WHO Guidelines

on Hand Hygiene in Health Care

First Global Patient Safety
Challenge Clean Care is Safer Care

WHO Library Cataloguing-in-Publication Data

WHO guidelines on hand hygiene in health care.
1.Hand wash - standards. 2.Hygiene. 3.Cross infection - prevention
and control. 4.Patient care - standards. 5.Health facilities standards. 6.Guidelines. I.World Health Organization. II.World
Alliance for Patient Safety.
ISBN 978 92 4 159790 6

(NLM classification: WB 300)

World Health Organization 2009

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Printed in

WHO Guidelines
on Hand Hygiene in Health Care
First Global Patient Safety
Challenge Clean Care is Safer Care

CONTENTS

CONTENTS
INTRODUCTION

PART I.

REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

1.

Definition of terms

2.

Guideline preparation process

2.1
2.2
2.3
3.

Preparation of the Advanced Draft

Pilot testing the Advanced Draft
Finalization of the WHO Guidelines on Hand Hygiene in Health Care
The burden of health care-associated infection
Health care-associated infection in developed countries
Burden of health-care associated infection in developing countries

4.

Historical perspective on hand hygiene in health care

5.

Normal bacterial flora on hands

10

6.

Physiology of normal skin

11

7.

Transmission of pathogens by hands

12

3.1
3.2

7.1
7.2
7.3
7.4
7.5
8.

Organisms present on patient skin or in the inanimate environment

Organism transfer to health-care workers hands
Organism survival on hands
Defective hand cleansing, resulting in hands remaining contaminated
Cross-transmission of organisms by contaminated hands
Models of hand transmission
Experimental models
Mathematical models

22

9.

Relationship between hand hygiene and the acquisition of

health care-associated pathogens

24

10.

Methods to evaluate the antimicrobial efficacy of handrub and

handwash agents and formulations for surgical hand preparation

25

8.1
8.2

10.1
10.2
10.3
11.

Current methods
Shortcomings of traditional test methods
The need for better methods

Review of preparations used for hand hygiene

11.1
11.2
11.3
11.4
11.5
11.6
11.7
11.8
11.9
11.10
11.11
11.12
11.13

30

Water
Plain (non-antimicrobial) soap
Alcohols
Chlorhexidine
Chloroxylenol
Hexachlorophene
Iodine and iodophors
Quaternary ammonium compounds
Triclosan
Other agents
Activity of antiseptic agents against spore-forming bacteria
Reduced susceptibility of microrganisms to antiseptics
Relative efficacy of plain soap, antiseptic soaps and
detergents, and alcohols

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

12.

WHO-recommended handrub formulation

12.1
12.2
13.

Skin reactions related to hand hygiene

Frequency and pathophysiology of irritant contact dermatitis
Allergic contact dermatitis related to hand hygiene products
Methods to reduce adverse effects of agents

61

14.1
14.2
14.3

Factors to consider when selecting hand hygiene products

Pilot testing
Selection factors

64

15.1
15.2

Hand hygiene practices among health-care workers

and adherence to recommendations

66

15.

16.

16.1
16.2
16.3
17.

Hand hygiene practices among health-care workers

Observed adherence to hand cleansing
Factors affecting adherence
Religious and cultural aspects of hand hygiene
Importance of hand hygiene in different religions
Hand gestures in different religions and cultures
The concept of visibly dirty hands
Use of alcohol-based handrubs and alcohol prohibition by some religions
Possible solutions

78

17.1
17.2
17.3
17.4
17.5

Behavioural considerations
Social sciences and health behaviour
Behavioural aspects of hand hygiene

85

18.1
18.2

Organizing an educational programme to promote hand hygiene

89

18.

19.

19.1
19.2
19.3

Process for developing an educational programme when implementing guidelines

Organization of a training programme
The infection control link health-care worker

Formulating strategies for hand hygiene promotion

20.1
20.2
20.3

93

Elements of promotion strategies

Developing a strategy for guideline implementation
Marketing technology for hand hygiene promotion

The WHO Multimodal Hand Hygiene Improvement Strategy

21.1
21.2
21.3
21.4
21.5
22.

Lessons learnt from local production of the WHO-recommended handrub formulations in

different settings worldwide
54

14.

21.

General remarks

Surgical hand preparation: state-of-the-art

Evidence for surgical hand preparation
Objective of surgical hand preparation
Selection of products for surgical hand preparation
Surgical hand antisepsis using medicated soap
Surgical hand preparation with alcohol-based handrubs
Surgical hand scrub with medicated soap or surgical hand preparation
with alcohol-based formulations

13.1
13.2
13.3
13.4
13.5
13.6

20.

49

99

Key elements for a successful strategy

Essential steps for implementation at heath-care setting level
WHO tools for implementation
My five moments for hand hygiene
Lessons learnt from the testing of the WHO Hand Hygiene
Improvement Strategy in pilot and complementary sites

Impact of improved hand hygiene

124

II

CONTENTS

23.

Practical issues and potential barriers to optimal hand hygiene practices

Glove policies
Importance of hand hygiene for safe blood and blood products
Jewellery
Fingernails and artificial nails
Infrastructure required for optimal hand hygiene
Safety issues related to alcohol-based preparations

128

24.

Hand hygiene research agenda

146

PART II.

CONSENSUS RECOMMENDATIONS

151

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Ranking system for evidence

Indications for hand hygiene
Hand hygiene technique
Recommendations for surgical hand preparation
Selection and handling of hand hygiene agents
Skin care
Use of gloves
Other aspects of hand hygiene
Educational and motivational programmes for health-care workers
Governmental and institutional responsibilities
For health-care administrators
For national governments

PART III.

PROCESS AND OUTCOME MEASUREMENT

157

1.

Hand hygiene as a performance indicator

158

23.1
23.2
23.3
23.4
23.5
23.6

1.1
1.2
1.3
1.4
2.
3.

3.1
3.2
3.3
3.4
3.5
3.6
PART IV.

Monitoring hand hygiene by direct methods

The WHO-recommended method for direct observation
Indirect monitoring of hand hygiene performance
Automated monitoring of hand hygiene
Hand hygiene as a quality indicator for patient safety

164

Assessing the economic impact of hand hygiene promotion

168

Need for economic evaluation

Costbenefit and costeffectiveness analyses
Review of the economic literature
Capturing the costs of hand hygiene at institutional level
Typical cost-savings from hand hygiene promotion programmes
Financial strategies to support national programmes

TOWARDS A GENERAL MODEL OF CAMPAIGNING FOR BETTER HAND HYGIENE

A NATIONAL APPROACH TO HAND HYGIENE IMPROVEMENT

174

1.

Introduction

175

2.

Objectives

175

3.

Historical perspective

176

Public campaigning, WHO, and the mass media

177

4.

4.1

National campaigns within health care

5.

Benefits and barriers in national programmes

178

6.

Limitations of national programmes

179

III

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

7.

The relevance of social marketing and social movement theories

7.1
8.

180

Hand hygiene improvement campaigns outside of health care

Nationally driven hand hygiene improvement in health care

181

9.

Towards a blueprint for developing, implementing and evaluating a

national hand hygiene improvement programme within health care

182

10.

Conclusion

182

PART V.

PATIENT INVOLVEMENT IN HAND HYGIENE PROMOTION

189

1.

Overview and terminology

190

2.

Patient empowerment and health care

190

Components of the empowerment process

191

3.

3.1
3.2
3.3
3.4
4.
4.1
5.

5.1
5.2

Patient participation
Patient knowledge
Patient skills
Creation of a facilitating environment and positive deviance
Hand hygiene compliance and empowerment
Patient and health-care worker empowerment

192

Programmes and models of hand hygiene promotion, including patient

and health-care worker empowerment

194

Evidence
Programmes

6.

WHO global survey of patient experiences

195

7.

Strategy and resources for developing, implementing, and evaluating

a patient/health-care worker empowerment programme in a health-care
facility or community

196

PART VI.

COMPARISON OF NATIONAL AND SUB-NATIONAL GUIDELINES FOR HAND HYGIENE

199

REFERENCES

206

APPENDICES

239

1.
2
3.
4
5.
6.

Definitions of health-care settings and other related terms

Guide to appropriate hand hygiene in connection with Clostridium difficile spread
Hand and skin self-assessment tool
Monitoring hand hygiene by direct methods
Example of a spreadsheet to estimate costs
WHO global survey of patient experiences in hand hygiene improvement

240
242
246
247
250
251

ABBREVIATIONS

258

ACKNOWLEDGEMENTS

259

IV

INTRODUCTION

INTRODUCTION
The WHO Guidelines on Hand Hygiene in Health Care provide health-care workers (HCWs), hospital
administrators and health authorities with a thorough review of evidence on hand hygiene in health care and
specific recommendations to improve practices and reduce transmission of pathogenic microorganisms to patients
and HCWs. The present Guidelines are intended to be implemented in any situation in which health care is
delivered either to a patient or to a specific group in a population. Therefore, this concept applies to all settings
where health care is permanently or occasionally performed, such as home care by birth attendants. Definitions of
health-care settings are proposed in Appendix 1. These Guidelines and the associated WHO Multimodal Hand
Hygiene Improvement Strategy and an Implementation Toolkit (http://www.who.int/gpsc/en/) are designed to offer
health-care facilities in Member States a conceptual framework and practical tools for the application of
recommendations in practice at the bedside. While ensuring consistency with the Guidelines recommendations,
individual adaptation according to local regulations, settings, needs, and resources is desirable.
international panel of
experts mandated by
WHO together with
grading of the evidence
and proposes
guidelines that could be
used worldwide.

The development of the Guidelines began in autumn 2004 and

the preparation process is thoroughly described in Part I, Section
2. In brief, the present document is the result of the update and
finalization of the Advanced Draft, issued in April 2006, according
to the literature review and data and lessons learnt from pilot
testing. A Core Group of experts coordinated the work of
reviewing the available scientific evidence, writing

the document, and fostering discussion among authors; more 3

than 100 international experts contributed to preparing the
document. Authors, technical contributors, external reviewers,
and professionals who actively participated in the work process
up to final publication are listed in the Acknowledgements at the 4
end of the document.
The WHO Guidelines on Hand Hygiene in Health Care provide a
comprehensive review of scientific data on hand hygiene
rationale and practices in health care. This extensive review
includes in one document sufficient technical information
to support training materials and help plan implementation
strategies. The document comprises six parts; for convenience, the
figures and tables are numbered to correspond to the part and the
section in which they are discussed:

Part I reviews scientific data on hand hygiene practices in

health care and in health-care settings in particular.

Part II reports consensus recommendations of the

Part
III
discusses
process and outcome
measurements.
Part IV proposes the
promotion
of
hand
hygiene on a large
scale.

Part V covers the

aspect of patient
participation in hand
hygiene promotion.

Part VI reviews existing

national and sub-national
guidelines
for
hand
hygiene.

An Executive Summary of the

Advanced Draft of the
Guidelines is available as a
separate document, in
Chinese, English, French,
Russian and Spanish versions
(http://www.who.
int/gpsc/tools/en/). An
Executive Summary of the
present Guidelines will be
translated into all WHO official
languages.

It is anticipated that the

recommendations in these
Guidelines will remain valid
until 2011. The Patient Safety
Department (Information,
Evidence and Research
Cluster) at WHO
headquarters is committed to
ensuring that the WHO
Guidelines on Hand Hygiene
in Health Care are updated
every two to three years.

PART I.
REVIEW
OF SCIENTIFIC DATA
RELATED TO HAND HYGIENE

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

1.
Definition of terms
Hand hygiene. A general term referring to any action of hand cleansing
(see below Hand hygiene practices).
hands as alcoholbased handrubs or
washing hands with
Hand hygiene products
an antimicrobial
Alcohol-based (hand) rub. An soap and water,
they are not a
alcohol-containing
substitute for using
preparation (liquid, gel or
an alcohol-based
foam) designed for
handrub or
application to the hands
antimicrobial soap.
to inactivate
microorganisms and/or
Detergent
temporarily suppress their
(surfactant).
growth. Such preparations
Compounds that
may contain one or more
possess a cleaning
types of alcohol, other
action. They are
active ingredients with
composed of a
excipients, and
hydrophilic and a
humectants.
lipophilic part and
can be divided into
Antimicrobial (medicated)
four groups: anionic,
soap. Soap (detergent)
containing an antiseptic agent cationic, amphoteric,
at a concentration sufficient to and non-ionic.
Although products
inactivate microorganisms
and/or temporarily suppress used for
handwashing or
their growth. The detergent
antiseptic handwash
activity of such soaps may
in health care
also dislodge transient
represent
microorganisms or other
contaminants from the skin to various types of
detergents, the term
facilitate their subsequent
soap will be used to
removal by water.
refer to such
detergents in these
Antiseptic agent. An
antimicrobial substance that guidelines.

inactivates microorganisms
or inhibits their growth on
living tissues. Examples
include alcohols,
chlorhexidine gluconate
(CHG), chlorine derivatives,
iodine, chloroxylenol
(PCMX), quaternary
ammonium compounds,
and triclosan.
Antiseptic hand wipe. A
piece of fabric or paper prewetted with an antiseptic
used for wiping hands to
inactivate and/or remove
microbial contamination.
They may be considered as
an alternative to washing
hands with nonantimicrobial soap and
water but, because they are
not as effective at reducing
bacterial counts on HCWs

Plain soap.
Detergents that
contain no added
antimicrobial
agents, or may
contain these
solely as
preservatives.

Waterless antiseptic
agent. An antiseptic
agent (liquid, gel or
foam) that does not
require the use of
exogenous water.
After application, the
individual rubs the
hands together until
the skin feels dry.

Hand hygiene
practices

Antiseptic
handwashing.
Washing hands with
soap and water, or
other detergents
containing an
antiseptic agent.

erming, handwashing
with an antimicrobial
soap and water,
hygienic hand
antisepsis, or hygienic
handrub. Since
microorganisms without the disinfection refers
normally to the
need for an exogenous
decontamination of
source of water and
requiring no rinsing or drying inanimate surfaces
with towels or other devices. and objects, this term
is not used in these
Guidelines.
Hand
Antiseptic handrubbing
(or handrubbing).
Applying an antiseptic
handrub to reduce or
inhibit the growth of

antisepsis/decontamination/deg
erming. Reducing or inhibitingHygienic hand
the growth of microorganismsantisepsis.
by the application of anTreatment of
antiseptic
handrub
or
byhands with either
performing
an
antiseptican antiseptic
handrub or
handwash.

antiseptic
handwash to
Hand care. Actions to
reduce the
reduce the risk of skin
transient microbial
damage or irritation.
flora without
necessarily
Handwashing. Washing
affecting the
hands with plain or
antimicrobial soap and water. resident skin flora.
Hygienic handrub.
Treatment of hands
with an antiseptic
handrub to reduce
the transient flora
without necessarily
affecting the
resident skin flora.
Hand disinfection is extensively These preparations
used as a term in some parts of are broad spectrum
and fast-acting, and
the world and can refer to
antiseptic handwash, antiseptic persistent activity is
not necessary.
handrubbing, hand
Hand cleansing. Action of
performing hand hygiene
for
the
purpose
of
physically or mechanically
removing dirt, organic
material,
and/or
microorganisms.

antisepsis/decontamination/deg
2

Hygienic handwash.
Treatment of hands
with an antiseptic
handwash and
water to reduce the
transient flora
without necessarily
affecting the
resident skin flora. It
is broad spectrum,
but is usually less
efficacious and acts
more slowly than
the hygienic
handrub.
Surgical hand
antisepsis/surgical
hand preparation/
presurgical hand
preparation.
Antiseptic handwash
or antiseptic handrub
performed
preoperatively by the
surgical team to
eliminate transient
flora and reduce
resident skin flora.
Such antiseptics
often have persistent
antimicrobial activity.

Surgical
handscrub(bing)/pres
urgical scrub refer to
surgical hand
preparation with
antimicrobial soap
and water. Surgical
handrub(bing) refers
to surgical hand
preparation with a
waterless, alcoholbased handrub.

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

environment.

Associated
terms

Humectant.
Ingredient(s)
added to hand
hygiene
products to
moisturize the
skin.

Cumulative
Medical
effect. Increasing gloves.
antimicrobial
Disposable
effect with
gloves used
repeated
during
applications of a medical
given antiseptic. procedures;
they include
Efficacy/efficace examination
ous. The
(sterile or
(possible) effect non-sterile)
of the application gloves,
of a hand
surgical
hygiene
gloves, and
formulation when medical
tested in
gloves for
laboratory or in handling
vivo situations. chemothera
py agents
Effectiveness/eff (chemother
ective. The
apy gloves).
clinical
conditions under Patient zone.
which a hand
Concept related
hygiene product to the
has been tested geographical
for its potential to visualization of
reduce the
key moments for
spread of
hand hygiene. It
pathogens, e.g. contains the
field trials.
patient X and
Excipient. Inert
substance
included in a
product
formulation to
serve as a
vehicle for the
active
substance.
Health-care
area. Concept
related to the
geographical
visualization
of key
moments for
hand hygiene.
It contains all
surfaces in
the healthcare setting
outside the
patient zone
of patient X,
i.e. other
patients and
their patient
zones and the
health-care
facility

his/her
immediate
surroundings.
This typically
includes the
intact skin of the
patient and all
inanimate
surfaces that are
touched by or in
direct physical
contact with the
patient such as
the bed rails,
bedside table,
bed linen,
infusion tubing
and other
medical
equipment. It
further contains
surfaces
frequently
touched by
HCWs while
caring for the
patient such as
monitors, knobs
and buttons, and
other high
frequency touch
surfaces.

