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Health care associated infections are drawing increasing attention from patients, insurers, governments and regulatory bodies. This is not only because of the magnitude of the problem in terms of the associated morbidity, mortality and cost of treatment, but also due to the growing recognition that most of these are preventable. The medical community is witnessing in tandem unprecedented advancements in the understanding of pathophysiology of infectious diseases and the global spread of multi-drug resistant infections in health care set-ups. These factors, compounded by the paucity of availability of new antimicrobials have necessitated a re-look into the role of basic practices of infection prevention in modern day health care. There is now undisputed evidence that strict adherence to hand hygiene reduces the risk of cross-transmission of infections. With "Clean Care is Safer Care" as a prime agenda of the global initiative of WHO on patient safety programmes, it is time for developing countries to formulate the much-needed policies for implementation of basic infection prevention practices in health care set-ups. This review focuses on one of the simplest, low cost but least accepted from infection prevention: hand hygiene.
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Introduction
Hand hygiene is now regarded as one of the most
important element of infection control activities.
In the wake of the growing burden of health care
associated infections (HCAIs), the increasing severity
of illness and complexity of treatment, superimposed
by multi-drug resistant (MDR) pathogen infections,
health care practitioners (HCPs) are reversing back to
the basics of infection preventions by simple measures
like hand hygiene. This is because enough scientic
evidence supports the observation that if properly
implemented, hand hygiene alone can signicantly
Review Article
Hand hygiene: Back to the basics of infection control
Purva Mathur
Department of Laboratory Medicine, Jai Prakash Narain Apex Trauma Centre, All India Institute
of Medical Sciences, New Delhi, India
Received January 13, 2010
Health care associated infections are drawing increasing attention from patients, insurers, governments
and regulatory bodies. This is not only because of the magnitude of the problem in terms of the associated
morbidity, mortality and cost of treatment, but also due to the growing recognition that most of these
are preventable. The medical community is witnessing in tandem unprecedented advancements in the
understanding of pathophysiology of infectious diseases and the global spread of multi-drug resistant
infections in health care set-ups. These factors, compounded by the paucity of availability of new
antimicrobials have necessitated a re-look into the role of basic practices of infection prevention in
modern day health care. There is now undisputed evidence that strict adherence to hand hygiene reduces
the risk of cross-transmission of infections. With “Clean Care is Safer Care” as a prime agenda of the
global initiative of WHO on patient safety programmes, it is time for developing countries to formulate
the much-needed policies for implementation of basic infection prevention practices in health care set-
ups. This review focuses on one of the simplest, low cost but least accepted from infection prevention:
hand hygiene.
Key words Alcohol-based hand rubs - compliance - hand hygiene - hand hygiene agents - hand washing - India
reduce the risk of cross-transmission of infection in
healthcare facilities (HCFs)1-5.
Historical background
The signicance of hand washing in patient
care was conceptualized in the early 19th century6-8.
Labarraque6 provided the rst evidence that hand
decontamination can markedly reduce the incidence of
puerperal fever and maternal mortality. Semmelweis7
worked in the Great hospital in Vienna in the 1840s.
There were two maternity clinics in the hospital, with
alternate day admission policy. The rst clinic was
attended by medical students, who moved straight
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from autopsy rooms to the delivery suite and had an
average maternal mortality rate due to puerperal fever
of about 10 per cent. The second clinic, attended by
midwives had a maternal mortality of only 2 per cent.
The puzzled Semmelweis got a breakthrough in 1847,
following the death of colleague Jokob Kolletschka,
who had been accidentally got a cut by a student’s
scalpel while performing an autopsy. His autopsy
showed a pathological condition similar to that of
women drying from puerperal fever. Semmelweis
concluded that some “unknown cadaverous material”
caused puerperal fever. He instituted a policy of
washing hands with chlorinted lime for those leaving
the autopsy room, following which the rate of maternal
mortality dropped ten-folds, comparable to the second
clinic. Thus, he almost conducted a controlled trial,
in an era when microbes were yet to be discovered
and the germ theory of disease was not dened6-8. In
another landmark study in the wake of Staphylococcal
epidemics in 1950s, Mortimer et al 9 showed that
direct contact was the main mode of transmission of S.
aureus in nurseries. They also demonstrated that hand
washing by patients’ contacts reduced the level of S.
aureus acquisition by babies.
