment was completed in May 2009 with 527 students from 30 schools. Theintervention began in August 2009 and will continue through May 2011. Study resultsshould be available at the end of 2011.Limitations The changed design does not allow us to directly measure the effectiveness ofhand sanitizer use as a supplement to traditional hand washing practices.Conclusions The need to balance a rigorous study design with one that is acceptable tothe community requires investigators to be actively involved with communitycollaborators and able to adapt study protocols to fit changing communitypractices.

Simple yet powerful tool" perfectly describes hand hygiene that involves washing hands with soap and water or using hand sanitizer. Despite its simplicity, it is incredibly effective in preventing the spread of infections and promoting public health. This action significantly reduces pathogen transmission, making it essential in healthcare settings and daily life. This study evaluates the role of hand hygiene in preventing zoonotic diseases among zoo workers, who are in close contact with animals. The objectives are to assess the importance of hand hygiene in reducing disease transmission, evaluate current practices, and propose recommendations for improvement. Effective hand hygiene requires a systematic approach, including education on its significance, training in correct techniques, ensuring access to soap and sanitizers, promoting awareness through campaigns, and continuously refining strategies. For zoo workers, regular hand washing and using personal protective equipment are vital. This proactive approach can limit the impact of outbreaks, aiding global health security. This study underscores the importance of strict hand hygiene protocols to protect zoo workers, animals, and visitors, ensuring a safer environment for all. KEYWORDS: Hand hygiene, pathogens.

Tolerance and acceptability of 14 surgical and hygienic alcohol-based hand rubs

BackgroundRecent studies put under scrutiny the prevailing hand hygiene guidelines, which incorporate quantitative parameters regarding handrub volume and hand size. Understanding the criticality of complete (i.e., efficient) hand hygiene in healthcare, objectivization of hand hygiene related parameters are paramount, including the formulation of the ABHR. Complete coverage can be achieved with optimal Alcohol-Based Hand Rub (ABHR) provided. The literature is limited regarding ABHR formulation variances to antimicrobial efficiency and healthcare workers’ preference, while public data on clinically relevant typical application differences is not available. This study was designed and performed to compare gel and liquid format ABHRs (the two most popular types in Europe) by measuring several parameters, including application time, spillage and coverage.MethodologySenior medical students were invited, and randomly assigned to receive pre-determined ABHR volumes (1.5 or 3 ml). All the 340 participants were given equal amounts of gel and liquid on two separate hand hygiene occasions, which occurred two weeks apart. During the hand hygiene events, by employing a digital, fully automated system paired with fluorescent-traced ABHRs, disinfectant hand coverage was objectively investigated. Furthermore, hand coverage in relation to the participants’ hand sizes was also calculated. Additional data collection was performed regarding volume differences and their effect on application time, participants’ volume awareness (consciousness) and disinfectant spillage during the hand hygiene events.ResultsThe 1.5 ml ABHR volume (commonly applied in healthcare settings) is insufficient in either formulation, as the non-covered areas exceeded significant (5%+) of the total hand surface area. 3 ml, on the contrary, resulted in almost complete coverage (uncovered areas remained below 1.5%). Participants typically underestimated the volume which they needed to apply. While the liquid ABHR spreads better in the lower, 1.5 ml volume compared to the gel, the latter was easier handled at larger volume. Drying times were 30/32 s (gel and liquid formats, respectively) when 1.5 ml handrub was applied, and 40/42 s when 3 ml was used. As the evaporation rates of the ABHR used in the study are similar to those available on the market, one can presume that the results presented in the study apply for most WHO conform ABHRs.ConclusionThe results show that applying 1.5 ml volume was insufficient, as large part of the hand surface remained uncovered (7.0 ± 0.7% and 5.8 ± 1.0% of the hand surface in the case of gel and liquid, respectively) When 3 ml handrub was applied drying times were 40 and 42 s (gel and liquid, respectively), which is a very long time in daily clinical practice. It looks like we cannot find a volume that fits for everyone. Personalized, hand size based ABHR volumes may be the solution to find an optimal balance between maximize coverage and minimise spillage and drying time. 3 ml can be a good volume for those who have medium size hands. Large handed people should use more handrub to reach appropriate coverage, while small-handed ones may apply less to avoid massive spillage and not to take unrealistically long to dry.