Persistent
activity. The
prolonged or
extended
antimicrobial
activity that
prevents the
growth or
survival of
microorganism
s after
application of a
given
antiseptic; also
called
residual,
sustained or
remnant
activity. Both
substantive
and nonsubstantive
active
ingredients can
show a
persistent
effect
significantly
inhibiting the
growth of
microorganism
s after
application.
Point of care.
The place where
three elements
come together:
the patient, the
HCW, and care
or treatment
involving contact
with the patient
or his/her
surroundings
(within the
patient zone).1
The concept
embraces the
need to perform
hand hygiene at
recommended
moments exactly
where care
delivery takes
place. This
requires that a
hand hygiene
product (e.g.
alcohol-based
handrub, if
available) be
easily accessible
and as close as
possible within
arms reach of
where patient
care or treatment
is taking place.
Point-of-care
products should
be accessible

without having to
leave the patient
zone.

Resident flora
(resident
Substantivity.
microbiota).
Microorganisms An attribute of
residing under some active
ingredients that
the superficial
adhere to the
cells of the
stratum corneum stratum
and also found corneum and
on the surface of provide an
inhibitory effect
the skin.
on the growth
of bacteria by
remaining on
the skin after
rinsing or
drying.
Surrogate
microorganism. A
microorganism
used to
represent a given
type or category
of nosocomial
pathogen when
testing the
antimicrobial
activity of
3

antiseptics.
Surrogates are
selected for their
safety, ease of
handling, and
relative
resistance to
antimicrobials.
Transient
flora
(transient
microbiota).
Microorgani
sms that
colonize the
superficial
layers of
the skin
and are
more
amenable
to removal
by routine
handwashin
g.
Visibly soiled
hands. Hands
on which dirt
or body fluids
are readily
visible.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

2.
Guidelines preparation process
The preparation process of the WHO Guidelines on Hand Hygiene in Health Care involved the steps that are
briefly described in this section.
2.1 Preparation of the Advanced Draft
The present guidelines were developed by the Clean
Care is Safer Care team (Patient Safety Department,
Information, Evidence and Research Cluster).
A Core Group of international experts in the field of
infection control, with specific expertise in hand hygiene,
participated in the writing and revision of the document.
The group was constituted at WHO Headquarters in
Geneva in December 2004. During its first meeting, the
experts discussed the approach to be emphasized in these
guidelines and their content and drew up a plan for their
preparation. The objectives identified were to develop a
document including a comprehensive overview of
essential aspects of hand hygiene in health care and
evidence- and consensus-based recommendations for
optimal hand hygiene practices and
successful hand hygiene promotion. Users were meant to be
policy-makers, managers and HCWs in different settings and
geographical areas. It was decided to adopt the CDC
Guideline for Hand Hygiene in Health-Care Settings issued in
2002 as

a basis for the present document but to introduce many

new topics. A distinctive feature of the present Guidelines
is the fact that they were conceived with a global
perspective; therefore, they are not targeted at only
developing or developed countries, but at all countries
regardless of the resources available (see also Part VI).
Various task forces were established (Table I.2.1) to
examine different controversial topics in depth and reach
consensus on the best approach to be included in the
document for both implementation and research purposes.
According to their
expertise, authors were assigned various chapters, the
content of which had to be based on the scientific literature
and their experience. A systematic review of the literature was
performed through PubMed (United States National Library of
Medicine), Ovid, MEDLINE, EMBASE, and the Cochrane
Library, and secondary papers were identified from reference
lists and existing relevant guidelines. International and
national infection control guidelines and textbooks were also
consulted. Authors provided the list of keywords that they
used for use in the next update of the Guidelines.
In April 2005 and March 2006, the Core Group reconvened
at WHO Headquarters in Geneva for task force meetings,
final revision, and consensus on the first draft.
Recommendations were formulated on the basis of the
evidence described in the various sections; their terminology
and consistency were
discussed in depth during the expert consultations. In
addition to expert consensus, the criteria developed by the
Healthcare Infection Control Practices Advisory Committee
(HICPAC) of the United States Centers for Disease Control
and Prevention (CDC), Atlanta, GA, were used to categorise

the consensus
recommendations in the
WHO Guidelines for Hand
Hygiene

in Health Care (Table I.2.2). In

the case of difficulty in
reaching consensus, the
voting system was adopted.
The final draft was submitted
to a list of external and
internal reviewers whose
comments were considered
during the March 2006 Core
Group consultation. The
Advanced Draft of the WHO
Guidelines on Hand Hygiene
in Health Care was published
in April 2006.

2.2 Pilot testing the

Advanced Draft
According to WHO
recommendations for
guideline preparation, a
testing phase of the
guidelines was undertaken.
In parallel with the Advanced
Draft, an implementation
strategy
(WHO Multimodal Hand
Hygiene Improvement
Strategy) was
developed, together with
a wide a range of tools
(Pilot

Implementation Pack) to
help health-care settings to
translate the guidelines into
practice (see also Part I,
Sections 21.14). The aims
of this testing were: to
provide local data on the
resources required to carry
out the recommendations; to
generate information on
feasibility, validity, reliability,
and cost effectiveness of
the interventions; and to
adapt and refine proposed
implementation strategies.
Eight pilot sites from seven
countries representing the
six WHO regions were
selected for pilot testing and
received technical and, in
some cases, financial
support from the First Global
Patient Safety Challenge
team (see also Part I,
Section 21.5). Other health-

care settings around the world volunteered to participate chapters by the same
autonomously in the testing phase, and these were named deadline. The First Global
complementary test sites. Analysis of data and evaluation Patient Safety Challenge
team and the Guidelines
of the lessons learnt from pilot and complementary sites
were undertaken and are reported in Part I, Section 21.5. editor contributed with the
content of several chapters
and took the responsibility to
revise the updated and new
2.3 Finalization of the WHO Guidelines on
material, to perform technical
Hand Hygiene in Health Care
editing, and to add any further
In August 2007, the expert Core Group reconvened in Geneva relevant reference published
between October 2007 and
to start the process of guideline finalization. Authors were
June 2008. Six new chapters,
asked to update their text according to relevant new
11 additional paragraphs, and
publications up to October 2007 and to return the work by
three new appendices were
December 2007; some authors were asked to write new
4

added in the present final

version compared with the
Advanced Draft. External and
internal

reviewers were asked again

to comment on the new
parts of the guidelines.
In September 2008, the last
Core Group consultation took
place in Geneva. The final
draft of the Guidelines was
circulated

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

ahead of the meeting, including relevant comments from the

reviewers. A specific session of the meeting was dedicated to
the evaluation of data and lessons learnt from the testing sites
and how to integrate these aspects into the text. Final
discussion took place about the content of the final version of

the document with a particular focus on the

recommendations and the research agenda, and reviewers
comments and queries; approval was obtained by
consensus. Following the consultation, the final amendments
and insertions were made and, at the latest stage, the
document was submitted to a WHO reference editor.

Table I.2.1
Task forces for discussion and expert consensus on critical issues related to hand hygiene in health care
Task forces on hand hygiene in health care

Behavioural changes

Education/training/tools

WHO-recommended hand antisepsis formulations

Glove use and reuse

Water quality for handwashing

Patient involvement

Religious and cultural aspects of hand hygiene

Indicators for service implementation and monitoring

Regulation and accreditation

10

Advocacy/communication/campaigning

11

National guidelines on hand hygiene

12

Frequently asked questions development

Table I.2.2
Modified CDC/HICPAC ranking system for evidence
CATEGORY

CRITERIA

IA

Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or
epidemiological studies.

IB

Strongly recommended for implementation and supported by some experimental, clinical, or epidemiological
studies and a strong theoretical rationale.

IC

Required for implementation, as mandated by federal and/or state regulation or standard.

II

Suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical
rationale or a consensus by a panel of experts.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

3.
The burden of health care-associated infection
This section summarizes the epidemiological data and relevant issues related to the global burden of health
care-associated infection (HCAI) and emphasizes the importance of preventing HCAI by giving priority to the
promotion of hand hygiene best practices in health care. When available, national or multicentre surveys were
preferred to single hospital surveys, and only studies or reports published in English were considered. This
overview of available data on HCAI is therefore not to be considered exhaustive, but rather as an informative,
evidence-based introduction to the topic of hand hygiene in health care.
HCAI is a major problem for patient safety and its surveillance
and prevention must be a first priority for settings and
institutions committed to making health care safer. The impact
of HCAI implies prolonged hospital stay, long-term disability,
increased resistance of microorganisms to antimicrobials,
massive additional financial burden, high costs for patients and
their families, and excess deaths. Although the risk of acquiring
HCAI is universal and pervades every health-care facility
and system around the world, the global burden is unknown
because of the difficulty of gathering reliable diagnostic
data. Overall estimates indicate that more than 1.4 million
patients worldwide in developed and developing countries are
affected at any time.2 Although data on the burden of diseases
worldwide that are published in WHOs World Health Reports
inform HCWs, policy-makers, and the public of the most
important diseases in terms of morbidity and mortality, HCAI
does not appear on the list of the 136 diseases evaluated.3 The
most likely reason is that the diagnosis of HCAI is complex,
relying on multiple criteria and not on a single laboratory test. In
addition, although national surveillance systems exist in many
industrialized countries,4 e.g. the National Nosocomial Infection
Surveillance (NNIS) system in the United States of America
(USA) (http://www.cdc.gov/ncidod/dhqp/nnis.html), they often
use different diagnostic criteria and methods, which render
international comparisons difficult due to benchmarking
obstacles. In developing countries, such systems are seldom in

place. Therefore, in many settings, from hospitals to

ambulatory and long-term care, HCAI appears to be a
hidden, cross-cutting concern that no institution or country
can claim to have solved as yet.
For the purpose of this review on the HCAI burden worldwide,
countries are ranked as developed and developing
according to the World Bank classification based on their
estimated per capita income (http://siteresources.worldbank.
org/DATASTATISTICS/Resources/CLASS.XLS).

Control through
Surveillance
(HELICS)
In developed countries, HCAI concerns 5 (http://helics.univ15% of hospitalized patients and can
lyon1.fr/helicshome
affect 937% of those admitted to
. htm),
approximately 5
intensive care units (ICUs).2,5 Recent
million HCAIs are
studies conducted in Europe reported
hospital-wide prevalence rates of patients estimated to occur
in acute care
affected by HCAI ranging from 4.6% to
hospitals in Europe
9.3%.6-14 According to data provided by
the Hospital in Europe Link for Infection annually,

3.1 Health care-associated

infection in developed countries

25 million extra days of

hospital stay and a
corresponding economic
burden of 1324 billion. In
general, attributable mortality
due to HCAI in Europe is
estimated to be 1% (50 000
deaths per year), but HCAI
contributes to death in at
least 2.7% of cases (135 000
deaths per year). The
estimated HCAI incidence
rate in the USA was 4.5% in
2002, corresponding to 9.3
infections per 1000 patientdays and 1.7 million affected
patients; approximately 99
000 deaths were attributed to
HCAI.7 The annual economic
impact of HCAI in the USA
was approximately US$ 6.5
billion in 2004.15
In the USA, similar to the
position in other
industrialized countries,
the most frequent type of
infection hospitalwide is
urinary tract infection
(UTI) (36%), followed by
surgical site infection
(SSI) (20%), bloodstream
infection (BSI), and
pneumonia (both 11%).7 It
is noteworthy, however,
that some infection types
such as BSI and
ventilator-associated
pneumonia have a more
severe impact than others
in terms of mortality and
extra-costs. For instance,
representing
around

the mortality rate

directly attributable to BSIs in
ICU patients has been
estimated to be 1640% and
prolongation of the length of
stay 7.525 days.16,17
Furthermore, nosocomial BSI,
estimated to account for 250
000 episodes every year in
the USA, has shown a trend
towards increasing frequency
over the last decades,
particularly in cases due to
antibiotic-resistant
organisms.18
The HCAI burden is greatly
increased in high-risk
patients such as those
admitted to ICUs.
Prevalence rates of
infection acquired in ICUs
vary from 9.731.8% in
Europe19 and 937% in the
USA, with crude mortality
rates ranging from 12% to
80%.5 In the USA, the
national infection rate in
ICUs was estimated to be
13 per 1000 patient-days in
2002.7 In ICU settings
particularly, the use of
various invasive devices
(e.g. central venous
catheter, mechanical
ventilation or urinary

catheter) is one of the most

important risk factors for
acquiring HCAI. Deviceassociated infection rates
per
1000
device-days
detected through the NNIS
System in the USA are
summarized in Table I.3.1.20
In surveillance
pathogens most
studies conducted
frequently
in developed
detected in HCAI
countries, HCAI
are reported by
diagnosis relies
infection site both
mostly on
hospitalwide and
microbiological
in ICUs.21,22
and/or laboratory
Furthermore, in
criteria. In largehigh-income
scale studies
countries with
conducted in the
modern and
USA, the

sophisticated health-care provision,

many factors have been shown to be
associated with the risk of acquiring an

HCAI. These
factors can be
related to the
6

infectious agent
(e.g. virulence,
capacity to

survive in the
environment,
antimicrobial

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

well
demonstrated by
an electronic
search of the
period 1995
2008, which
allowed the
resistance), the retrieval of
host (e.g.
around 200
advanced age, scientific papers
low birthweight, published in
underlying
English and
diseases, state approximately
of debilitation,
100 in other
immunosuppre languages.23
ssion,
Overall, no more
malnutrition),
than 80 of these
and the
papers featured
environment
rigorous, high
(e.g. ICU
quality,
27,30,33-35,43-47
methodological
characteristics.

admission,
prolonged
hospitalization,
invasive
devices and
procedures,
antimicrobial
therapy).

3.2 Burden
of health
careassociated
infection in
developing
countries

The magnitude of
the problem is
particularly
relevant in
settings where
basic infection
control measures
are virtually nonexistent. This is
the result of the
combination of
numerous
unfavourable
factors such as
understaffing,
poor hygiene

While HCAI
surveillance is
already a
challenging task
in highly
resourced
settings, it may
often appear an
unrealistic goal in
everyday care in
developing
countries. In
addition to the
usual difficulties
to define the
diagnosis of
HCAI must be
added the paucity
and unreliability
of laboratory
data, lack of
standardized
information from
medical records,
and scarce
access to
radiological
facilities. Limited
data on HCAI
from these
settings are
available from the
literature. This is

and sanitation,
lack or shortage
of basic
equipment, and
inadequate
structures and
overcrowding,
almost all of
which can be
attributed to
limited financial
resources. In
addition to these
specific factors,
an unfavourable
social
background and
a population
largely affected
by malnutrition
and other types
of infection
and/or diseases
contribute to
increase the risk
of HCAI in
developing
countries.24,25
Under these
conditions,
thousands of
infections in
particular due to
hepatitis B and C

viruses and
human
immunodeficienc
y virus (HIV)
transmission
are still acquired
from patients,
but also from
HCWs through
unsafe use of
injections,
medical devices
and blood
products,
inadequate
surgical
procedures, and
deficiencies in
biomedical waste
management.24
When
referring to
endemic
HCAI, many
studies
conducted in
developing
countries
report
hospitalwide
rates higher
than in
developed
countries.
Nevertheless,
it is important
to note that
most of these
studies
concern single
hospitals and
therefore may
not be
representative
of the problem
across the
whole
country.26-36
For example,
in one-day
prevalence
surveys
recently
carried out in
single
hospitals in
Albania,36
Morocco,35
Tunisia,34 and
the United
Republic of
Tanzania,33
HCAI prevalence
rates were
19.1%, 17.8%,
17.9%, and
14.8%,
respectively.
Given the
difficulties to
comply with the
USA Centers for
Disease Control

and urinary
catheters,
and sedative

and Prevention
(CDC) definitions
of nosocomial
infection,37 the
most frequently
surveyed type of
infection is SSI,
which is the
easiest to define
according to

medication.

infection rates,
several-fold
higher than in
developed
clinical criteria. countries. As an
The risk for
example, in
patients to
Table I.3.1,
develop SSI in devicedeveloping
associated
countries is
infection rates
significantly
reported from
higher than in
multicentre
developed
studies
countries (e.g. conducted in
30.9% in a
adult and
paediatric
paediatric ICUs
hospital in
are compared
Nigeria,38 23% in with the USA
general surgery NNIS

in a hospital in
the United
Republic of
Tanzania,33 and
19% in a
maternity unit in
Kenya39 ).
The burden
of HCAI is
also much
more
severe
in
high-risk
populations
such
as
adults
housed in
ICUs
and
neonates,
with general
infection
rates,
particularly
deviceassociated

system
rates.20,40,41 In
a systematic
review of the
literature,
neonatal
infections
were reported
to be 320
times higher
among
hospital-born
babies in
developing
than in
developed
countries.42
A very limited
number of
studies from
developing
countries
assessed
HCAI risk
factors by
multivariate
analysis. The
most
frequently
identified
were
prolonged
length of
stay, surgery,
intravascular

The magnitude
and scope of the
HCAI burden
worldwide
appears to be
very important
and greatly
underestimated.
Methods to
assess the size
and nature of the
problem exist and
can contribute to
correct monitoring
and to finding
solutions.
Nevertheless,
these tools need
to be simplified
and adapted
so as to be
affordable in
settings where
resources and
data sources
are limited.
Similarly,
preventive
measures
have been
identified and
proven
effective; they
are often
simple to
implement,
such as hand
hygiene.
However,
based on an
improved
awareness of
the problem,
infection
control must
reach a higher
position
among the
first priorities
in national
health
programmes,
especially in
developing
countries.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.3.1
Device-associated infection rates in ICUs in developing countries compared with NNIS rates
Surveillance network,
study period, country

Setting

No. of patients

CR-BSI*

VAP*

CR-UTI*

INICC, 20032005,
5 developing countries41

PICU

1,529

16.1

10.6

5.3

NNIS, 20022004, USA20

PICU

6.6

2.9

4.0

INICC, 20022005,
8 developing countries*

Adult
ICU

21,069

12.5

24.1

8.9

NNIS, 20022004, USA20

Adult
ICU

4.0

5.4

3.9

* Overall (pooled mean) infection rates/1000 device-days.