In 1975 and 1985, the CDC published guidelines
on hand washing practices in hospitals, primarily
advocating hand washing with non antimicrobial soaps;
washing with antimicrobial soap was advised before
and after performing invasive procedures or during care
for high risk patients. Alcohol-based solutions were
recommended only in situations where sinks were not
available10,11. In 1995, the Hospital Infection Control
Practices Advisory Committee (HICPAC) advocated
the use of antimicrobial soap or a waterless antiseptic
agent for cleaning hands upon leaving the rooms of
patients infected with multidrug-resistant pathogens12.
In 2002, the CDC published revised guidelines for
hand hygiene3. A major change in these guidelines was
the recommendation to use alcohol based hand rubs
for decontamination of hands between each patient
contact (of non-soiling type) and the use of liquid soap
and water for cleaning visibly contaminated or soiled
hands. A systematic review of handwashing by the
Thames Valley University as part of the evaluation of
processes and indicators in infection control (EPIC)
study13, concluded that there was a good evidence that
direct patient contact resulted in hand contamination by
pathogens. The EPIC study also showed the superiority
of 70 per cent alcohol/ alcohol based antiseptic hand
rubs13,14.
With the growing burden of HAIs, limited options
of effective antimicrobials evidence supporting the
role of hand hygiene in reduction of HAIs, the WHO
has launched a global hand hygiene campaign. In 2005,
it introduced the rst Global Patient Safety Challenge
“Clean Care is Safer Care (CCiSC)”, as part of its world
alliance for patient safety15,16. In 2006, advanced draft
guidelines on “Hand Hygiene in Health Care” were
published and a suite of implementation tools were
developed and tested17. The rst Global Handwashing
Day was observed on October 15, 2008. A WHO
Patient Safety 2009 initiative has been established to
catalyse this progress. This is the next phase of the
‘First Challenge’s work on CCiSC’15-18. This initiative
has, as of April 2009, seen a total of 3,863 health care
facilities registering their commitment, effectively
equating to a staff of over 3.6 million people, globally.
On May 5, 2009, the WHO highlighted the importance
of hand hygiene and launched guidelines and tools
on hand hygiene, based on the next phase of patient
safety work programme “SAVE LIVES: Clean Your
Hands”1,2,15-18.
Normal ora of hands
There are two types of microbes colonizing hands:
the resident ora, which consists of microorganisms
residing under the supercial cells of the stratum
corneum and the transient ora, which colonizes the
supercial layers of the skin, and is more amenable
to removal by routine hand hygiene. Transient
microorganisms survive, but do not usually multiply
on the skin. They are often acquired by health care
workers (HCWs) during direct contact with patients
or their nearby contaminated environmental surfaces
and are the organisms most frequently associated with
HCAIs1-3.
Colonization of hands with pathogens and their role
in transmission
The hands of HCWs are commonly colonized
with pathogens like methicillin resistant S. aureus
(MRSA), vancomycin resistant Enterococcus (VRE),
MDR-Gram Negative bacteria (GNBs), Candida spp.
and Clostridium difcle, which can survive for as
long as 150 h. Approximately 106 skin epithelial cells
containing viable microorganisms are shed daily from
the normal skin2,19, which can contaminate the gowns,
bed linen, bedside furniture, and other objects in the
patient’s immediate environment. Hand carriage of
resistant pathogens has repeatedly been shown to be
associated with nosocomial infections1-3. The highest
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rates of hand contamination are reported from critical
care areas, which also report most cases of cross-
transmission. The hands may become contaminated by
merely touching the patent’s intact skin or inanimate
objects in patients’ rooms or during the “clean”
procedures like recording blood pressure1-3.