INICC = International Nosocomial Infection Control Consortium; NNIS = National Nosocomial Infection Surveillance system; PICU =
paediatric intensive care unit; CR-BSI = cather-related bloodstream infection; VAP = ventilator-associated pneumonia; CR-UTI = catheterrelated urinary tract infection.
Argentina, Colombia, Mexico, Peru, Turkey
Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, Turkey
Reproduced from Pittet, 200825 with permission from Elsevier.

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

4.
Historical perspective
on hand hygiene in health care
Handwashing with soap and water has been considered a measure of personal hygiene for centuries 48,49 and has
been generally embedded in religious and cultural habits (see Part I, Section 17). Nevertheless, the link between
handwashing and the spread of disease was established only two centuries ago, although this can be considered
as relatively early with respect to the discoveries of Pasteur and Lister that occurred decades later.
The 1980s represented a
In the mid-1800s, studies by Ignaz Semmelweis in Vienna, Austria, landmark in the evolution of
concepts of hand hygiene in
and Oliver Wendell Holmes in Boston, USA, established that
health care. The first national
hospital-acquired diseases were transmitted via the hands of
HCWs. In 1847, Semmelweiss was appointed as a house officer in hand hygiene
one of the two obstetric clinics at the University
guidelines were published in the 1980s, followed by several
of Vienna Allgemeine Krankenhaus (General Hospital). He
others in more recent years in
observed that maternal mortality rates, mostly attributable to
different countries. In 1995 and
puerperal fever, were substantially higher in one clinic compared
1996, the CDC/Healthcare
with the other (16% versus 7%).50 He also noted that doctors and
Infection Control Practices
medical students often went directly to the delivery suite after
Advisory Committee (HICPAC)
performing autopsies and had a disagreeable odour on their hands
in the USA recommended that
despite handwashing with soap and water before entering the clinic. either antimicrobial soap or a
He hypothesized therefore that cadaverous particles were
waterless antiseptic agent be
transmitted via the hands of doctors and students from the autopsy
used56,57 for cleansing hands
room to the delivery theatre and caused the puerperal fever. As a
upon leaving the rooms of
consequence, Semmelweis recommended that hands be scrubbed patients with multidrugin a chlorinated lime solution before every patient contact and
resistant pathogens. More
particularly after leaving the autopsy room. Following the
recently, the HICPAC
implementation of this measure, the mortality rate fell dramatically
guidelines issued in 200258
to 3% in the clinic most affected and remained low thereafter.
defined alcohol-based
handrubbing, where available,
Apart from providing the first evidence that cleansing heavily
as the standard of care for
contaminated hands with an antiseptic agent can reduce
hand hygiene practices in
nosocomial transmission of germs more effectively than
health-care settings, whereas
handwashing with plain soap and water, this approach includes all handwashing is reserved for
the essential elements for a successful infection control
particular situations only.59 The
intervention: recognize-explain-act.51 Unfortunately, both Holmes present guidelines are based
and Semmelweis failed to observe a sustained change in their
on this previous document and
colleagues behaviour. In particular, Semmelweis experienced great represent the most extensive
difficulties in convincing his colleagues and administrators of the
review of the evidence related
benefits of this procedure. In the light of the principles of social
to hand hygiene in the
marketing today, his major error was that he imposed a system
literature. They aim to expand
change (the use of the chlorinated lime solution) without consulting the scope of recommendations
the opinion of his collaborators. Despite these drawbacks, many
to a global perspective, foster
lessons have been learnt
discussion and expert
consultation on controversial
from the Semmelweis intervention; the recognize-explain-act
issues related to hand hygiene
approach has driven many investigators and practitioners since
in health
then and has also been replicated in different fields and settings.
care, and to propose
Semmelweis is considered not only the father of hand

hygiene, but his intervention is also a model of

epidemiologically driven strategies to prevent infection.

a practical approach
for successful
implementation (see
also Part VI).

A prospective controlled trial conducted in a hospital nursery52

and many other investigations conducted over the past 40
As far as the implementation
years have confirmed the important role that contaminated
HCWs hands play in the transmission of health care-associated of recommendations on
hand hygiene improvement
pathogens (see Part I, Sections 79).

significant progress has

been achieved since the
introduction and validation of
the concept that promotional
strategies must be
53-55
multimodal to
achieve any degree of
success. In 2000, Pittet et al.
reported the experience of
the Genevas University
Hospitals with
the implementation of a
strategy based on several
essential components and
not only the introduction of
an alcohol-based handrub.
The study showed
remarkable results in terms
of
an improvement in hand
hygiene compliance
improvement and HCAI
reduction.60 Taking inspiration
from this innovative
approach, the results of which
were also demonstrated to be
long-lasting,61 many other
studies including further
original aspects have
enriched the scientific
literature (see Table I.22.1).
Given its very solid evidence
base, this model has been
adopted by the First Global
Patient Safety Challenge to
develop the WHO Hand
Hygiene Improvement Strategy
aimed at translating into
practice the recommendations
included in the present
guidelines. In this final version
of the guidelines, evidence
generated from the pilot testing
of the strategy during 2007
2008 is included (see also Part
I, Section 21.5).62

is concerned, very
9

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

5.
Normal bacterial flora on hands
In 1938, Price63 established that bacteria recovered from the hands could be divided into two categories, namely
resident or transient. The resident flora (resident microbiota) consists of microorganisms residing under the
superficial cells of the stratum corneum and can also be found on the surface of the skin. 64,65 Staphylococcus
epidermidis is the dominant species,66 and oxacillin resistance is extraordinarily high, particularly among HCWs.67
Other resident bacteria include S. hominis and other coagulase-negative staphylococci, followed by coryneform
bacteria (propionibacteria, corynebacteria, dermobacteria, and micrococci).68 Among fungi, the most common
genus of the resident skin flora, when present, is Pityrosporum (Malassezia) spp.69. Resident flora has two main
protective functions: microbial antagonism and the competition for nutrients in the ecosystem. 70 In general, resident
flora is less likely to be associated with infections, but may cause infections in sterile body cavities, the eyes, or on
non-intact skin.71
Normal human skin is
Transient flora (transient microbiota), which colonizes the
colonized by bacteria, with total
superficial layers of the skin, is more amenable to removal by
aerobic bacterial counts
routine hand hygiene. Transient microorganisms do not usually
ranging from more than 1 x 106
multiply on the skin, but they survive and sporadically multiply on colony forming units (CFU)/cm2
skin surface.70 They are often acquired by HCWs during direct
on the scalp, 5 x 105 CFUs/cm2
contact with patients or contaminated environmental surfaces
in the axilla, and 4 x 104
adjacent to the patient and are the organisms most frequently
CFU/cm2 on the abdomen to 1
associated with HCAIs. Some types of contact during routine
x 104 CFU/cm2 on the
neonatal care are more frequently associated with higher levels of
forearm.77 Total bacterial
bacterial contamination of HCWs hands: respiratory secretions,
counts on the hands of HCWs
nappy/diaper change, and direct skin contact.72,73 The
have ranged from 3.9 x 104 to
transmissibility of transient flora depends on the species present,
4.6 x 106 CFU/cm2. 63,78-80
the number of microorganisms on the surface, and
Fingertip contamination ranged
the skin moisture.74,75 The hands of some HCWs may
from 0 to 300 CFU when
become persistently colonized by pathogenic flora such as
sampled by agar contact
S. aureus, Gram-negative bacilli, or yeast.76
methods.72 Price and

subsequent investigators
documented that although the
count of transient and resident
flora varies considerably
among individuals, it is often
relatively constant for any
given individual.63,81

1
0

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

6.
Physiology of normal skin
The skin is composed of three layers, the epidermis (50100 m), dermis (12 mm) and hypodermis
(12 mm) (Figure I.6.1). The barrier to percutaneous absorption lies within the stratum corneum, the
most superficial layer of the epidermis. The function of the stratum corneum is to reduce water loss,
provide protection against abrasive action and microorganisms, and generally act as a permeability
barrier to the environment.
The epidermis is a
dynamic structure
and the renewal of
the stratum corneum is
controlled by
of insoluble bundled keratins surrounded by a cell
complex regulatory
envelope stabilized by cross-linked proteins and
systems of cellular
covalently bound lipids. Corneodesmosomes are
differentiation.
membrane junctions interconnecting corneocytes and
Current knowledge of
contributing to stratum corneum cohesion. The
function of the
intercellular space between corneocytes is composed of the
stratum corneum has
lipids primarily generated from the exocytosis of
come
from studies of
lamellar bodies during the terminal differentiation of the the epidermal
keratinocytes. These lipids are required for a competent
responses
to
skin barrier function.
perturbation of the
skin barrier such as:
(i) extraction of skin
The epidermis is composed of 1020 layers of cells.
lipids with apolar
This pluristratified epithelium also contains
solvents; (ii)
melanocytes involved in skin pigmentation, and
physical stripping of the
stratum corneum using
Langerhans cells, involved in antigen presentation
adhesive tape; and (iii)
and immune responses. The epidermis, as for any
chemically-induced
epithelium, obtains its nutrients from the dermal
irritation. All such
vascular network.
experimental
manipulations lead to a
transient decrease of
Figure I.6.1
the skin barrier efficacy
The anatomical layers of the cutaneous tissue
as determined by
transepidermal water
The stratum corneum is a 1020 m thick, multilayer stratum of flat,
polyhedral-shaped, 2 to 3 m thick, non-nucleated cells named
corneocytes. Corneocytes are composed primarily

loss. These alterations of

the stratum corneum
generate an increase of
keratinocyte
proliferation and
differentiation in
response to this
aggression in order to
restore the skin barrier.
This increase in the
keratinocyte
proliferation rate could
directly influence
the integrity of the skin
barrier by perturbing: (i)
the uptake of nutrients,
such as essential fatty
acids; (ii) the synthesis of
proteins and lipids; or (iii) the
processing of precursor
molecules required for skin
barrier function.

Subcutaneous tissue
Anatomical layers

Epidermis
Dermis

Superficial fascia

Deep
fascia

Subcutaneous tissue

Mus
cle
11

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

7.
Transmission of pathogens by hands
Transmission of health care-associated pathogens from one patient to another via HCWs hands requires five
sequential steps (Figures I.7.16): (i) organisms are present on the patients skin, or have been shed onto
inanimate objects immediately surrounding the patient; (ii) organisms must be transferred to the hands of HCWs;
(iii) organisms must be capable of surviving for at least several minutes on HCWs hands; (iv) handwashing
or hand antisepsis by the HCW must be inadequate or entirely omitted, or the agent used for hand hygiene
inappropriate; and (v) the contaminated hand or hands of the caregiver must come into direct contact with
another patient or with an inanimate object that will come into direct contact with the patient. Evidence
supporting each of these elements is given below.
colonized with P. mirabilis
7.1 Organisms present on patient skin or in the
and found 10600 CFU/ml in
inanimate environment
glove juice samples. Pittet
and colleagues72 studied
Health care-associated pathogens can be recovered not only from contamination of HCWs
infected or draining wounds, but also from frequently colonized
hands before and after direct
areas of normal, intact patient skin.82-96 The perineal or inguinal
patient contact, wound care,
areas tend to be most heavily colonized, but the axillae, trunk, and intravascular catheter care,
upper extremities (including the hands) are also frequently
respiratory tract care or
colonized.85,86,88,89,91,93,97 The number of organisms such as S.
handling patient secretions.
aureus, Proteus mirabilis, Klebsiella spp. and
Using agar fingertip
Acinetobacter spp. present on intact areas of the skin of some patients impression plates, they found
can vary from 100 to 106 CFU/cm2.86,88,92,98 Diabetics, patients
that the number of bacteria
undergoing dialysis for chronic renal failure, and those with chronic
recovered from fingertips
dermatitis are particularly likely to have skin areas colonized with S.
ranged from 0 to 300 CFU.
aureus.99-106. Because nearly 106 skin squames containing viable
Direct patient contact and
microorganisms are shed daily from normal skin,107 it is not surprising respiratory tract care were
that patient gowns, bed linen, bedside furniture and other objects in the most likely to contaminate
immediate environment of
the fingers of caregivers.
Gram-negative bacilli
the patient become contaminated with patient flora. 93-96,108-114
accounted for 15% of isolates
Such contamination is most likely to be due to
staphylococci, enterococci or Clostridium difficile which are more and S. aureus for 11%.
Importantly, duration of patientresistant to desiccation. Contamination of the inanimate
care activity was strongly
environment has also been detected on ward handwash station
associated with the intensity of
surfaces and many of the organisms isolated were
bacterial contamination of
staphylococci.115 Tap/ faucet handles were more likely to be
contaminated and to be in excess of benchmark values than other HCWs hands in this study. A
similar study of hand
parts of the station. This study emphasizes the potential
contamination during routine
importance of environmental contamination on microbial cross
neonatal care defined skin
contamination and pathogen spread.115 Certain Gram-negative
rods, such as Acinetobacter baumannii, can also play an important contact, nappy/diaper change,
role in environmental contamination due to their long-time survival and respiratory care as
independent predictors of hand
capacities.116-119
contamination.73 In the latter
study, the use of gloves did not
7.2 Organism transfer to health-care workers hands
fully protect HCWs hands from
bacterial contamination, and
Relatively few data are available regarding the types of patientglove contamination was
care activities that result in transmission of patient flora to
almost as high as ungloved
hand contamination following
HCWs hands.72,89,110,111,120-123 In the past, attempts have been
patient contact. In contrast, the
made to stratify patient-care activities into those most likely to
124
use of gloves during
cause hand contamination, but such stratification schemes
procedures such as nappy/
were never validated by quantifying the level of bacterial
diaper change and respiratory
contamination that occurred. Casewell & Phillips121
care almost halved the average
demonstrated that nurses could contaminate their hands with
increase of bacteria CFU/min
1001000 CFU of Klebsiella spp. during clean activities such
on HCWs hands.73
as lifting patients; taking the patients pulse, blood pressure or
oral temperature; or touching the patients hand, shoulder or
groin. Similarly, Ehrenkranz and colleagues88 cultured the hands Several other studies have
documented that HCWs can
of nurses who touched the groin of patients heavily
contaminate their hands or
gloves with Gram-negative

bacilli, S. aureus, enterococci

or C. difficile by performing
clean procedures or
touching intact areas of skin
of hospitalized
patients.89,95,110,111,125,126 A
recent study that involved
culturing HCWs hands after
various activities showed that
hands were contaminated
following patient contact and
after contact with body fluids
or waste.127 McBryde and
colleagues128 estimated the
frequency of HCWs glove
contamination with
methicillin-resistant S.
aureus (MRSA) after contact
with a colonized patient.
HCWs were intercepted after
a patient-care episode and
cultures were taken from
their gloved hands before
handwashing had occurred;
17% (confidence interval (CI)
95% 925%) of contacts with
patients, a patients clothing
or a patients bed resulted in
transmission of MRSA from a
patient to the HCWs gloves.
In another study involving
HCWs caring for patients
with vancomycin-resistant
enterococci (VRE), 70% of
HCWs contaminated their
hands or gloves by touching
the patient and the patients
environment.114 Furthermore,
HCWs caring for infants with
respiratory syncytial virus
(RSV) infections have
acquired infection by
performing activities such as
feeding infants, nappy/diaper
change, and playing with
the infant.122 Caregivers
who had contact only with
surfaces contaminated with
the infants secretions also
acquired RSV. In the above
studies, HCWs
contaminated their hands
with RSV and inoculated

their oral or conjunctival mucosa. Other

12

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

studies have
also
documented
that the hands
(or gloves) of
HCWs may be
contaminated
after touching
inanimate
objects in
patients
rooms.73,111,112,12
5-130

Furthermore, a
recent two-part
study conducted
in a non-healthcare setting
found in the
initial phase that
patients with
natural
rhinovirus
infections often
contaminated
multiple
environmental
sites in their
rooms. In the
second part of
the study,
contaminated
nasal secretions
from the same
individuals were
used to
contaminate
surfaces in
rooms, and
touching
contaminated
sites 1178
hours later
frequently
resulted in the
transfer of the
virus to the
fingertips of the
individuals.131
Bhalla and
colleagues
studied patients
with skin
colonization by
S. aureus
(including
MRSA) and
found that the
organism was
frequently
transferred to
the hands of
HCWs who
touched both
the skin of

patients and
surrounding
environmental
surfaces.96Hayd
en and
colleagues
found that
HCWs seldom
enter patient
rooms without
touching the
environment,
and that 52% of
HCWs whose
hands were free
of VRE upon
entering rooms
contaminated
their hands or
gloves with

VRE after
touching the
environment
without touching
the patient.114
Laboratorybased studies
have shown that
touching
contaminated
surfaces can
transfer S.
aureus or Gramnegative bacilli
to the fingers.132
Unfortunately,
none of the
studies dealing
with HCW hand
contamination
was designed to
determine if the
contamination
resulted in the
transmission of
pathogens to
susceptible
patients.
Many other
studies have
reported
contamination of
HCWs hands
with potential
pathogens, but
did not relate their
findings to the
specific type of
preceding patient
contact.78,79,94,132142

For example,
in studies
conducted before
glove use was
common among
HCWs, Ayliffe and
colleagues137
found that 15% of
nurses working in
an isolation unit
carried a median
of 1x 104 CFU of
S. aureus on their

hands; 29% of
nurses working in
a general hospital
had S. aureus on
their hands
(median count,

3.8

x 103
CFU), while 78%
of those working
in a hospital for
dermatology
patients had the
organism on
their hands
(median
count, 14.3 x 106
CFU). The same
survey revealed
that 1730% of
nurses
carried
Gram-negative
bacilli on their
hands (median
counts ranged from
3.4 x 103 CFU to
38 x 103 CFU).
Daschner135 found
that
S.
aureus
could be recovered
from the hands of