Importance of hand hygiene
Proper hand hygiene is the single most important,
simplest, and least expensive means of reducing the
prevalence of HAIs and the spread of antimicrobial
resistance1-3,20-23. Several studies have demonstrated
that handwashing virtally eradicates the carriage of
MRSA which invariably occurs on the hands of HCPs
working in ICUs24,25. An increase in handwashing
compliance has been found to be accompanied by a
fall in MRSA rates26. The hand hygiene liason group
identied nine controlled studies, all of which showed
signicant reductions in infection related outcomes,
even in settings with a high infection rates in critically ill
patients14,27,28. Transmission of Health-care-associated
Klebsiella sp. has also been documented to reduce
with improvement in hand hygiene2,3,23. The evidence
suggests that adherence to hand hygiene practices
has signicantly reduced the rates of acquisition of
pathogens on hands and has ultimately reduced the
rates of HAIs in a hospital22,23,26,29-31.
Indications for hand hygiene during patient care
Wash hands with soap and water when (i) visibly
dirty or contaminated with proteinaceous material,
blood, or other body uids and if exposure to
Bacillus anthracis is suspected or proven (since the
physical action of washing and rinsing hands in such
circumstances is recommended because alcohols,
chlorhexidine, iodophors, and other antiseptic agents
have poor activity against spores); (ii) After using a
restroom, wash hands with a non-antimicrobial soap
and water or with an antimicrobial soap and water; and
(iii) before and after having food1-3,21-23,32.
In all other clinical situations described below,
when hands are not visibly soiled, an alcohol-based
hand rub should be used routinely for decontaminating
hands1-3,21-23,32. (i) Before having direct contact with
patients. (ii) Before donning sterile gloves when
inserting a central intravascular catheter. (iii) Before
inserting indwelling urinary catheters, peripheral
vascular catheters, or other invasive devices that do
not require a surgical procedure. (iv) After contact
with a patient’s intact skin (e.g., when taking a pulse
or blood pressure or lifting a patient). (v) After contact
with body uids or excretions, mucous membranes,
nonintact skin, and wound dressings if hands are not
visibly soiled. (vi) After contact with inanimate objects
(including medical equipment) in the immediate
vicinity of the patient. (vii) After removing gloves.
(viii) If moving from a contaminated body site to a
clean body site during patient care.
The WHO “SAVE LIVES: Clean Your Hands”
programme1,2 reinforces the “My 5 Moments for Hand
Hygiene” approach as key to protect the patients, HCWs
and the health-care environment against the spread
of pathogens and thus reduce HAIs. This approach
encourages HCWs to clean their hands: before touching
a patient, before clean/aseptic procedures, after body
uid exposure/risk, after touching a patient and after
touching patient surroundings1,2.
Other precautions in relation to hand sanitation
Avoid unnecessary touching of surfaces in close
proximity to the patient. In 2002, the CDC/HICPAC
recommended that articial ngernails and extenders
not to be worn by HCPs who have contact with high-
risk patients, due to their association with outbreaks
of Gram-negative bacillary and candidal infections12.
Although rings harbour a high count of pathogens, they
have not been found to be associated with transmission
of infections12.
Method of hand washing1,2,21
For handwashing, remove the jewelry and rinse
hands under running water (preferably warm). Lather
with soap and using friction, cover all surfaces of hands
and ngers. Wash thoroughly under running water. Turn
off faucet with wrist/elbow. Dry hands with a single
use towel or by using forced air drying. Pat skin rather
than rubbing to avoid cracking. If disposable towels
are used, throw in trash immediately. Skin excoriation
may lead to bacteria colonizing the skin and the
possible spread of blood borne viruses as well as other
microorganisms. Sore hands may also lead to decreased
compliance with hand washing protocols1,2,21. If using
antiseptic rub, take an adequate amount and rub on all
surfaces for the recommended time. Let the antiseptic
dry on its own.
Agents used for hand hygiene
Table I lists the properties, advantages and
disadvantages of the commonly used agents for hand
hygiene1-4,21,33.
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Table I. Properties of hand hygiene products
Agent Concentration/available
products
Activity Advantages, disadvantages and precautions
Non medicated
(plain) soaps
Bars, soaps, tissues,
leaets &
liquid preparations
Detergent properties; Non
microbicidal; Reduces numbers
by mechanical removal of loosely
adherent microorganisms from
hands.