21%
of
ICU
caregivers
and
that
21%
of
doctors and 5%
of
nurse carriers
had >103 CFU of
the organism on
their hands.
Maki80 found
lower levels of
colonization on
the hands of
HCWs working in
a neurosurgery
unit, with an
average of 3
CFU of
S. aureus and
11 CFU of
Gram-negative
bacilli. Serial
cultures
revealed that
100% of HCWs
carried Gramnegative bacilli
at least once,
and 64%
carried S.
aureus at least
once. A study
conducted in
two neonatal
ICUs revealed
that Gramnegative bacilli
were recovered
from the hands
of 38% of
nurses.138

7.3 Organism

survival on
hands
Several studies
have shown the
ability of
microorganisms toNoskin and
survive on hands colleagues
for differing times. studied the
survival of VRE on
Musa and
hands and the
colleagues
demonstrated in a environment: both
laboratory study Enterococcus
that Acinetobacter faecalis and E.
faecium survived
calcoaceticus
for at least 60
survived better
than strains of A. minutes on gloved
and ungloved
lwoffi at 60
145
minutes after an fingertips.
inoculum of 104 Furthermore,
Doring and
CFU/finger.143 A
colleagues
similar study by
showed that
Fryklund and
Pseudomonas
colleagues using
aeruginosa and
epidemic and
Burkholderia
non-epidemic
cepacia were
strains of
transmissible by
Escherichia coli handshaking for
and Klebsiella
up to 30 minutes
spp. showed a
when the
50% killing to be organisms were
achieved at 6
suspended in
minutes and 2
saline, and up to
minutes,
180 minutes
when they were
respectively.144
suspended in
sputum.146 The
study by Islam
and colleagues
with Shigella
dysenteriae type
1 showed its
capacity to
survive on hands
for up to 1
hour.147 HCWs
who have hand
dermatitis may
remain colonized
for prolonged
time periods. For
example, the
hands of a HCW
with psoriatic
dermatitis
remained
colonized with
Serratia
marcescens for
more than three
months.148 Ansari
and
colleagues149,150
studied

rotavirus, human
parainfluenza
virus 3, and
rhinovirus 14
survival on
hands and
potential for
cross-transfer.
Survival
percentages for

rotavirus at 20
minutes and 60
minutes after
inoculation were
16.1% and 1.8%,
respectively.
Viability at 1 hour
for human
parainfluenza
virus 3 and
rhinovirus 14 was
<1% and 37.8%,
respectively.
The abovementioned
studies clearly
demonstrate that
contaminated
hands could be
vehicles for the
spread of certain
viruses and
bacteria. HCWs
hands become
progressively
colonized with
commensal flora
as well as with
potential
pathogens during
patient care.72,73
Bacterial
contamination
increases linearly
over time.72 In
the absence of
hand hygiene
action, the longer
the duration of
care, the higher
the degree
of hand
contamination.
Whether care
is provided to
adults or
neonates,
both the
duration and
the type of
patient care
affect HCWs
hand
contamination.
72,73
The
dynamics of
hand
contamination
are similar on
gloved versus
ungloved
hands;

gloves reduce
hand
contamination,
but do not fully
protect from
acquisition of
bacteria during
patient care.
Therefore, the
glove surface is
contaminated,
making cross-

soap or alcoholbased handrub

yielded lower log
reductions
(greater number
of bacteria
remaining on
hands) than using
7.4
3 ml of product to
Defective
clean hands. The
hand
findings have
cleansing
clinical relevance
, resulting
since some HCWs
in hands
use as little as 0.4
remaining
ml of soap to
contamin
clean their hands.
ated
Kac and
152
Studies showing colleagues
the adequacy or conducted a
comparative,
inadequacy of
hand cleansing by cross-over study
of microbiological
microbiological
efficacy of
proof are few.
From these few handrubbing with
studies, it can be an alcohol-based
solution and
assumed that
handwashing with
hands remain
contaminated with an unmedicated
soap. The study
the risk of
results were: 15%
transmitting
of HCWs hands
organisms via
were
hands. In a
laboratory-based contaminated with
study, Larson and transient
pathogens before
colleagues151
found that using hand hygiene;
only 1 ml of liquid no transient
pathogens were

transmission
through
contaminated
gloved hands
likely.

13

recovered after
handrubbing,
while two cases
were found
after
handwashing.
Trick and
colleagues153
did a
comparative
study of three
hand hygiene
agents (62%
ethyl alcohol
handrub,
medicated
handwipe, and
handwashing
with plain soap
and water) in a
group of
surgical ICUs.
They also
studied the
impact of ring
wearing on
hand
contamination.
Their results
showed that
hand
contamination
with transient
organisms was
significantly
less likely after
the

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

use of an
alcoholbased
handrub
compared
with the
medicated
wipe or soap
and water.
Ring
wearing
increased
the
frequency of
hand
contaminatio
n with
potential
health careassociated
pathogens.
Wearing
artificial
acrylic
fingernails
can also
result in
hands
remaining
contaminate
d with
pathogens
after use

the outbreak
were
handmade,
thus
suggesting
inadequate
hand hygiene.
Noskin and
colleagues145
showed that a
5-second
handwash with
water alone
produced no
change in
contamination
with VRE, and
20% of the
initial inoculum
was recovered
on unwashed
hands. In the
same study, a
5-second wash
with two soaps
did not remove
the organisms
completely
with
approximately
a 1% recovery;
a 30-second
wash with
either soap
was necessary
to remove the
organisms
completely
from the
hands.

of either
Obviously,
soap or
when HCWs
alcoholbased hand fail to clean
gel154 and their hands
has been
between
associated patient contact
with
or during the
outbreaks of
155 sequence of
infection
patient care
(see also
in particular
Part I,
when hands
Section
23.4).
move from a
microbiologica
Sala and
lly
colleagues15 contaminated
6
body site to a
investigated cleaner site in
an outbreak the same
patient
of food
microbial
poisoning
attributed to transfer is
norovirus
likely to occur.
genogroup 1 To avoid
and traced prolonged
the index
hand
case to a
contamination,
food handler it is not only
in the
important to
hospital
perform hand
cafeteria.
hygiene when
Most of the indicated, but
foodstuffs
also to use the
consumed in

appropriate
technique and
an adequate
quantity of the
product to
cover all skin
surfaces for
the
recommended
length of time.

7
.
5
C
r
o
s
s
t
r
a
n
s
m
i
s
s
i
o
n
o
f
o
r
g
a
n
i
s
m
s
b
y
c
o
n
t
a
m
i
n
a
t
e
d
h
a
n
d
s
Crosstransmission of
organisms

occurs
through
contaminate
d hands.
Factors that
influence the
transfer of
microorganis
ms from
surface to
surface and
affect crosscontaminatio
n rates are
type of
organism,
source and
destination
surfaces,
moisture
level, and
size of
inoculum.
Harrison and
colleagues15
7
showed
that
contaminate
d hands
could
contaminate
a clean
paper towel
dispenser
and vice
versa. The
transfer
rates ranged
from 0.01%
to 0.64%
and 12.4%
to 13.1%,
respectively.
A study
by
Barker
and
colleagu
es158
showed
that
fingers
contami
nated
with
noroviru
s could
sequenti
ally
transfer
virus to
up to
seven
clean
surfaces
, and
from
contami
nated
cleaning
cloths to
clean
hands

and
surfaces.
Contamina
ted
HCWs hands
have been
associated
with endemic
HCAIs.159,160
Sartor and
colleagues160
provided
evidence that
endemic

S.
marces
cens
was
transmit
ted from
contami
nated
soap to
patients
via the
hands
of
HCWs.
During
an
outbrea
k
investigation of
S. liquefaciens,
BSI, and
pyrogenic
reactions in a
haemodialysis
centre,
pathogens were
isolated from
extrinsically
contaminated
vials of
medication
resulting from
multiple dose
usage,
antibacterial
soap, and hand
lotion.161
Duckro and
colleagues126
showed that
VRE could be
transferred from
a contaminated
environment or
patients intact
skin to clean
sites via the
hands of HCWs
in 10.6% of
contacts.
Several
HCAI
outbreaks
have been
associated
with
contaminate
d HCWs
hands.162-164

El Shafie
and
colleagues16
4

Contaminated
HCWs hands
were clearly
related to
outbreaks
among
investigate surgical148,162
d an
and
outbreak of neonatal163,165
multidrug- ,166
patients.
resistant A.
baumannii Finally,
and
several
documente studies have
d identical shown that
strains from pathogens
patients,
can be
hands of
transmitted
staff, and
from out-ofthe
hospital
environmen sources to
t. The
patients via
outbreak
the hands of
was
HCWs. For
terminated example, an
when
outbreak of
remedial
postoperative
measures S.
were taken. marcescens
wound
14

infections was
traced to a
contaminated
jar of exfoliant
cream in a
nurses
home.167 An
investigation

suggested that
the organism
was
transmitted to
patients via
the hands of
the nurse, who
wore artificial
fingernails. In
another
outbreak,
Malassezia
pachydermatis
was probably
transmitted
from a nurses
pet dogs to
infants in an
intensive care
nursery via the
hands of the
nurse.168

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Figure I.7.1
Organisms present on patient skin or the immediate environment

A bedridden patient colonized with Gram-positive cocci, in particular at nasal, perineal, and inguinal areas (not shown), as well as axillae and
upper extremities. Some environmental surfaces close to the patient are contaminated with Gram-positive cocci, presumably shed by the
patient. Reprinted from Pittet, 2006885 with permission from Elsevier.

15

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Figure I.7.2
Organism transfer from patient to HCWs hands

Contact between the HCW and the patient results in cross-transmission of microorganisms. In this case, Gram-positive cocci from the
patients own flora transfer to HCWs hands. Reprinted from Pittet, 2006885 with permission from Elsevier.

16

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Figure I.7.3
Organism survival on HCWs hands*

(1) Microorganisms (in this case Gram-positive cocci) survive on hands. Reprinted from Pittet, 2006885 with permission from Elsevier.
(2) When growing conditions are optimal (temperature, humidity, absence of hand cleansing, or friction), microorganisms can continue to
grow. Reprinted from Pittet, 2006885 with permission from Elsevier.

(3) Bacterial contamination increases linearly over time during patient contact. Adapted with permission from Pittet, 1999.14
* The figure intentionally shows that long-sleeved white coats may become contaminated by microorganisms during patient care.
Although evidence to formulate it as a recommendation is limited, long sleeves should be avoided.

17

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Figure I.7.4
Incorrect hand cleansing*

Inappropriate handwashing can result in hands remaining contaminated; in this case, with Gram-positive cocci. Reprinted from Pittet,
2006885 with permission from Elsevier.
* The figure intentionally shows that long-sleeved white coats may become contaminated by microorganisms during patient care.
Although evidence to formulate it as a recommendation is limited, long sleeves should be avoided.

18

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Figure I.7.5a
Failure to cleanse hands results in between-patient cross-transmission*

(A) The doctor had a prolonged contact with patient A colonized with Gram-positive cocci and contaminated his hands. Reprinted from
Pittet, 2006885 with permission from Elsevier.
* The figure intentionally shows that long-sleeved white coats may become contaminated by microorganisms during patient care.
Although evidence to formulate it as a recommendation is limited, long sleeves should be avoided.

19

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Figure I.7.5b
Failure to cleanse hands results in between-patient cross-transmission*

(B) The doctor is now going to have direct contact with patient B without cleansing his hands in between. Cross-transmission of Gram-positive cocci
from patient A to patient B through the HCWs hands is likely to occur. Reprinted from Pittet, 2006 885 with permission from Elsevier.

* The figure intentionally shows that long-sleeved white coats may become contaminated by microorganisms during patient care.
Although evidence to formulate it as a recommendation is limited, long sleeves should be avoided.

2
0

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Figure I.7.6
Failure to cleanse hands during patient care results in within-patient cross-transmission*

The doctor is in close contact with the patient. He touched the urinary catheter bag previously and his hands are contaminated with Gramnegative rods from touching the bag and a lack of subsequent hand cleansing. Direct contact with patients or patients devices would
probably result in cross-transmission. Reprinted from Pittet with permission from Elsevier, 2006. 885
* The figure intentionally shows that long-sleeved white coats may become contaminated by microorganisms during patient care.
Although evidence to formulate it as a recommendation is limited, long sleeves should be avoided.

21

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

8.
Models of hand transmission
spp. were
transferred in
greater numbers
than was E. coli
8.1 Experimental models from a
contaminated to a
Several investigators have clean fabric
studied the transmission of following hand
contact. Patrick and
infectious agents using
different experimental
colleagues75 found
models. Ehrenkranz and
that organisms
colleagues88 asked nurses were transferred to
to touch a patients groin for various types of
15 seconds as though they surfaces in much
were taking a femoral pulse. larger numbers (>104)
from wet hands than
The patient was known to
from hands that had
be heavily colonized with
been dried carefully.
Gram-negative bacilli.
Nurses then cleansed their Sattar and
colleagues170
hands by washing with
demonstrated that the
plain soap and water or
transfer of S. aureus
by using an alcoholfrom fabrics commonly
based handrub. After
used for clothing and
cleansing their hands,
bed linen to fingerpads
they touched a piece of
occurred more
urinary catheter material
frequently when
with their fingers and the
fingerpads were moist.
catheter segment was
cultured. The study
revealed that touching
8.2 Mathematical
intact areas of moist skin
models
transferred enough
organisms to the nurses
Mathematical
hands to allow
modelling has been
subsequent transmission
used to examine the
to catheter material
relationships between
despite handwashing
the multiple factors
with plain soap and
that influence
water; by contrast,
pathogen
alcohol-based handrubbing
transmission in
was effective and prevented
health-care facilities.
cross-transmission to the
These factors include
device. Marples and
hand hygiene
colleagues74 studied the
compliance, nurse
transmission of organisms
staffing levels,
from artificially
frequency of
contaminated donor
introduction of
fabrics to clean recipient
colonized or infected
fabrics via hand contact and patients onto a ward,
found that the number of
whether or not
organisms transmitted was cohorting is practised,
greater
characteristics of
if the donor fabric or the
patients and antibiotic
hands were wet. Overall,
use practices, to
only 0.06% of the
name but a few.171
organisms obtained from
Most reports
the contaminated donor
describing the
fabric were transferred to
mathematical
the recipient fabric via
modelling of health
hand contact. Using the
care-associated
same experimental model,
pathogens have
Mackintosh and
attempted to quantify
169
colleagues found that S.
the influence of
saprophyticus, P.
various factors on a
aeruginosa, and Serratia
single ward such as

an ICU.172-175 Given
that such units tend to
house a relatively
small number of
patients at any time,
random variations
(stochastic events)
such as the number
of patients admitted
with a particular
pathogen during a
short time period can
have a significant
impact on
transmission
dynamics. As a result,
stochastic models
appear to be the most
appropriate for
estimating the impact
of various infection
control measures,
including hand
hygiene compliance,
on colonization and
infection rates.
In a mathematical
model of MRSA
infection in an ICU,
Sebille and
colleagues172
found that the
number of patients
who

predicted that
improving hand
hygiene
became colonized by strains compliance from
transmitted from HCWs was very low levels to
20% or 40%
one of the most important
determinants of transmission significantly
rates. Of interest, they found reduced
that increasing hand hygiene transmission, but
compliance rates had only a that improving
compliance to
modest effect on the
levels above 40%
prevalence of MRSA
would have
colonization. Their model
relatively little
estimated that if the
impact on the
prevalence of MRSA
prevalence of S.
colonization was 30% without
aureus.
any hand hygiene, it would
Grundmann and
decrease to only 22% if hand
colleagues175
hygiene compliance
conducted an
increased to 40% and to 20%
investigation that
if hand hygiene compliance
included cultures of
increased to 60%. Antibiotic
patients at the time
policies had relatively little
of ICU admission
impact in this model.
and twice-weekly
observations of the
Austin and
frequency of contact
colleagues173 used
between HCWs
daily surveillance
and patients,
cultures of patients,
cultures of HCWs
molecular typing of
hands, and
isolates, and
molecular typing of
monitoring of
MRSA isolates. A
compliance with
stochastic model
infection control
predicted that a
practices to study the
12% improvement
transmission dynamics of
in adherence to
VRE in an ICU. The study
hand hygiene
found that hand hygiene and
policies or in
staff cohorting were
cohorting levels
predicted to be the most
might have
effective control measures.
compensated for
The model predicted that for
staff shortages
a given level of hand hygiene
and prevented
compliance, adding staff
transmission during
cohorting would lead to the
periods of
better control of VRE
overcrowding and
transmission. The rate at
high workloads.
which new VRE cases were
admitted to the ICU played A stochastic model by
an important role in the level McBryde and
of transmission of VRE in the colleagues used
unit.
surveillance cultures,
In a study that used a
stochastic model of
transmission dynamics,
Cooper and colleagues176

hand hygiene
compliance
observations, and
evaluation of the
22

likelihood of
transmission from a
colonized patient to a
HCW, as well as other
factors, to estimate
the impact of various
interventions on
MRSA transmission in
an ICU.177 They found
also that improving
hand hygiene was
predicted to be the
most effective
intervention. Unlike
several earlier
studies, their model
suggested that
increasing levels of
hand hygiene
compliance above
40% to 60%
continued to have a
beneficial impact on
reducing MRSA
transmission. A model
using Monte Carlo
simulations to study
the impact of various
control measures on
MRSA transmission
on a general medical
ward also suggested
that improving hand
hygiene compliance
was likely to be the
most effective
measure for reducing
transmission.178
While the abovementioned studies
have provided new
insights into the
relative contribution
of various infection
control
measures, all have
been based on
assumptions that may
not be valid in all
situations. For
example, most studies
assumed that
transmission of
pathogens occurred
only via the hands of
HCWs