Advantage: Good for removal of soil and
proteinaceous material (e.g., blood)
Disadvantage: Do not have any antimicrobial
activity; Contamination of hands may occur
(e.g., Pseudomonas aeruginosa from sink/ water/
contaminated soap); May result in paradoxical
increases in bacterial counts on the skin; causes
irritant contact dermatitis and dry skin
Alcohols 60-95% ethanol,
isopropanol,
n-propanol or a
combination of these.
Available as rinses, gels,
and foams.
Good: GP bacteria, GN bacteria,
Env. viruses, Mycobacteria, Fungi
Fair: N. Env viruses Nil: Spores
Advantage: Fast action; effectively reduces
bacterial counts; addition of low concentrations
(0.5-1.0%) of chlorhexidine results in greater
residual activity than alcohol alone
Advantage: Not appropriate for use when
hands are visibly dirty or contaminated with
proteinaceous materials; Flammable; Volatile; No
appreciable residual activity; Efcacy affected
by several factors (type of alcohol, volume,
concentration, contact time & wet hands during
application); Frequent use can cause drying of
the skin (reduced or eliminated by adding 1-3%
glycerol/ other skin conditioning agents)
Chlorhexidine 0.5-4% Good : GP bacteria
Fair: GN bacteria , Env. viruses
Poor: N. Env viruses,
Mycobacteria, Fungi Nil : Spores
Advantage: Safe & relatively non allergic;
Activity minimally affected by presence of
organic material, including blood; Substantial
residual activity
Disadvantage: Activity is reduced by natural
soaps, inorganic anions, nonionic surfactants
and hand creams containing anionic emulsifying
agents; Less rapid action than alcohols; Toxic to
eye, ears, brain tissue & meninges; Concentration-
dependent skin irritation
Chloroxylenol
(PCMX)
0.5-4%. Good: GP bacteria
Poor: GN bacteria , Env. viruses,
Mycobacteria, Fungi
Doubtful efcacy: N. Env viruses
Nil: Spores
Advantage: Activity is minimally affected by the
presence of organic matter; Allergic reactions
uncommon
Advantage: Less rapid and less residual activity
compared to chlorhexidine; Activity is neutralized
by nonionic surfactants; Absorbed through the
skin; but is well-tolerated
Hexachlorophene 3% Good: GP bacteria
Poor: GN bacteria, Mycobacteria,
Fungi
Doubtful efcacy: Viruses,
Nil:: Spores
Advantage: Residual activity for several hours;
Gradually reduces bacterial counts on hands after
multiple uses
Advantage: With repeated use of 3%
hexachlorophene preparations, the drug is
cutaneously absorbed; Routine bathing of
neonates or burn patients with hexachlorophene
is contraindicated because of its potential
neurotoxicity.
Contd....
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Iodine & iodophors 0.5-10%
povidone-iodine
(typical 10% povidone-
iodine formulations
contain 1% available
iodine; free iodine
concentrations
of 1 ppm)
Good: GP bacteria, GN bacteria
Fair: Env. viruses, N. Env viruses,
Mycobacteria, Fungi Doubtful
efcacy: Spores
Advantage: Iodophors cause less skin irritation/
fewer allergic reactions than iodine, but more
irritant contact dermatitis than other antiseptics
Advantage: Activity substantially reduced in the
presence of organic substances; is affected by pH,
temperature, exposure time, concentration of total
available iodine, and the amount/ type of organic/
inorganic compounds present (e.g., alcohols and
detergents); May become contaminated with
Gram negative bacilli
Quaternary
ammonium
compounds
Alkyl benzalkonium
benzethonium chloride,
Cetrimide, and
Cetylpyridium chloride
Fair:: GP bacteria
Poor: GN bacteria, Env. viruses
Doubtful efcacy: N. Env viruses,
Mycobacteria, Fungi Nil: Spores
Advantage: Usually well tolerated.
Advantage: Antimicrobial activity adversely
affected by presence of organic material; Not
compatible with anionic detergents; Prone to
contamination by GNB
Triclosan 2,4,4’ –trichloro-2’-
hydroxydiphenyl
ether: 0.2-2%
Good: GP bacteria
Fair: GNB
Doubtful efcacy: Viruses,
Mycobacteria, Fungi
Nil: Spores
Advantage: Persistent activity on the skin;
Activity not substantially affected by organic
matter; Most formulations are well-tolerated
Advantage: Activity affected by pH, presence of
surfactants, emollients, or humectants and ionic
nature of the formulation; Occasional reports
of contamination with GNB. Widespread use in
non-medical products like lotions & deodorants
may cause resistance in microbes.