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

and that contaminated environmental surfaces played no role in

transmission. The latter may not be true for some pathogens
that can remain viable in the inanimate environment for
prolonged periods. Also, most, if not all mathematical models
were based on the assumption that when HCWs did clean their
hands,100% of the pathogen of interest was eliminated from the
hands, which is unlikely to be true in many instances.176
Importantly, all the mathematical models described above
predicted that improvements in hand hygiene compliance could
reduce pathogen transmission. However, the models did not
agree on the level of hand hygiene compliance that is necessary
to halt transmission of health care-associated pathogens. In
reality, the level may not be the same for all pathogens and in
all clinical situations. Further use of mathematical models of
transmission of health care-associated pathogens is warranted.
Potential benefits of such studies include evaluating the benefits
of various infection control interventions and understanding the
impact of random variations in the incidence and prevalence of
various pathogens.171

23

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

9.
Relationship between hand hygiene and the
acquisition of health care-associated pathogens
Despite a paucity of appropriate randomized controlled trials, there is substantial evidence that hand antisepsis
reduces the transmission of health care-associated pathogens and the incidence of HCAI. 58,179,180 In what would
be considered an intervention trial using historical controls, Semmelweis 179 demonstrated in 1847 that the
mortality rate among mothers delivering at the First Obstetrics Clinic at the General Hospital of Vienna was
significantly lower when hospital staff cleaned their hands with an antiseptic agent than when they washed their
hands with plain soap and water.
to-nurse ratio remained an
In the 1960s, a prospective controlled trial sponsored by the independent risk factor for BSI,
USA National Institutes of Health (NIH) and the Office of the suggesting that nursing staff
Surgeon General compared the impact of no handwashing
reduction below a critical
versus antiseptic handwashing on the acquisition of S.
threshold may have
contributed to this outbreak by
aureus among infants in a hospital nursery.52 The
jeopardizing adequate
investigators demonstrated that infants cared for by nurses
catheter care. Vicca184
who did not wash their hands after handling an index infant
colonized with S. aureus acquired the organism significantly demonstrated the relationship
between understaffing and the
more often, and more rapidly, than did infants cared for by
spread of MRSA in intensive
nurses who used hexachlorophene to clean their hands
care.
between infant contacts. This trial provided compelling
These findings show
evidence that when compared with no handwashing, hand
cleansing with an antiseptic agent between patient contacts indirectly that an
imbalance between
reduces transmission of health care-associated pathogens.
workload and staffing
leads to relaxed attention
A number of studies have demonstrated the effect of hand
to basic control measures,
cleansing on HCAI rates or the reduction in cross-transmission
such as hand hygiene, and
of antimicrobial resistant pathogens (see Part I, Section 22 and
Table I.22.1). For example, several investigators have found that spread of microorganisms.
Harbarth and
health care-associated acquisition of MRSA was reduced when
the antimicrobial soap used for hygienic hand antisepsis was
colleagues185 investigated
181,182
changed.
In one of these studies, endemic MRSA in a
an
neonatal ICU was eliminated seven months after introduction of outbreak of Enterobacter
a new hand antiseptic agent (1% triclosan) while continuing all
cloacae in a neonatal ICU and
other infection control measures, including weekly active
showed that the daily number
of hospitalized children was
surveillance cultures.181 Another study reported an MRSA
above the maximal capacity of
outbreak involving 22 infants in a neonatal unit.182 Despite
intensive efforts, the outbreak could not be controlled until a new the unit, resulting in an
antiseptic agent was added (0.3% triclosan) while continuing all available space
previous control measures, which included the use of gloves and per child well below current
recommendations. In
gowns, cohorting, and surveillance cultures. Casewell &
parallel, the number of staff
Phillips121 reported that increased handwashing
frequency among hospital staff was associated with a decrease in on duty was significantly
below that required by the
transmission of Klebsiella spp. among patients, but they
did not quantify the level of handwashing among HCWs. It is workload, and this also
important to highlight, however, that although the introduction resulted in relaxed attention
of a new antiseptic product was a key factor to improvement in to basic infection control
all these studies, in most cases, system change has been only measures. Adherence to
hand hygiene practices
one of the elements determining the success of multimodal
before device contact was
hand hygiene promotion strategies; rather, success results
only 25% during the
from the overall effect of the campaign.
workload peak, but
increased to 70% after the
In addition to these studies, outbreak investigations have
suggested an association between infection and understaffing or end of the
understaffing and
overcrowding that was consistently linked with poor adherence
183
to hand hygiene. During an outbreak, Fridkin investigated risk overcrowding period.
Continuous surveillance
factors for central venous catheter-associated BSI. After
showed that being hospitalized
adjustment for confounding factors, the patientduring this period carried a
24

fourfold increased risk of

acquiring an HCAI. This study
not
only shows the association
between workload and
infections, but also highlights
the intermediate step poor
adherence to hand hygiene
practices. Robert and
colleagues suggested that
suboptimal nurse staffing
composition for the three
days before BSI (i.e. lower
regular-nurse-to-patient and
higher pool-nurse-to-patient
ratios) was an independent
risk factor for
infection.186 In another study in
ICU, higher staff level was
indeed independently
associated with a > 30%
infection risk reduction and the
estimate was made that, if the
nurse-to patient ratio was
maintained > 2.2, 26.7% of all
infections could be avoided.187
Overcrowding and
understaffing are commonly
observed in health-care
settings and have been
associated throughout the
world, particularly in
developing countries where
limited personnel and facility
resources contribute to the
perpetuation
of this problem.183-186,188-190
Overcrowding and
understaffing were
documented in the largest
nosocomial outbreak
attributable to Salmonella spp.
ever reported191; in this
outbreak in Brazil, there was a
clear relationship between
understaffing and the quality
of health care, including hand
hygiene.

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

10.
Methods to evaluate the antimicrobial efficacy of
handrub and handwash agents and formulations for
surgical hand preparation
With the exception of non-medicated soaps, every new formulation for hand antisepsis should be tested for its
antimicrobial efficacy to demonstrate that: (i) it has superior efficacy over normal soap; or (ii) it meets an agreed
performance standard. The formulation with all its ingredients should be evaluated to ensure that humectants or
rehydrating chemicals added to ensure better skin tolerance do not in any way compromise its antimicrobial
action.
applies to pre-surgical
Many test methods are currently available for this purpose, but
scrubs, the objective is to
some are more useful and relevant than others. For example,
evaluate the test formulation
determination of the minimum inhibitory concentration (MIC) of such for its ability to reduce the
formulations against bacteria has no direct bearing on the killing
release of naturally present
effect expected of such products in the field. Conditions in
resident flora from the
suspension and in vitro192 or ex vivo193 testing do not reflect those hands. The basic
on human skin. Even simulated-use tests with subjects are
experimental design of
considered by some as too controlled, prompting testing under in these methods is
praxi or field conditions. Such field testing is difficult to control for summarized below and the
extraneous influences. In addition, and importantly, the findings of procedures are presented in
field tests provide scant data on a given formulations ability to
detail in Table I.10.1.
cause a measurable reduction in hand-transmitted nosocomial
infections. While the ultimate approach in this context would be
In Europe, the most
clinical trials, they are generally quite cumbersome and expensive. commonly used
For instance, power analysis reveals that for demonstrating a
methods to test hand
reduction in hand-transmitted infections from 2% to 1% by changing antiseptics are those of
to a presumably better hand antiseptic agent, almost 2500 subjects the European
would be required in each of two experimental arms at the
Committee for
statistical pre-settings
Standardization (CEN).
of (unidirectional) = 0.05 and a power of 1- = 0.9.194

For this

reason, the number of such trials remains quite

limited.195-197 To achieve a reduction from 7% to 5% would
require 3100 subjects per arm. This reinforces the utility of
well-controlled, economically affordable, in vivo laboratorybased tests to provide sufficient data to assess a given
formulations potential benefits under field use.

10.1 Current methods

Direct comparisons of the results of in vivo efficacy testing of
handwashing, antiseptic handwash, antiseptic handrub, and
surgical hand antisepsis are not possible because of wide
variations in test protocols. Such variations include: (i) whether
hands are purposely contaminated with a test organism before use
of the test agent; (ii) the method used to contaminate fingers or
hands; (iii) the volume of hand hygiene product applied; (iv) the
time the product is in contact with the skin; and

(v) the method used to recover the organism from the skin
after the test formulation has been used.
Despite the differences noted above, most testing falls into one of
two major categories. One category is designed to evaluate
handwash or handrub agents to eliminate transient pathogens
from HCWs hands. In most such studies, the subjects hands are
experimentally contaminated with the test organism before
applying the test formulation. In the second category, which

In the USA and

Canada, such

formulations are regulated by

the Food and Drug
Administration (FDA)198 and
Health Canada, respectively,
which refer to the standards
of ASTM International
(formerly, the American
Society for Testing and
Materials).
It should be noted that the
current group of experts
recommends using the term
efficacy to refer to the
(possible) effect of the
application of a hand hygiene
formulation when tested in
laboratory or in vivo
situations. By contrast, it
would recommend using the
term effectiveness to refer
to the clinical conditions
under which hand hygiene
products have been tested,
such as field trials, where the
impact of a hand hygiene
25

formulation is monitored on
the rates of crosstransmission of infection or
resistance.199

10.1.1 Methods to test

activity of hygienic
handwash and handrub
agents
The following in vivo methods
use experimental
contamination to test the
capacity of a formulation to
reduce the level of transient
microflora on the hands
without regard to the resident
flora. The formulations to be
tested are hand antiseptic
agents intended for use by
HCWs, except in the surgical
area.

CEN standards: EN 1499 and

EN 1500
In Europe, the most common
methods for testing hygienic
hand antiseptic agents are EN
1499200 and EN 1500.201
Briefly, the former standard
requires 1215 subjects, and
the latter

(in the forthcoming

amendment) 1822, and a
culture of E. coli. Subjects
are assigned randomly to
two groups where one
applies the test formulation
and the other a
standardized

reference solution. In a
consecutive run, the two
groups reverse roles (crossover design).

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

If an
antiseptic
soap has
been tested
according to
EN 1499,200
the mean
log10
reduction by
the
formulation
must be
significantly
higher than
that obtained
with the
control (soft
soap). For
handrubs
(EN 1500),
the mean
acceptable
reduction
with a

test
formula
tion
shall
not be
signific
antly
inferior
to that
with
the
referen
ce
alcohol
-based
handru
b
(isopro
pyl
alcohol
or
isoprop
anol
60%
volume
).

ASTM
standards

ASTM
E1174202
Curr
ently
,
hand
was
h or
hand
rub
agen

ts are
evaluat
ed
using
this
method
in
North
Americ
a. The
efficacy
criteria
of
the
FDAs
Tentative
Final
Monograp
h (TFM)
are a 2log10
reduction
of
the
indicator
organism
on each
hand
within

5
minutes
after the
first use,
and a 3log10
reduction
of the
indicator
organism
on each
hand
within 5
minutes
after the
tenth
use.198
The
performan
ce criteria
in
EN
1500 and
in the TFM
for
alcoholbased
handrubs
are not the
same.48,198,2
01

Therefore, a
formulation
may pass
the
TFM
criterion,
but may not
meet

that of EN
1500 or
vice
versa.203
It should
be
emphasiz
ed here
that the
level of
reduction

in
microbial
counts
needed
to
produce
a
meaningf
ul drop in
the handborne
spread of
nosocomi
al
pathogen
s remains
unknown.
48,204

ASTM E1838
(fingerpad
method
for
viruses)
205

The
fingerpad
method
can be
applied
with equal
ease to
handwash
or handrub
agents.
When
testing
handwash
agents, it
can also
measure
reductions
in the
levels of
viable virus
after
exposure
to the test
formulation
alone, after
posttreatment
water
rinsing and
post-rinse
drying of
hands.
This
method
also
presents a
lower risk
to subjects
because it
entails
contaminat
ion of
smaller
and welldefined
areas on

the skin
in
contrast
to using
whole
hands
(see
below).
The
method
can be
applied
to
tradition
al as
well as
more
recently
discover
ed
viruses
such as
caliciviru
ses.206

ASTM
E-2276
(fingerp
ad
method
for
bacteria
) 207
This
method
is for
testing
handwas
h or
handrub
against
bacteria.
It is
similar in
design
and
applicati
on to the
method
E1838205
describe
d above
for
working
with
viruses.

ASTM
E-2613
(fingerp
ad
method
for
fungi)
208

This
metho
d is for
testing
handw
ash or
handr

ub
against
fungi. It
is similar
in design
and
applicatio
n to the
methods

describ
ed
above
for
working
with
viruses
(E1838)20
5
and
bacteri
a
(E2276).2
07

ASTM E2011
(whole
hand
method for
viruses)
209

In this
method,
the
entire
surface
of both
hands is
contami
nated
with the
test
virus,
and the
test
handwa
sh or
handrub
formulat
ion is
rubbed
on
them.
The
surface
of both
hands is
eluted
and the
eluates
assayed
for
viable
virus.

10.1.2
Surgical hand
preparation
In contrast
to hygienic
handwash
or
handrub,
surgical
hand
preparatio
n is
directed
against the
resident
hand flora.
No
experiment
al
contaminat
ion of
hands is
used in
any
existing
methods.

CEN standard:
EN 12791
(surgical hand
preparation)
210

This European
norm is
comparable
with that
described in
EN 1500,
except that the
bactericidal
effect of a
product is
tested:
(i) on clean, not
experimentally
contaminated
hands; (ii) with
1820 subjects;
(iii) using the
split-hands
model by
Michaud,
McGrath &
Goss211 to
assess the
immediate
effect on one
hand and a 3hour effect (to
detect a
possible
sustained
effect) on the
other,
meanwhile

gloved hand; claim for

(iv) in
sustained
addition, a activity, the
cross-over product must
design is
demonstrate a
used but,
significantly
contrary to lower bacterial
hygienic
count than the
hand
reference at 3
antisepsis, hours.
the two
experimental
runs are
ASTM
separated by standard:
one week to ASTM E-1115
(surgical hand
enable
212
regrowth of scrub)
the resident
flora; (v) the This test
method is
reference
designed to
antisepsis
measure the
procedure
reduction in
uses as
many 3-ml bacterial flora
portions of n- on the skin. It
is intended for
propanol
60% (v/v) as determining
immediate
are
necessary to and persistent
keep hands microbial
reductions,
wet for 3
after single or
minutes;
thus, the total repetitive
quantity used treatments, or
may vary
both. It may
according to also be used
the size and to measure
temperature cumulative
of the hands antimicrobial
and other
activity after
factors; (vi) repetitive
the product is treatments.
used
according to In North
manufacturer America, this
s instructionsmethod is
required to
with a
assess the
maximum
activity of
allowed
contact time surgical
198
of 5 minutes; scrubs. The
TFM
requires
(vii) the
requirements that
are that the formulations:
immediate (i) reduce the
and 3-hour number of
effects of a bacteria 1-log10
product must on each hand
within
not be
significantly 1 minute of
product use
inferior to
and that the
those of the
bacterial
reference
colony count
hand
on each
antisepsis;
hand does
and (viii) if
not
there is a
subsequentl
26

y exceed
baseline
within 6
hours on
day 1; (ii)
produce a 2log10
reduction in
bacterial

counts on
each hand
within 1
minute of
product use by
the end of the
second day of
enumeration;
and (iii)
accomplish a
3-log10
reduction of
bacterial
counts on
each hand
within 1
minute of
product use by
the end of the
fifth day when
compared to
the
established
baseline.198

10.2
Shortcoming
s of
traditional
test methods
10.2.1
Hygienic
handwash
and
handrub;
HCW
handwash
and handrub
A major
obstacle for
testing hand
hygiene
products to
meet
regulatory
requirements
is the cost,
which can be
prohibitive
even for large
multinational
companies.
Cases in
point are the

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

few investigators
have used 15second
handwashing or
hygienic hand
antisepsis
protocols.151,219222
extensive and
Therefore,
varied evaluations almost no data
as specified in the exist regarding
TFM198 ; time-kill the efficacy of
curves must also antimicrobial
soaps under
be established
along with tests conditions in
on the potential which they are
for development actually used.
of antimicrobial
Similarly, some
resistance. In
accepted
vivo, at least 54 methods for
subjects are
evaluating
necessary in each waterless
arm to test the
antiseptic agents
product and a
for use as
positive control, antiseptic
hence a minimum handrubs, such
of 2 x 54 subjects. as the reference
The immense
hand antisepsis in
expenditure
EN 1500,201
would, however,
require that 3 ml
be much smaller if
of alcohol be
the same subjects
rubbed into the
were used to test
hands for 30
both formulations
seconds, followed
concurrently in
by a repeat
two runs in a
application of the
cross-over
same type. Again,
fashion as
this type of
described in EN
protocol does not
1499 and EN
reflect actual
200,201
1500.
The
usage patterns
results could then
among HCWs.
be intraHowever, it could
individually
be argued that
compared, thus
non-inferiority in
allowing a
the efficacy of a
considerable
test product as
reduction in
compared with
sample size at the
the reference is
same statistical
easier to prove
power.
with longer skin
contact. Or,
Another
inversely, to prove
shortcoming of
a difference
existing test
between two
methods is the
duration of hand treatments of very
short duration,
treatments that
require subjects such as 15
seconds, under
to treat their
hands with the
valid statistical
hand hygiene
settings is difficult
product or a
and requires large
positive control
sample sizes, i.e.
for 30 seconds198 large numbers of
or 1 minute,200
subjects.
despite the fact Therefore a
that the average reference
duration of hand treatment, which
cleansing by
has usually been
HCWs has been chosen for its
observed to be
comparatively
less than 15
high efficacy, may
seconds in most include longer
studies.124,213-218 A skin contact than

is usual in real
practice. By this,
the non-inferiority
of a test product
can be
demonstrated
with economically
justifiable sample
sizes.
The TFM,198 for
instance,
requires that a
handwash to be
used by HCWs
demonstrates
an in vivo
reduction in the
number
of the indicator
organisms on
each hand by 2
log within 5
minutes after the
first wash and by
3 log after the
tenth wash. This
requirement is
inappropriate to
the needs of
working in a
health-care setting
for two reasons.
First, to allow a
preparation to
reduce the
bacterial release
by only 2 log
within a maximum
time span of 5
minutes seems an
unrealistically low
requirement, as
even with
unmedicated soap
and water a
reduction of 3
log is achievable
within 1
minute.48,223
Furthermore, 5
minutes is much
too long to wait
between two
patients. Second,
the necessity for
residual action of
a hand antisepsis
formulation in the
non-surgical area
has been
challenged.224-226
The current
group of experts
does not believe
that for the
aforementioned
purpose a
residual
antimicrobial
activity is
necessary in the
health-care
setting. Rather, a

fast and strong

immediate effect
against a broad
spectrum of
transient flora is
required to
render hands
method.72 This
safe, not only in method entails
a very short time, taking imprints of
but also already the fingerpads
after the first
and thumb on to
application of the a nutritive agar
formulation.
preferably
Therefore, the
containing
requirement that a neutralizers for
product must
the non-alcoholdemonstrate a
based antiseptic
stronger activity agent in use. This
after the tenth
is done by
wash than after applying gentle
pressure with the
the first seems
difficult to justify. fingers and
thumb individually
on to the agar for
An in-use
5 seconds. This
test that is
method provides
simple to
less accurate
use in the
bacterial counts
clinical
than the fingertip
setting to
rinse method, but
document
it has the
microbial
advantage of
colonization
ease of use in the
is the
field and provides
fingerprint
good results
imprint
when evaluating
transient flora
and their
inactivation. The
problem with
such a qualitative
method is that it
often gives
confounding
results. Indeed,
the bacterial
count recovered
after the use of
the test
formulation can
be much higher
than the one in
controls because
of the
disaggregation of
micro-colonies of
resident bacteria.

10.2.2
Surgical
handwash
and
handrub;
surgical
hand
scrub;
surgical
hand
preparation
As with hygienic
hand antisepsis, a
major shortcoming

for testing surgical

scrubs is the
resource
expenditure
associated with
the use of the
TFM model. The
required in vitro
tests are the same
as described
under Part I,
Section 10.2.1,
above (see also
Table I.10.1) No
less than 130
subjects are
necessary to test
a product,
together with an
active control in
the suggested
parallel arm
design. For some
products, this
number will even
have to be
multiplied for
concomitant
testing of the
vehicle and
perhaps
of a placebo to
demonstrate
efficacy.198 As
mentioned with
the test model for
HCW
handwashes and
described in EN
12791,210 this
large number of
subjects could be
much reduced if
the tests are not
conducted with
different
populations of
subjects for each
arm but if the
same individuals
participate in
each arm, being
randomly
allocated to the
various
components of a
Latin square
design, the
experiments of
which can be
carried out at
weekly intervals.
The results are
then treated as
related samples
with intraindividual
comparison.
Additionally, it is
not clear why the
vehicle or a
placebo needs to
be tested in
parallel

if a product is
shown to be
equivalent in its
antimicrobial
efficacy to an
active control
scrub. For the
patient and for
the surgeon,
it is of no interest
whether the
product is
sufficiently
efficacious
because of the
active ingredient
only or, perhaps,
additionally by a
synergistic or
even
antimicrobial
effect of the
vehicle.
In contrast to
the
requirement of
EN 12791
where a
sustained (or
persistent)
effect of the
surgical scrub
is optional, the
TFM model
requires a
formulation to
possess this
feature (see

above).
However, the
continued
presence of a
microbicidal
chemical to
produce a
sustained
effect may be
unnecessary in
view of the fact
that volatile
ingredients
such as shortchain
aliphatic alcohols
(e.g. ethanol, isopropanol, and npropanol)48
appear fully
capable of
producing the
same effect.227
With their strong
antibacterial
efficacy, the
importance of a
sustained effect is
questionable, as
regrowth of the
skin flora takes
several hours
even without the
explicitly
sustained effect of
the alcohols.
Furthermore,
whether a longterm effect
(several days),
27

such as
recommended in
the TFM model, is
necessary or not
remains

a matter for
discussion. It is,
however, difficult
to understand
why the efficacy
of a scrub is
required to
increase from
the first to the
fifth day of
permanent use.
Ethical
considerations
would suggest
that the first
patient on a
Monday, when
the required
immediate
bacterial
reduction from
baseline is only 1
log, should be
treated under the
same safety
precautions as
patients
operated on the
following Friday
when, according
to the TFM
requirement, the
log reduction has
to be 3.0.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

With regard to the statistical analysis of EN 12791, in which

the efficacy of a product is compared with that of a reference
(including a handrub with 60% n-propanol for 3 minutes), the
currently suggested model of a comparative trial is no longer
up to date. It should be exchanged for a non-inferiority trial.
Furthermore, the latest CDC/HICPAC guideline for hand hygiene
in health-care settings58 considers it as a shortcoming that in vivo
laboratory test models use non-HCWs as surrogates for HCWs,
as their hand flora may not reflect that on the hands of caregivers
working in health-care settings. This argument is only valid for
testing surgical scrubs, however, because protocols

for evaluating hygienic handwash or rub preparations

include experimental hand contamination. Besides, the
antimicrobial spectrum of a product should be known from
the results of preceding in vitro tests.

10.3 The need for better methods

Further studies will be needed to identify necessary
amendments to the existing test methods and to
evaluate amended protocols, to devise standardized
protocols for obtaining more realistic views of microbial
colonization, and to better estimate the risk of pathogen
transfer and cross-transmission.72
To summarize, the following amendments to traditional
test methods are needed.

The few existing protocols should be adapted so that

they lead to comparable conclusions about the efficacy
of hand hygiene products.

Protocols should be updated so that they can be

performed with economically justifiable expenditure.

To be plausible, results of in vivo test models should

show that they are realistic under practical conditions
such as the duration of application, the choice of test
organism, or the use of subjects.

Requirements for efficacy should not be formulated with a

view to the efficacy of products available on the market, but
in consideration of objectively identified needs.

In vivo studies in the laboratory on surgical hand

preparation should be designed as clinical studies,
i.e. to determine equivalence (non-inferiority) rather
than comparative efficacy.

Protocols for controlled field trials should help to

ensure that hand hygiene products are evaluated
under more plausible, if not more realistic, conditions.

In addition, tests on the antimicrobial efficacy of hand hygiene

products should be conducted in parallel with studies on the
impact (effectiveness) of their use on cross-transmission of
infection or resistance. Indeed, there is no doubt that results from
well-controlled clinical studies are urgently needed to generate
epidemiological data on the benefits of various groups of hand
hygiene products on reducing the spread of HCAI, i.e. a more
direct proof of clinical effectiveness.
2
8

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.10.1
Basic experimental design of current methods to test the efficacy of hand hygiene and surgical hand preparation formulations
Method

Test organism(s)

Basic procedure

EN 1499

E. coli

excess

(hygienic handwash)

(K12)

fluid drained off, and air-dried for 3 minutes. Bacteria recovered for the initial values by
kneading the fingertips of each hand separately for 60 seconds in 10 ml of broth without
neutralizers. Hands removed from the broth and treated with the product following the
manufacturers instructions (but for no longer than 1 minute) or the reference solution (a
20% solution of soft soap). Recovery of bacteria for final values (see EN 1500).

EN 1500

E. coli

as

(hygienic handrub)

(K12)

in EN 1499. Hands rubbed for 30 seconds with 3 ml of isopropanol 60% v/v; same
operation repeated with a total application time not exceeding 60 seconds. The
fingertips of both hands rinsed in water for 5 seconds and excess water drained off.
Fingertips of each hand kneaded separately in 10 ml of broth with added neutralizers.
These broths are used to obtain the final (post-treatment) values. Log10 dilutions of
recovery medium containing neutralizer are prepared and plated out. Within 3 hours, the
same subjects tested with the reference formulation or the test product. Colony counts
obtained and log reductions calculated.

ASTM E-1174

S. marcescens

To test the efficacy of handwash or handrub agents on the reduction of transient

(efficacy of HCW or
consumer handwash
formulation)

and E. coli

microbial flora. Before baseline bacterial sampling and prior to each wash with the test
material, 5 ml of a suspension of test organism are applied to and rubbed over hands.
Test material put onto hands and spread over hands and lower third of forearms with
lathering. Hands and forearms rinsed with water. Elutions are performed after required
number of washes using 75 ml of eluent for each hand in glove. The eluates are tested
for viable bacteria.

ASTM E-1838

Adenovirus,

and

(fingerpad method
for viruses)

rotavirus, rhinovirus
and hepatitis A virus

fingerpad, the inoculum dried and exposed for 1030 seconds to 1 ml of test formulation
or control. The fingerpads then eluted and eluates assayed for viable virus. Controls
included to assess input titre, loss on drying of inoculum, and mechanical removal of
virus. The method applicable to testing both handwash and handrub agents.

ASTM E-2276

E. coli,

Similar to ASTM E-1838.

(fingerpad method
for bacteria)

S. marcescens,
S. aureus, and

Hands washed with a soft soap, dried, immersed in broth culture for 5 seconds,

Basic procedure for hand contamination and initial recovery of test bacteria same

10 l of the test virus suspension in soil load placed at the centre of each thumb-

S. epidermidis
Similar to ASTM E-1838.

ASTM E-2613

Candida albicans

(fingerpad method
for fungi)

and Aspergillus

ASTM E-2011

Rotavirus and

1838), if

(whole hand method

for viruses)

rhinovirus

necessary. Both hands are contaminated with the test virus, and test formulation is used
to wash or rub on them. The entire surface of both hands eluted and the eluates assayed
for infectious virus.

EN 12791

Resident skin

reference

(surgical hand
preparation)

flora (no artificial

contamination)

hand antisepsis 3-minute rub with n-propanol 60% v/v; longest allowed treatment
with product 5 minutes; 1 week between tests with reference and product. Test for
persistence (3 hours) with split hands model is optional (product shall be significantly
superior to reference).

niger
This method is designed to confirm the findings of the fingerpad method (E-

Same as for EN 1500 with the following exceptions: no artificial contamination;

The method is designed to assess immediate or persistent activity against the

ASTM E-1115

Resident skin

resident

(test method for

evaluation of
surgical handscrub
formulations)

flora (no artificial

contamination)

flora. Subjects perform simulated surgical scrub and hands sampled by kneading them
in loose-fitting gloves with an eluent. The eluates are assayed for viable bacteria.

29

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

11.
Review of preparations used for hand hygiene
11.1 Water
The purpose of routine handwashing in patient care is to
remove dirt and organic material as well as microbial
contamination acquired by contact with patients or the
environment.
While water is often called a universal solvent, it cannot
directly remove hydrophobic substances such as fats and oils
often present on soiled hands. Proper handwashing therefore
requires the use of soaps or detergents to dissolve fatty
materials and facilitate their subsequent flushing with water.
To ensure proper hand hygiene, soap or detergent must be
rubbed on all surfaces of both hands followed by thorough
rinsing and drying. Thus, water alone is not suitable for
cleaning soiled hands; soap or detergent must be applied as
well as water.

11.1.1 Association of water contamination with infections

Tap water may contain a variety of microorganisms
including human pathogens. Tables I.11.1 and I.11.2 list
known or suspected waterborne pathogens, together with
their health significance, stability in water, and relative
infectivity.228

11.1.2 Microbially-contaminated tap water in healthcare institutions

Tap water in health-care institutions can be a source of
nosocomial infections. A Medline search from 1966 to
2001 found 43 such outbreaks, of which 69% (29) could
be linked by epidemiological and molecular evidence to
biofilms (a community of microorganisms growing as a
slimy layer on surfaces immersed in a liquid) in water
storage tanks, tap water, and water from showers.229-232
Pathogens identified
in waterborne nosocomial infections include: Legionella
spp., P. aeruginosa,233,234 Stenotrophomonas
maltophilia,235 Mycobacterium avium,236 M. fortuitum,237 M.
chelonae,238

Fusarium spp.,239 and A. fumigatus.240 Even if hand

hygiene practices are in place, a plausible route for
transmitting these organisms from water to patient could
be through HCWs hands if contaminated water is used to
wash them. WHO has developed a reference document
on Legionella spp. and the prevention of legionellosis
which provides a comprehensive overview of the sources,
ecology, and laboratory detection
241

of this microorganism. It should be noted, however,

that Legionella spp. are transmitted primarily through
inhalation of aerosolized or aspirated water.
A Norwegian study to determine the occurrence,
distribution, and significance of mould species in drinkingwater found 94 mould species belonging to 30 genera,
including Penicillium,
Trichoderma, and Aspergillus spp. Of these, Penicillium
spp. were abundantly distributed and appeared to

survive water treatment.

Although heating of water
reduced the levels of
fungal contamination, A.
ustus appeared to be
somewhat resistant to
such treatment.
Potentially pathogenic
species

of fungi in tap water may

be particularly important in
settings where
immunocompromised
patients are housed.242

11.1.3 Tap water quality

Tap water, in addition to
being a possible source of
microbial contamination,
may include substances
that may interfere with the
microbicidal activities of
antiseptics and
disinfectants.

Examples of common
water contaminants and
their effects are
summarized in Table I.11.1.
The physical, chemical
and microbiological
characteristics of water to
be used for handwashing
in health-care institutions
must meet local
regulations.228 The
institution is responsible
for the quality of water
once it enters the building.
WHO
has developed guidelines
for essential environmental
health standards in health
care for developing
countries.243 In Europe, the
quality of drinkable water in
public buildings is regulated
by the European Councils
Directive Water for Human
Consumption (Regulation
1882/2003/EC) 244 (Table
I.11.3). In

France, national guidelines

for health-care settings have
recently proposed
microbiological standards for
water quality (Table I.11.4).
If an institutions water is
suspected of being
contaminated, it can be
made microbiologically
safer by filtration and/or
disinfection.228 Disinfectants
include chlorine,
monochloramine, chlorine
dioxide, ozone, and
ultraviolet irradiation.228
Chlorine, in gas or liquid

form, remains the most common chemical used for this

purpose, but is prone to generating potentially toxic byproducts in the treated water. Ozone has high installation
costs; monochloramine, while being slower than chlorine in
its microbicidal action, does leave a disinfectant residual
and is also less likely to generate harmful by-products.

system through crossconnections, leakage,

seepage or backflow.
However, conventional
levels of disinfectant
residuals may be ineffective
against massive
contamination influx.245

The first step of conventional water treatment is the

removal of as much of the organic matter and particulates
as possible through coagulation, sedimentation, and
filtration. Water is then disinfected before entering the
distribution system. It
is highly desirable to maintain a disinfectant residual in the
treated water while it is in transit, in order to limit the
growth of microorganisms in the distribution system and to
inactivate any pathogens that may enter the distribution

Ultraviolet radiation is a
potential alternative to
chemical disinfection of
small water systems,
as long as such water
is free of suspended
matter, turbidity, and

colour. The main

disadvantage is that
ultraviolet treatment
does not leave a
disinfectant residual.246
In Japan, the regulation on
water supply mandates the
use of sterile water instead
of tap water for
preoperative scrubbing of
hands. However, a
Japanese study showed
that bacterial counts on
hands were essentially the
same, irrespective of

30

According to the recommendations included in this

document, drinkable water should be used for
handwashing.

11.1.4 Water temperature

the type of water used, and emphasized the importance of
maintaining a free chlorine residual of >0.1 ppm in tap
water.247
In many developing countries, tap water may be
unfit for drinking. While drinkable water may also be
ideal for
handwashing, available evidence does not support the need
for potable water for washing hands. In a resource-limited
area of rural Bangladesh,248 education and promotion of
handwashing with plain soap and available water
significantly reduced the spread of diarrhoeal diseases
across all age groups.248 A similar study in Pakistan
corroborated these findings.249
Nevertheless, if the water is considered potentially unsafe
for handwashing, the use of antibacterial soap alone may
not be adequate. Washed hands may require further
decontamination with antiseptic handrubs, especially in
areas with high-risk populations,250 while steps are initiated
to improve water quality through better treatment and
disinfection.
Health-care institutions in many parts of the developing world
may not have piped-in tap water, or it may be available only
intermittently. An intermittent water supply system often has
higher levels of microbial contamination because of the
seepage of contamination occurring while the pipes are
supplied with treated water. On-site storage of sufficient
water is often the only option in sites without a reliable
supply. However, such water

is known to be prone to microbial contamination unless

stored and used properly and may require point-of-use
treatment and/ or on-site disinfection.251
Containers for on-site storage of water should be emptied
and cleaned252 as frequently as possible and, when
possible, inverted to dry. Putting hands and contaminated
objects into

stored water should be avoided at all times. Storage

containers should ideally be narrow-necked to facilitate
proper coverage, with a conveniently located tap/faucet
for ease of water collection.
CDC has developed guidelines for safe water systems
and hand hygiene in health care in developing
countries,253 which were field-tested in Kenya and have
been adapted to other countries in Africa and in Asia.254

Apart from the issue of skin tolerance and level of

comfort, water temperature does not appear to be a
critical factor for microbial removal from hands being
washed. In contrast, in a study comparing water
temperatures of 4 C, 20 C and 40 C, warmer
temperatures have been shown to be very significantly
associated with skin irritation.255 The use of very hot
water for handwashing should therefore be avoided as it
increases the likelihood of skin damage.