Octenidine
(activity under
evaluation)
Bispyridine 0.1% Good: Bacteria, Viruses
Fair: Fungi, Mycobacteria
Effective & safe antiseptic.
Good residual activity
Useful antiseptic for mucus membrane of genital
tract and oral cavity
Env. viruses, enveloped viruses; N Env viruses, non enveloped viruses; GP, Gram-positive; GN, Gram-negative; GNB, Gram-negative
bacteria/bacilli. Source: Refs 1-4, 21, 25
Agent Concentration/available
products
Activity Advantages, disadvantages and precautions
Selecting hand hygiene products for health set-ups
The major determinants for product selection are
antimicrobial prole, user acceptance, and cost2,4,21.
Post-contamination hand hygiene products must have
at least bactericidal, fungicidal (yeasts), and virucidal
(coated viruses) activity. Since hands of HCWs are
frequently contaminated with blood during routine
patient care, activity against coated viruses should be
included in the minimum spectrum of activity of an
agent for hand hygiene4. Additional activity against
fungi (including molds), mycobacteria, and bacterial
spores may be relevant in high risk wards or during
outbreaks. Pre-operative hand hygiene should be at
least bactericidal and fungicidal (yeasts), since the
hands of most HCWs carry yeasts and surgical- site
infections have also been associated with hand carriage
of yeasts during an outbreak4.
Hospital administrators should also take into
account the acceptability of product (smell, feel, skin
irritation) by the users and its allergenic potential1-4,21.
When comparing the cost of hand hygiene products, it
has been found that the excess hospital cost associated
with only 4-5 HAIs of average severity may equal the
entire annual budget for hand hygiene products used
for in-patient care areas3,34.
One of the key elements in improving hand hygiene
practice is the use of an alcohol based hand rub instead
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of washing with soap and water. An alcohol-based
hand rub requires less time, is microbiologically more
effective and is less irritating to skin than traditional
hand washing with soap and water2,3,35. In the ICUs,
switching to alcohol hand disinfection would decrease
the time necessary for hand hygiene from 1.3 h (or 17%
of total nursing time) to 0.3 h (or 4% of total nursing
time)35,36.
Reasons for poor hand hygiene practices
In most health care institutions, adherence to
recommended hand-washing practices remains
unacceptably low, rarely exceeding 40 per cent of
situations in which hand hygiene is indicated35,37.
Hand hygiene reects attitudes, behaviours and
beliefs. Some of the observed/self reported factors
found to be affecting hand hygiene behaviours are
enlisted in Table II2,3,38-41.
Methods used to improve hand hygiene compliance
Multimodal strategies have been shown to be more
successful in improving rates of adherence with hand
hygiene in HCWs than single interventions16. Targeted,
multi-faceted approaches focusing on system change,
administrative support, motivation, availability of
alcohol-based hand rubs, training and intensive
education of HCWs and reminders in the workplace
have been recommended for improvement in hand
hygiene16.
Recent studies support the fact that interactive
educational programmes combined with free
availability of hand disinfectants signicantly
increased the hand hygiene compliance42,43. A single
lecture on basic hand hygiene protocols had a
signicant and sustained effect in enhancing hand
hygiene compliance in a Swedish hospital42. The
four member States of the European Union, which
implemented National Hand Hygiene Campaigns
found the following strategies to be extremely
useful in their countries: Governmental support, the
use of indicators for hand hygiene benchmarking,
developing national surveillance systems for auditing
alcohol based hand rub consumption and auditing
hand hygiene compliance44. Trampuz et al35 advocated
simple training sessions for HCWs to be held in each
ward to introduce the advantage of alcohol hand rubs
over hand washing.