11.1.5 Hand drying

Because wet hands can more readily acquire and spread
microorganisms, the proper drying of hands is an integral
part of routine handwashing. Careful hand drying is a
critical factor

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND

HYGIENE

been proven not to be associated with the aerosolization of

pathogens.
When clean or disposable towels are used, it is important to
pat the skin rather than rub it, to avoid cracking. Skin
excoriation may lead to bacteria colonizing the skin and
possible spread

determining the level of bacterial transfer associated with

touch-contact after hand cleansing. Care must also be
taken to avoid recontamination of washed and dried
hands.75 Recognition of this fact could significantly
improve hand hygiene practices in clinical and public
health sectors.75
Paper towels, cloth towels, and warm air dryers are
commonly used to dry washed hands. One study compared
four methods of hand drying: cloth towels from a roller;
paper towels left on a sink; warm air dryer; and letting
hands dry by evaporation;256 no significant difference in the
efficacy of the methods was
reported. Reusing or sharing towels should be avoided
because of the risk of cross-infection.257 In a comparison of
methods to test the efficiency of hand drying for the removal
of bacteria from washed hands, warm air drying performed
worse than drying with paper towels.258 This is in contrast to
another
study, which found warm air dryers to be the most
efficient when compared with paper and cloth
towels.257 However, air dryers may be less practical
because of the longer time needed to achieve dry
hands,258 with a possible negative
impact on hand hygiene compliance. Furthermore, one
study suggested that some air driers may lead to the
aerosolization of waterborne pathogens.259 Further studies
are needed to issue recommendations on this aspect.
Ideally, hands should be dried using either individual paper
towels or hand driers which can dry hands effectively and
as quickly as it can be done with paper towels, and have

of bloodborne viruses as well as other

microorganisms.79 Sore hands may also lead to
decreased compliance with hand hygiene practices
(see also Part I, Section 15).

11.2 Plain (non-antimicrobial) soap

Soaps are detergent-based products that contain esterified
fatty acids and sodium or potassium hydroxide. They are
available in various forms including bar soap, tissue, leaf, and
liquid preparations. Their cleansing activity can be attributed to
their detergent properties which result in the removal of lipid
and adhering dirt, soil, and various organic substances from
the hands. Plain soaps have minimal, if any, antimicrobial
activity, though handwashing with plain soap can remove
loosely adherent transient flora. For example, handwashing
with plain soap and water for 15 seconds reduces bacterial
counts on the skin by 0.61.1 log10, whereas washing for 30
seconds reduces counts by 1.82.8 log10.48 In several studies,
however, handwashing with plain soap failed to remove
pathogens from the hands of HCWs.88,110,260 Handwashing with
plain soap can result in a paradoxical increase in bacterial
counts on the skin.220,261-263 Because soaps may be associated
with considerable skin irritation and dryness,220,262,264 adding
humectants to soap preparations may reduce their propensity
to cause irritation. Occasionally, plain soaps have become
contaminated, which may lead to the colonization of HCWs

hands with Gram-negative bacilli.160 Nevertheless, there

is some evidence that the actual hazard of transmitting
microorganisms through handwashing with previously
used soap bars is negligible.265,266
31

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

compounds
(QAC),
povidoneiodine,
triclosan or
CHG.137,221,267-

11.3
Alcohols

286

The
antimicrobial
Most
activity of
alcoholalcohols
based
results from
hand
their ability
antisepti
to denature
cs
proteins.287
contain
Alcohol
either
solutions
ethanol,
containing
isopropa
6080%
nol or nalcohol are
propanol
most
effective,
, or a
with higher
combinat
concentratio
ion
of
ns being
two
of
less
these
potent.288,289
products.
This paradox
Concentr
results from the
ations
fact that
are given
proteins are
as either
not denatured
percenta
easily in the
ge
absence of
of volume (=
287
ml/100 ml, water. The
alcohol content
abbreviated
of solutions
% v/v),
may be
percentage
expressed as a
of weight (= percentage by
g/100 g,
weight (m/m),
abbreviated which is not
% m/m), or affected by
percentage temperature or
of
other variables,
weight/volu or as a
me (= g/100 percentage by
volume (v/v),
ml,
abbreviated which may
be affected
% m/v).
Studies of by
temperature,
alcohols
specific
have
evaluated gravity and
reaction
either
concentratio
individual
290
alcohols in n. For
example,
varying
70% alcohol
concentratio
by weight is
ns (most
equivalent to
studies),
76.8% by
combination volume if
s of two
prepared at
alcohols, or 15 C, or
alcohol
80.5% if
solutions
prepared at
containing 25 C.290
small
Alcohol
amounts of concentratio
hexachlorop ns in
hene,
antiseptic
quaternary handrubs
ammonium are often

expressed
as a
percentage
by
volume.198

Alcohols have
excellent in
vitro
germicidal
activity
against Grampositive and
Gramnegative
vegetative
bacteria
(including
multidrugresistant
pathogens
such as
MRSA and
VRE), M.
tuberculosis,
and a variety
of fungi.287289,291-296

However, they
have virtually
no activity
against
bacterial
spores or
protozoan
oocysts, and
very poor
activity
against some
nonenveloped
(nonlipophilic)
viruses. In
tropical
settings, the
lack of activity
against
parasites is a
matter of
concern about
the
opportunity to
promote the
extensive use
of alcoholbased
handrubs,
instead of
handwashing,
which may at
least
guarantee a
mechanical
removal
effect.
Some
enveloped
(lipophilic)
viruses such
as herpes
simplex virus
(HSV), HIV,

Typically, log
influenza
virus, RSV, reductions
of the
and
release of
vaccinia
test
virus are
susceptible bacteria
to alcohols from
when tested artificially
contaminat
in vitro
ed hands
(Table
average
297
I.11.5).
3.5 log10
Other
after a 30enveloped
second
viruses that application,
are
and 4.0
somewhat 5.0 log
10
less
after a 1susceptible, minute
but are
application.
48
killed by
In 1994,
6070%
the FDA
alcohol,
TFM
include
classified
hepatitis B ethanol
virus (HBV) 6095% as
and
a generally
safe and
probably
hepatitis C effective
virus.298 In a active
agent for
porcine
use in
tissue
antiseptic
carrier
hand
model used
hygiene or
to study
HCW
antiseptic
handwash
activity,
products.198
70%
Although the
ethanol and
TFM
70%
considered
isopropanol
that there were
were found
insufficient
to reduce
data to classify
titres of an isopropanol
enveloped 7091.3% as
bacteriopha effective, 60%
ge more
isopropanol
effectively has
than an
subsequently
antimicrobia been adopted
l soap
containing
4% CHG.192
Numerous
studies have
documented
the in vivo
antimicrobial
activity of
alcohols.
Early
quantitative
studies of
the effects
of antiseptic
handrubs
established
that alcohols
effectively
reduce
bacterial
counts on
hands.63,288,2
92,299

in Europe as
the reference
standard
against which
alcohol-based
handrub
products are
compared201
(see Part I,
Section
10.1.1).
Although npropanol is
found in
some hand
sanitizers in
Europe,300 it
is not
included by
the TFM in
the list of
approved
active agents
for hand
antisepsis
and surgical
hand
preparation in
the USA.58
Alcohols
are rapidly
germicidal
when
applied to
the skin,
but have
no
appreciable
persistent
(residual)
activity.
However,
regrowth of
bacteria on
the skin
occurs
slowly after
use
of
alcoholbased
hand
antisept
ics,
presum
ably
becaus
e of the
sublethal
effect
alcohols
have on
some of
the skin
bacteria.301,302
Addition of

chlorhexidine enveloped
, quaternary viruses
ammonium (Table
compounds, I.11.5). For
octenidine or example,
triclosan to in vivo
alcoholstudies
based
using a
formulations fingerpad
can result in model
persistent
have
activity.48 A demonstra
synergistic ted that
combination 70%
of a
isopropan
humectant ol and
(octoxyglycer 70%
ine) and
ethanol
preservatives were more
has resulted
effective
in prolonged
than
activity
medicated
against
soap or
transient
nonpathogens.30
medicated
3
soap in
Nevertheless reducing
, a recent
rotavirus titres
study on
on
bacterial
fingerpads.257,3
population 04
A more
kinetics on
recent
study
gloved hands
using
the
same
following
test methods
treatment
with alcohol- evaluated a
commercially
based
available
handrubs
product
with and
containing 60%
without
supplements ethanol, and
(either CHG found that the
product
or
mecetronium reduced the
etilsulfate) infectivity titres
concluded of three nonenveloped
that the
contribution viruses
(rotavirus,
of
supplements adenovirus,
to the delay and rhinovirus)
to 4
of bacterial by 3 305
regrowth on logs. Other
gloved hands non-enveloped
viruses such as
appeared
hepatitis A and
227
minor.
enteroviruses
(e.g. poliovirus)
Alcohol
may require
s, when
7080%
used in
alcohol to be
concent
reliably
rations
inactivated.306,3
present
07
It is worth
in
noting
that both
alcohol70%
ethanol
based
and a 62%
handrub
ethanol foam
s, also
product with
have in
humectants
vivo
reduced
activity
hepatitis A
against
virus titres on
a
whole hands or
number
fingertips to a
of non-

greater degree
than nonmedicated
soap, and both
reduced viral
counts on
hands to about
the same
extent as
antimicrobial
soap
containing 4%
CHG.308 The
same study
found that both
70% ethanol
and
the 62%
ethanol foam
product
demonstrate
d greater
virucidal
activity
against
poliovirus
than either
nonantimicrobial
soap or a 4%
CHGcontaining
soap.308
However,
depending
on the
alcohol
concentratio
n, time, and
viral variant,
alcohol may
not
be effective
against
hepatitis A and
other nonlipophilic
viruses.
Schurmann
concluded that
the inactivation
of naked (nonenveloped)
viruses is
influenced by
temperature,
the ratio of
disinfectant to
virus volume,
and protein
load.309
Various 70%
alcohol
solutions
(ethanol, npropanol,
isopropanol)
were tested
against a
surrogate of
norovirus and
ethanol with
30-second
exposure
demonstrated
virucidal

activity
superior to
the
others.310 In
a recent
experimenta
l study, ethyl
alcoholbased
products
showed
significant
reductions
of the tested
surrogate
for a nonenveloped

human virus;
however,
activity was
not superior to
nonantimicrobial
or tap/faucet
water
controls311.

In general,
ethanol has
greater activity
against
viruses than
isopropanol70.
Further in vitro
and in vivo
32

studies of both
alcohol-based
formulations
and
antimicrobial
soaps are
warranted to
establish the
minimal level
of virucidal
activity that is
required to
interrupt direct
contact
transmission
of viruses in
health-care
settings.

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

88,125,137,221,223,273-279,286,313-321

Alcohols are
not good
cleansing
agents and
their use is not
recommended
when hands
are dirty or
visibly
contaminated
with
proteinaceous
materials.
When
relatively small
amounts of
proteinaceous
material (e.g.
blood) are
present,
however,
ethanol and
isopropanol
may reduce
viable bacterial
counts on
hands,312 but
do not obviate
the need for
handwashing
with water and
soap whenever
such
contamination
occurs.179 A
few studies
have examined
the ability of
alcohols to
prevent the
transfer of
health careassociated
pathogens by
using
experimental
models of
pathogen
transmission.74

handrub with an
alcohol-based
hand rinse. In
contrast, transfer
of the organisms
occurred in 92%
of experiments
following
handwashing
with plain soap
and water. This
experimental
model suggests
that when HCWs
hands are
heavily
contaminated,
alcohol-based
handrubbing can
prevent
pathogen
transmission
more effectively
than
handwashing
with plain soap
and water.
Table I.11.6
summarizes a
number of studies
that have
compared alcoholbased products
with plain or
antimicrobial
soaps to
determine which
was more
effective for
standard
handwashing or
hand antisepsis
by HCWs (for
details see Part I,
Section 11.13).

The efficacy of
alcohol-based
hand hygiene
products is
affected by a
number of factors
including the type
of alcohol used,
concentration of
,88,169
alcohol, contact
Ehrenkranz
time, volume of
and
alcohol used, and
colleagues88
whether the
found that
hands are wet
Gram-negative
when the alcohol
bacilli were
is applied. Small
transferred
volumes (0.20.5
from a
ml) of alcohol
colonized
applied to the
patients skin
hands
to a piece
are no more
of catheter
effective than
material via the washing hands
hands of nurses with plain soap
in only 17% of
and water.74,169
experiments
Larson and
following
colleagues151

antiseptic

documented
that 1 ml
of alcohol was
significantly less
effective than 3
ml. The ideal
volume of
product to apply
to the hands is
not known and
may vary for
different
formulations. In
general,
however, if
hands feel dry
after being
rubbed together
for less than 10
15 seconds,

it is likely that
an insufficient
volume of
product was
applied.
Alcoholimpregnated
towelettes
contain only a
small amount
of
330-332
alcohol and
are not much
more effective
than washing
with soap and
water.74,
60,333-335

322,323

Alcohol-based
handrubs
intended for use
in hospitals are
available as
solutions (with
low viscosity),
gels, and foams.
Few data are
available
regarding the
relative efficacy
of various
formulations.
One small field
trial found that
an ethanol gel
was somewhat
less effective
than a
comparable
ethanol solution
at reducing
bacterial counts
on the hands of
HCWs.324
Recent studies
found similar
results
demonstrating
that solutions

reduced bacterial
counts on the

hands to a
significantly
greater extent
than the tested
gels.203,325 Most
gels showed
results closer to Frequent use of
alcohol-based
a 1-minute
simple handwash formulations for
hand antsepsis
than to a 1minute reference tends to cause
drying of the
antisepsis.296
New generations skin unless
humectants or
of gel
formulations with other skin
conditioning
higher
agents are
antibacterial
added to the
efficacy than
formulations.
previous
products have For example,
the drying effect
since been
of alcohol can
proposed.70
Further studies be reduced or
are warranted to eliminated by
adding 13%
determine the
relative efficacy glycerol or other
of alcohol-based skin conditioning
solutions and
219,221,267,268,273,
agents.
301,313,326,327
gels in reducing
transmission of Moreover, in
health careprospective
associated
trials, alcoholpathogens.
based solutions
Furthermore, it is or gels
worth
containing
considering that humectants
compliance is
caused
probably of
significantly less
higher
skin irritation
importance, thus and dryness
if a gel with lower than the soaps
in vitro activity is or antimicrobial
more frequently detergents
used, the overall
tested.262,264,328,3
outcome is still 29
These
expected to be
studies,
which
better.
were conducted
in clinical
settings, used a
variety of
subjective and
objective
methods for
assessing skin
irritation and
dryness. Further
studies of this
type are
warranted to
establish if
products with
different
formulations
yield similar
results.

Even welltolerated alcoholbased handrubs

containing
humectants may
cause a transient
stinging sensation
at the site of any

broken skin (cuts,

abrasions).
Alcohol-based
handrub
preparations with
strong fragrances
may be poorly
tolerated by a few
HCWs with
respiratory
allergies. Allergic
contact dermatitis
or contact urticaria
syndrome caused
by hypersensitivity
to alcohol, or to
various additives
present in some
alcohol-based
handrubs, occurs
rarely (see also
Part I, Section
14).
A systematic
review of
publications
between 1992
and 2002 on the
effectiveness of
alcohol-based
solutions for
hand hygiene
showed that
alcohol-based
handrubs remove
organisms more
effectively,
require less time,
and irritate skin
less often than
handwashing
with soap or
other antiseptic
agents and
water.333 The
availability of
bedside alcoholbased solutions
increased
compliance with hand hygiene among
HCWs.

Regarding

surgical hand
preparation, an
alcohol-based
waterless
surgical scrub
was shown to
have the same
efficacy and
demonstrated
greater
acceptability
and fewest
adverse effects
on skin
compared with
an alcoholbased wateraided solution
and a brushbased iodine
solution.336
Alcohols are

flammable, and
HCWs handling
alcohol-based
preparations
should respect
safety standards
(see Part I,
Section 23.6).
Because
alcohols are
volatile,
containers
should be
designed so that
evaporation is
minimized and
initial
concentration is
preserved.
Contamination
of alcohol-based
solutions has
seldom been
reported. One
report
documented a
pseudoepidemic of
infections
resulting from
contamination of
ethyl alcohol by

Bacillus cereus
spores337 and
in-use
contamination
by Bacillus spp.
has been
reported.