Other factors like positive role modeling (hand
hygiene behaviour of senior practitioners) and the use
of performance indicators also remarkably improve
adherence to hand hygiene40,41. There should be
adequate supply of hand hygiene products, lotions
and creams, disposable towels and facilities for hand
Table II. Factors affecting compliance to hand hygiene
Health care staff related
factors
Clinical factors Environmental/institutional/behavioral/
other factors
Physician status (rather than
a nurse)
Working in an intensive-care unit Wearing gowns/gloves (beliefs that glove use obviates the need
for hand hygiene)
Nursing assistant status
(rather than a nurse)
Working during the week (versus the
weekend)
Hand washing agents causing irritation and dryness
Male sex If involved in activities with high risk of
cross-transmission
Sinks are inconveniently located/shortage of sinks
Lack of soap and paper towels
Lack of role models among
colleagues or superiors
Understafng, patient overcrowding,
insufcient time
Belief of low risk of acquiring infection from patients
Not thinking about it/
forgetfulness
Patient needs take priority Lack of knowledge of guidelines/protocols
Hand hygiene interferes with health-care
worker relationships with patients
Skepticism regarding the value of hand hygiene
Disagreement with the recommendations
Lack of institutional priority
Lack of active participation in hand-hygiene promotion at
individual or institutional level
Lack of administrative sanction of non-compliers/rewarding
compliers
Source: Refs 2,3,38-41
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washing, where necessary2-4,35,40,41. Alcohol hand rubs
should be available at the point of care in sufcient
quantities. It needs to be emphasized that wearing
gloves does not replace the need for hand hygiene and
that contamination may occur during glove removal.
Studies by Pitet26,45 showed a remarkable and long
lasting improvement in hand hygiene compliance
using a multimodal strategy, which has been adopted
by the rst Global Patient Safety Challenge of WHO
to develop hand hygiene strategies. The availability
of individual, pocket carried bottles also increased
compliance38-40,46-48.
Apart from this, all hospitals should have a
dynamic infection control team, robust surveillance
system, adequate staff to disseminate evidence-based
knowledge in an easily comprehensible way to all
cadres of staff. At a more local or regional level, there
is a need for institutional frameworks or programmes
to deal with HAIs49. The Institute for Healthcare
Improvement (www.ihi.org) offers elaborate training
modules on various aspects of patient care. The guide
for implementation of WHO’s CCiSC and a range of
tools to facilitate hand hygiene is available50.
Research and education
To develop successful interventions, more research
into behavioural determinants is needed, in particular,
how these determinants can be applied to improve
hand hygiene51,52. Process indicators are vital and an
understanding of why some interventions succeed
and others fail is needed. Since hand hygiene is more
of a behavioural practice, the rst step towards the
development of interventions should be to identify the
prevalence of risk behaviours (i.e. non compliance)
and the difference in risk behaviours. Since the reasons
for non-compliance vary among countries, large scale
systematic studies are needed to identify the reasons
thereof and plan remedial strategies.
An expert panel has recommended that measuring
hand hygiene compliance is essential to understand the
current situation, facilitate change and to measure the
impact of interventions53. This can be done by direct
observation, automated electronic monitoring, product
consumption and self reporting by HCW54.
The important aspect of role models for students,
whose adherence is strongly inuenced by their
mentor’s attitude at bed side should be exploited in
moulding the behaviour of young medical students. A
few lectures in the undergraduate curriculum may prime
the medical students to this basic necessity. The Hand
Hygiene Liason Group strongly advocates teaching of
e
lementary hygiene practices at medical schools55. In an
elaborate study focusing on MBBS students, it was noted
that assessing the knowledge, attitude and practices of
nal year MBBS students and providing a positive role
modeling at undergraduate level is a good initiative56.
Indian scenario
In India, the quality of healthcare is governed by
various factors, the principal amongst these being
whether the health care organization is government
or private-sector run. There is also an economic and
regional disparity throughout the country. About 75 per
cent of health infrastructure, medical manpower and
other health resources are concentrated in urban areas,
where 27 per cent of the population lives57. There is
a lack of availability of clean water for drinking and
washing. Like in other developing countries, the
priority given to prevention and control of HCAI is
minimal. This is primarily due to lack of infrastructure,
trained manpower, surveillance systems, poor
sanitation, overcrowding and understafng of hospitals,
unfavourable social background of population, lack of
legislations mandating accreditation of hospitals and a
general attitude of non-compliance amongst health care
providers towards even basic procedures of infection
control. In India, although hand hygiene is imbibed as
a custom and promoted at school and community levels
to reduce the burden of diarrhoea, there is a paucity of
information on activities to promote hand hygiene in
HCFs. Sporadic reports document the role of hands in
spreading infection and isolated efforts at improving
hand hygiene across the country54,58-60.
The practice of compulsory training on standard
precautions, safe hospital practices and infection
control for all postgraduates upon course-induction, as
is being done in a few Delhi medical colleges seems
very promising for our country. Such an exercise may
be made mandatory across all medical and nursing
colleges of India, especially since the “patient safety”
is increasingly being prioritized by the Government of
India and the country being one of the 120 signatories
pledging support to the WHO launched world alliance
(available at http://www.who.int/patientsafery/
events/06/statememts/India_pledge.pdf).
Challenges ahead
Although evidence based guidelines are
increasingly being implemented in the developed
countries, the developing countries still lack basic health
care facilities, surveillance networks and resources to
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curtail HAIs61-63. Lack of hand washing facilities (e.g.,
sinks, running water and sewage systems) are major
deterrents for implementation of hand hygiene61. The
use of WHO advocated alcohol based hand rubs is
a practical solution to overcome these constraints,
because these can be distributed individually to staff
for pocket carriage and placed at the point of care.
The major advantage is that its use is well applicable
to situations typical of developing countries, such as
two patients sharing the same bed, or patient’s relatives
being requested to help in care provision. Several
hospitals are now reporting increased compliance after
implementation of CCiSC64. Several countries have
also initiated nationally co-ordinated activities (http://
www.who.int/gpsc/national-campaigns/en/) to promote
hand hygiene54. However, global Healthcare Infection
Prevention programmes can only be successful, if
these populous developing nations are able to control
the menace by formulation of national or local policies
and strictly implementing the guidelines.
Conclusion
Hand washing should become an educational
priority. Educational interventions for medical students
should provide clear evidence that HCWs hands
become grossly contaminated with pathogens upon
patient contact and that alcohol hand rubs are the easiest
and most effective means of decontaminating hands
and thereby reducing the rates of HAIs. Increasing
the emphasis on infection control, giving the charge
of infection control to senior organizational members,
changing the paradigm of surveillance to continuous
monitoring and effective data feedback are some of
the important measures which need to be initiated in
Indian hospitals.
One of the reasons microbes have survived in
nature is probably their simplicity: a simple genomic
framework with genetic encryptation of basic survival
strategies. To tackle these microbes, human beings will
have to follow basic and simple protocols of infection
prevention. The health care practitioners in our country
need to brace themselves to inculcate the simple, basic
and effective practice of hand hygiene in their daily
patient care activities and serve as a role model for
future generations of doctors, nurses and paramedical
personnels.
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Reprint requests: Dr Purva Mathur, Assistant Professor, Department of Laboratory Medicine, Jai Prakash Narain Apex Trauma Centre,
All India Institute of Medical Sciences, New Delhi 110 029, India
e-mail: purvamathur@yahoo.co.in
620 INDIAN J MED RES, NOVEMBER 2011
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... Chlorhexidine is not always considered a beneficial antiviral agent, and its activity is restricted to lipid-enveloped viruses (Jing et al., 2020;Mcdonnell & Russell, 1999). Hand sanitizers cogent public health Marumure et al., Cogent Public Health (2022) with 0.5-4% chlorhexidine are reported to inactivate enveloped viruses, though these hand sanitizers' antiviral activity is less rapid than alcohols (Jing et al., 2020;Mathur, 2011). In addition, low efficacy of chlorhexidine based sanitizers was reported in Guidelines for the Diagnosis and Treatment of New Coronavirus Pneumonia (5 th edition) of the National Health Commission of the Republic of China, as its use in mouth rinse was less efficient in killing SARS-CoV-2 (Carrouel et al., 2020). ...
... Like chlorine, the antimicrobial action of iodine is rapid, even at low concentrations, but the exact mode of action is unknown. Virucidal activity of iodophor was reported in earlier studies, and it was implicated in the inactivation of canine coronaviruses (Mathur, 2011;Wood and Payne, 1998;Saknimit et al., 1988). Mcdonnell and Russell (1999) suggested that iodine molecules attack essential proteins, particularly the free sulfur amino acids cysteine and methionine in the viral capsid and nucleotides. ...
... Activity substantially reduced in the presence of organic substances; is affected by pH, temperature, exposure time, the concentration of total available iodine, and the amount of organic/inorganic compounds present (e.g., alcohols and detergents). Additionally, exposure to povidone-iodine is also associated with contact dermatitis (Mathur, 2011). ...
... Standard precautions Contains hand hygiene, use of Personal Protective Equipment [PPE], safe injection practices, safe handling and cleaning of polluted equipment, and respiratory hygiene/ cough etiquette. Hand hygiene is the most important activity to preventing infection to Nurses and patients [2]. ...
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Previous studies 1 of the transmission of staphylococci to newborn infants suggested that organisms on the hands of personnel carriers are more important than organisms expelled into the air from the respiratory tracts of such carriers. In addition, these studies provided evidence which indicates that the air is not a major route of spread of organisms between infants. The fact that organisms nonetheless do spread readily from one infant to another suggests that the hands of personnel may play a role in the transport of staphylococci between infants. The present studies were designed to test the effectiveness of handwashing by nursery personnel in preventing the spread of organisms between infants and thus to provide indirect evidence regarding the importance of this mode of spread. In addition, an attempt was made to test the role of the airborne route in the transmission of staphylococci among newborns. In order to provide results
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In 1998, the Department of Health (England) commissioned the first phase of national evidence-based guidelines for preventing healthcare associated infections. These focused on developing a set of standard principles for preventing infections in hospitals together with guidelines for preventing hospital-acquired infections (HAI) associated with the use of short-term indwelling urethral catheters in acute care and with central venous catheters in acute care. These guidelines are systematically developed broad statements (principles) of good practice that all practitioners can use and which can be incorporated into local protocols. A nurse-led, multi-professional team composed of infection prevention practitioners, clinical microbiologists/retrovirologist, epidemiologists, and researchers developed the guidelines. A rigorous guideline development process was used to inform the systematic reviews, the clinical and critical appraisal of relevant evidence, and linking that evidence to evolving guidelines. Both general and specialist clinical practitioners were involved in all stages of developing these guidelines, as were representatives from relevant Royal Colleges, learned societies, other professional organisations and key stakeholders. The introduction to these guidelines describes a robust and validated guideline development model that can be used by others to develop future guidelines. This model is described in more detail in the associated technical reports that can be found on the project web site <http://www. epic.tvu.ac.uk>. Locating and appropriately using good quality evidence to inform guideline development in this field is challenging. Evidence from rigorously conducted experimental studies was frequently limited and consequently a range of other types of evidence were systematically retrieved and carefully appraised. The concluding discussion on implementation highlights potential issues for clinical governance and areas for future research and suggests issues that need to be addressed to allow practitioners to successfully incorporate these guidelines into routine clinical practice.
: Method of using the Chloride of Soda, either for Dressing Ill-conditioned Sores, or as a means of Purifying Unhealthy Places, and of Disinfecting Animal Substances. By A. G. Labarraque, &c. &c. Translated by Jacob Porter, &c. &c. New Haven, 1830, pp. 7. (C) Copyright 1831 Southern Society for Clinical Investigation
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Healthcare-associated infections are an important cause of morbidity and mortality among hospitalized patients worldwide. Transmission of health care associated pathogens generally occurs via the contaminated hands of health care workers. Hand hygiene has long been considered one of the most important infection control measures to prevent health care-associated infections. For generations, hand washing with soap and water has been considered a measure of personal hygiene. As early as 1822, a French pharmacist demonstrated that solutions containing chlorides of lime or soda could eradicate the foul odor associated with human corpses and that such solutions could be used as disinfectants and antiseptics. This paper provides a comprehensive review of data regarding hand washing and hand antisepsis in healthcare settings. In addition, it provides specific recommendations to uphold improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in healthcare settings. This article also makes recommendations and suggests the significance of hand health hygiene in infection control.