338

11.4
Chlorhexidine
CHG, a cationic
bisbiguanide, was
developed in the
United Kingdom
in the early 1950s
and introduced
into the USA in
the 1970s.204,339
Chlorhexidine
base is barely
soluble in water,
but the
digluconate form
is water-soluble.
The antimicrobial
activity of
chlorhexidine
appears to be
attributable to the
33

attachment to,
and subsequent
disruption of
cytoplasmic
membranes,
resulting in
precipitation of
cellular
contents.48,204
Chlorhexidines
immediate
antimicrobial
activity is slower
than that of
alcohols. It has
good activity
against Grampositive bacteria,
somewhat less
activity against
Gram-negative
bacteria and
fungi, and
minimal activity
against
mycobacteria.48,20
4,339
Chlorhexidine

is not
sporicidal.48,339. It
has in vitro
activity against
enveloped

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

chlorhexidine
are more
effective than
plain soap, but
are less
effective than
antiseptic
viruses such detergent
as herpes preparations
simplex
containing
virus, HIV, 4%CHG.301,343
cytomegalov Preparations
irus,
with 2%
influenza, CHGare
and RSV, slightly less
but
effective than
significantly those
less activity containing 4%
against non- chlorhexidine.3
enveloped 44 A scrub
viruses such agent based
as rotavirus, on CHG(4%)
adenovirus, was shown to
and
be significantly
enteroviruse more effective
297,340,341
s.
to reduce
The
bacterial count
antimicrobial than a
activity of
povidone
chlorhexidin iodine (7.5%)
e is not
scrub
seriously
agent.247
affected by
the
Chlorhexidine
presence of has significant
organic
residual
material,
activity.273,281including
283,285,301,315,343
blood.
Addition of low
Because
concentrations
chlorhexidin
(0.51%) of
e is a
chlorhexidine to
cationic
alcohol-based
molecule, its
preparations
activity can
results in
be reduced significantly
by natural greater residual
soaps,
activity than
various
alcohol
inorganic
alone.283,301
anions, nonWhen used as
ionic
recommended,
surfactants,
chlorhexidine
and hand
has a good
creams
safety record.339
containing
Little, if any,
anionic
absorption of
emulsifying
204,33 the compound
agents.
occurs through
the skin. Care
CHGhas
must be taken
been
to avoid contact
incorporated with the eyes
into a
when using
number of preparations
hand
with 1%
hygiene
chlorhexidine or
preparations greater as the
. Aqueous or agent can cause
detergent conjunctivitis or
formulations serious corneal
containing damage.
0.5%, 0.75%Ototoxicity
, or 1%
precludes its
9,342

use in surgery
involving the
inner or middle
ear. Direct
contact with
brain tissue and
the meninges
should

be avoided.
The
frequency of
skin irritation
is
concentration
-dependent,
with products
containing
4% most
likely to
cause
dermatitis
when used
frequently for
antiseptic
handwashing
.345 True
allergic
reactions to
CHGare very
uncommon
(see also
Part I,
Section
14).285,339
Occasional
outbreaks of
nosocomial
infections
have been
traced to
contaminated
solutions of
chlorhexidine
.346-349
Resistance
to
chlorhexidine
has also
been
reported.350

11.5
Chloroxyleno
l
Chloroxylenol,
also known as
para-chlorometa-xylenol
(PCMX), is a
halogensubstituted
phenolic
compound that
has been used
widely as a
preservative in
cosmetics and
other products
and as an
active agent in
antimicrobial
soaps. It was

developed inof studies

Europe in have
sometimes
the late
1920s and been
contradictory.
has been
used in the For example,
USA since in experiments
where
the
antiseptics
1950s.351
were applied
The
to abdominal
antimicrobial skin, Davies
activity of
and
chloroxylenol
is apparently
attributable
to the
inactivation
of bacterial
enzymes and
alteration of
cell walls.48 It
has good in
vitro activity
against
Grampositive
organisms
and fair
activity
against
Gramnegative
bacteria,
mycobacteria
and some
viruses.48,351,
352

Chloroxyleno
l is less
active
against P.
aeruginosa,
but the
addition of
ethylenediaminetetra
acetic acid
(EDTA)
increases its
activity
against
Pseudomona
s spp. and
other
pathogens.
Relatively
few articles
dealing with
the efficacy
of
chloroxylen
olcontaining
preparation
s intended
for use by
HCWs have
been
published in
the last 25
years, and
the results

colleagues
found that
chloroxylenol
had the
weakest
immediate and
residual
activity of any
of the agents
studied.353.
When 30second
handwashes
were
performed,
however, using
0.6%
chloroxylenol,
2% CHG or
0.3%
triclosan, the
immediate
effect of
chloroxylenol
was similar to
that of the
other agents.
When used
18 times/day
for five days,
chloroxylenol
had
less
cumulative
activity than
didCHG.354
When
chloroxylenol
was used as a
surgical scrub,
Soulsby and
colleagues355
reported that
3%
chloroxylenol
had immediate
and residual
activity
comparable to
4%CHG, while
two other
studies found
that the
immediate and
residual
activity of
chloroxylenol
was inferior to
both CHG and
povidoneiodine.344,356
The disparity
between
published
studies may
result in part
from the
various
concentrations
of

chloroxylen
ol included
in the
preparation
s evaluated
and to other
aspects of
the
formulations
tested,
including
the
presence or
absence of
EDTA.351,352
Larson
concluded
that
chloroxylen
ol is not as
rapidly
active as
CHG or
iodophors,
and that its
residual
activity is
less
pronounced
than that
observed
withCHG.351
,352
In 1994,
the FDA
TFM
tentatively
classified
chloroxylen
ol as a
Category
IIISE active
agent
(insufficient
data to
classify as
safe and
effective).198
Further
evaluation
of this agent
by the FDA
is ongoing.

tolerated;
some cases of
allergic
reactions have
been
reported,357
but they are
relatively
uncommon.
Chloroxylen
ol is
available in
concentratio
ns ranging
from 0.3% to
3.75%. Inuse
contaminatio
n of a
chloroxyleno
l-containing
preparation
has been
reported.358

11.6
Hexachlorop
hene

Hexachloroph
ene is a
bisphenol
composed of
two phenolic
groups and
three chlorine
moieties. In
the 1950s and
early 1960s,
emulsions
containing 3%
hexachloroph
ene were
widely used
for hygienic
handwashing
as surgical
scrubs and for
routine
The
bathing of
antimicrobial infants in
activity of
hospital
chloroxyleno
nurseries. The
l is minimally
antimicrobial
affected by
activity of
the
presence of hexachloroph
ene is related
organic
matter, but to its ability to
inactivate
is
neutralized essential
by non-ionic enzyme
surfactants. systems in
Chloroxylen microorganis
ol is
ms.
absorbed
Hexachloroph
through the ene is
skin.351,352 bacteriostatic,
Chloroxylen with good
ol is
activity against
generally
S. aureus and
well
relatively weak

activity against
Gramnegative
bacteria, fungi,
and
mycobacteria.
352

Studies of
hexachlorophe
ne as a
hygienic
handwash or
surgical scrub
demonstrated
only modest
efficacy after a
single
handwash.125,3
13,359

Hexachloroph
ene has
residual
activity for
several hours
after use and
gradually
reduces
bacterial
counts on
hands after
multiple uses
(cumulative
effect).48,268,359,
360
In fact, with
repeated use
of 3%
hexachlorophe
ne
preparations,
the drug is
absorbed
through the
skin. Infants
bathed with
hexachlorophe
ne and
caregivers
regularly using
a 3%
hexachlorophe
ne preparation
for
handwashing
have blood
levels of 0.1
0.6 parts per
million (ppm)
hexachlorophe
ne.361
In the early
1970s, infants
bathed with
hexachloroph
ene
sometimes
developed
neurotoxicity
(vacuolar
degeneration)
.362 As a
result, in
1972, the
FDA warned
that

hexachloro
phene
should no
longer be
used

routinely for
bathing
infants. After
routine use of
hexachloroph
34

ene for
bathing
infants in
nurseries

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

has been
banned
worldwide.

204,367,369-372

was
discontinued, a
number of
investigators
noted that the
incidence of S.
aureus
infections
associated with
health care in
hospital
nurseries
increased
substantially.363,
364
In several
instances, the
frequency of
infections
decreased when
hexachlorophen
e bathing of
infants was
reinstituted.
However,
current
guidelines
recommend
against routine
bathing of
neonates with
hexachlorophen
e because of its
potential
neurotoxic
effects.365 The
agent is
classified by the
FDA TFM as not
generally
recognized as
safe and
effective for use
as an antiseptic
handwash.198
Hexachlorophen
e should not be
used to bathe
patients with
burns or
extensive areas
of abnormal,
sensitive skin.
Soaps
containing 3%
hexachlorophen
e are available
by prescription
only.352 Due to
its high rate of
dermal

11.7 Iodine and

iodophors
48,271,282,360,376-381

Iodine has been

recognized as
an effective
antiseptic since
the 1800s,
though
iodophors have
largely replaced
iodine as the
active
ingredient in
antiseptics
because iodine
often causes
irritation and
discolouring of
skin.

Iodine molecules
rapidly penetrate
the cell wall of
microorganisms
and inactivate
cells by forming
complexes with
amino acids and
unsaturated fatty
acids, resulting in
impaired protein
synthesis and
alteration of cell
membranes.367
Iodophors are
composed of
elemental iodine,
iodide or triiodide,
and a polymer
carrier
(complexing
agent) of high
molecular weight.
The amount of
molecular iodine
present (so-called
free iodine)
determines the
level of
antimicrobial
activity of
iodophors.
Available iodine
refers to the total
amount of iodine
that can be
titrated with
sodium
thiosulfate.368
absorption and
Typical 10%
subsequent toxic
povidone-iodine
70,366
effects,
formulations
hexachlorophene
contain 1%
-containing
products should available iodine
be avoided and and yield free
hexachlorophene iodine

concentrations of
1 ppm.368
Combining iodine
with various
polymers
increases the
solubility of iodine,
promotes
sustained-release
of iodine, and
reduces skin
irritation. The
most common
polymers
incorporated into
iodophors are
polyvinyl
pyrrolidone
(povidone) and
ethoxylated
nonionic
detergents
(poloxamers).367,36
8
The antimicrobial
activity of
iodophors can
also be affected
by pH,
temperature,
exposure

time,
concentration of
total
available
iodine, and the
amount and type
of organic and
inorganic
compounds
present
(e.g.
alcohols
and
detergents).
Iodine and
iodophors have
bactericidal
activity against
Gram-positive,
Gram-negative
and some
spore-forming
bacteria
(clostridia,
Bacillus spp.)
and are active
against
mycobacteria,
viruses, and fungi. However, in
concentrations used

in antiseptics,
iodophors are not
usually
sporicidal.373 In
vivo studies have
demonstrated that
iodophors reduce
the number of
viable organisms
that may be
recovered from
HCWs
hands.280,314,317,320,3
74
Povidone-iodine
510% has been
tentatively

classified by the
FDA TFM as a safe
and effective
(Category

I) active agent
for use as an
antiseptic
handwash and
HCW
handwash.198
The extent to
which iodophors
exhibit
persistent
antimicrobial
activity once
they have been
washed off the
skin is a matter
of some
controversy. In
a study by
Paulson,344
persistent
activity was
noted for six
hours, but
several other
studies
demonstrated
persistent
activity for 30
60 minutes
after washing
hands with an
iodophor.137,284,375
In studies where

bacterial counts
were obtained
after individuals
wore gloves for
14 hours after
washing,
however,
iodophors
demonstrated
poor persistent activity.
antimicrobial

The in vivo

activity of
iodophors is
significantly
reduced in
the presence
of organic
substances
such as
blood or
sputum.204
Povidone
iodine has
been found to
be less
effective than
alcohol 60%
(v/v) and
hydrogen
peroxide 3%
and 5% on S.
epidermidis
biofilms.382
Most iodophor
preparations
used for hand
hygiene contain
7.5 10%
povidone-iodine.
Formulations
with lower
concentrations
also have good
antimicrobial
activity, because
dilution tends to
increase free
iodine
concentrations.38
3
As the amount
of free iodine
increases,
however, the
degree of skin
irritation also
may increase.383
Iodophors cause
less skin irritation
and fewer allergic
reactions than
iodine, but more
irritant contact
dermatitis than
other antiseptics
commonly used
for hand
hygiene.220
Occasionally,

iodophor
antiseptics have
become
contaminated with
Gram-negative
bacilli as a result
of poor
manufacturing
processes and
have caused
outbreaks or
pseudo-outbreaks
of infection.368,384
An outbreak of P.
cepacia
pseudobacteremi
a involving 52
patients in four
hospitals in New
York over six
months was
attributed to the
contamination of
a 10% povidoneiodine solution
used as an
antiseptic and
disinfectant
solution.384

11.8
Quaternary
ammonium
compounds
Quaternary
ammonium
compounds
(QACs)
are
composed of a
nitrogen atom
linked directly
to four alkyl
groups, which
may
vary
considerably in
their structure
and
complexity.385
Among
this
large group of
compounds,
alkyl
benzalkonium
chlorides
are the most
widely used as
antiseptics. Other
compounds that
have been used
as antiseptics
include
benzethonium
chloride,
cetrimide, and
cetylpyridium
chloride.48 The
antimicrobial
activity of these
compounds was
first studied in the
early 1900s, and
a QAC for
preoperative

cleaning of
surgeons
hands was
used as early
as 1935.385 The
antimicrobial
activity of this
group

of
compounds
appears to
be
attributable
to adsorption
to the
cytoplasmic
membrane,
with
subsequent
leakage of
low
molecular
weight
cytoplasmic
constituents.
385

QACs are
primarily
bacteriostatic
and fungistatic,
although they
are
microbicidal
against some
organisms at
high
concentrations.
48
They are

more active
against Grampositive
bacteria than
against Gramnegative
bacilli. QACs
have relatively
weak activity
against
mycobacteria
and fungi and
have greater
activity against
lipophilic
viruses (Table
I.11.7).

Their
antimicrobial
activity is
adversely
affected by the
presence of
organic
material, and
they are not
compatible with
anionic
detergents.48,385
A QAC is
present as a
supplement in
some
commercially
available
alcohol-based
handrubs. A
35

study on the
population
kinetics of skin
flora on gloved
hands indicated
that the effect of
an alcoholbased handrub
containing
mecetronium
etilsulfate
(isopropanol
45% wt/wt plus
n-propanol 30%
wt/wt plus
mecetronium
etilsulfate 0.2%
wt/wt ) was not
significantly
different from npropanol 60%
v/v.227
Depending on
the QAC type
and formulation,
the antimicrobial
efficacy can be
severely
affected in the
presence
of
hard water (if it
is
a
diluted
product)
and
fatty materials.
Later
generations

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

infection or
pseudoinfection
have been
traced to
QACs
contaminat
ed with
Gramof QACs, negative
bacilli.386-388
e.g.
didecyldim For this
reason,
ethyl
ammoniumthese
compounds
chloride
have
(DDAC),
seldom
have
stronger been used
antimicrobi for hand
al activity antisepsis
and good during the
performan last 1520
ce in the years in the
presence USA. More
recently,
of hard
water and newer hand
hygiene
organic
soiling, but products
containing
their
benzalkoniu
activity
has been m chloride
studied on or
inanimate benzethoni
surfaces um chloride
have been
only.
introduced
for use by
HCWs. A
In 1994,
the FDA
recent
TFM
clinical
tentative study
ly
performed
classifie
among
d
benzalko surgical ICU
nium
HCWs
chloride
found that
and
cleaning
benzeth
hands with
onium
antimicrobi
chloride
as
al wipes
Category containing
IIISE
a QAC was
active
almost as
agents
(insuffici effective as
ent data handwashin
to
g with plain
classify
soap and
as safe
water, and
and
effective that both
were
for use
significantly
as an
antisepti less
c
effective
handwas
than
h).198
decontamin
Further
ating hands
evaluati
with an
on of
these
alcoholagents
based
by the
389
FDA is in handrub.
progress One
laboratory.
based study
reported
In
that an
general,
alcohol-free
QACs are handrub
relatively product
well
containing
tolerated. a QAC was
Unfortuna efficacious
tely,
in reducing
because
microbial
of weak
counts on
activity
the hands
against
of
3
Gramnegative volunteers.
90
Further
bacteria, studies
of
benzalkon such
ium
chloride is products
needed
prone to are
contamin to
determine if
ation by
newer
these
organism formulation
s are
s and a
effective in
number
health-care
of
outbreaks settings.
of

QACs have
been used as
antiseptics to
reduce the
bioburden on
skin (e.g. for
wound
cleansing
and on
mucous
membrane
as
mouthwashe
s for the
control of
dental
plaque).
They are also
extensively
used as
disinfectants
(spray &
wipe) for
household,
industrial, and
health-care
surfaces, as
well as for food
surface
disinfection, as
most
formulations do
not require to
be rinsed

off with
water
after
applicatio
n.391 The
presence
of lowlevel
residues
may allow
the
selective
developm
ent of
bacterial
strains
with
greater
tolerance
of QACs
over time;
intrinsic
and
acquired
resistance
mechanis
ms have
been
described.
392,393

In general,
QACs are
relatively
well
tolerated
and have
low
allergenic
potential. In
higher
concentrati
ons,
though,
they can
cause
severe
irritation to
skin and
mucous
membranes
.

11.9
Triclosan
Triclosan
(chemical
name
2,4,4
trichloro2hydroxydi
phenyl
ether) is
known
commerci
ally as
Irgasan
DP-300. It
is a
nonionic,
colourles
s
substanc
e
develope
d in the
1960s;

various
dressings
and
bandages
for release
over time
onto the
skin.
Triclosan
enters
bacterial
cells and
affects the
cytoplasmic
membrane
and
synthesis of
RNA, fatty
acids, and
proteins.394
Recent
studies
suggest
that this
agents
antibacteria
l activity is
attributable
in large
part to
binding to
the active
site of
enoyl-acyl
carrier
protein
39
reductase.
5,396

it is
poorly
soluble
in
water,
but
dissolve
s well in
alcohols
.
Concent
rations
ranging
from
0.2% to
2% have
antimicr
obial
activity.
Triclosan
has
Triclosan
been
has a
incorpor
fairly
ated in
broad
deterge
range of
nts
(0.4% to antimicro
bial
1%) and
activity
in
(Table
alcohols
(0.2% to I.11.7),
but tends
0.5%)
to be
used for
hygienic bacterios
tatic.48
and
Minimum
surgical
inhibitory
hand
antiseps concentr
ations
is or
(MICs)
preoper
range
ative
from 0.1
skin
10 g/
disinfect to
ml, while
ion; it is
minimum
also used bacterici
dal
for
antiseptic concentr
ations
body
are 25
baths to
500
control
g/ml.
MRSA. This Triclosan
agent is
s activity
incorporat against
Gramed into
positive
some
soaps (at a organism
s
1% w/v
(includin
concentrat g MRSA)
ion) and a is greater
variety of than
against
other
consumer Gramproducts negative
(deodorant bacilli,
particular
s,
ly P.
shampoos, aeruginos
lotions,
a.48,394
The
etc.), as
agent
well as
possesse
being
integrated s
reasonab
also into le activity
against
mycobac
teria and
Candida
spp., but

has little
activity
against
filamento
us fungi
and most
viruses of
nosocomi
al
significan
ce.
Triclosan
(0.1%)
reduces
bacterial
counts on
hands by
2.8 log10
after a 1minute
hygienic 4
handwash.
8
In a
number of
studies, log
reductions
achieved
have been
lower than
with
chlorhexidin
e, iodophors
or alcoholbased
48,1
products.
37,223,354,397
/ In
1994, the
FDA TFM
tentatively
classified
triclosan up
to 1% as a
Category
IIISE active
agent
(insufficient
data to
classify as
safe and
effective for
use as
an antiseptic
handwash).19
8
Further
evaluation of
this agent by
the FDA is
under way.
Similar to
chlorhexidin
e, triclosan
has
persistent
activity on
the skin. Its
activity in
hand-care
products is
affected by
pH, the
presence of
surfactants
or
humectants,
and the ionic
nature of the
particular
formulation.4
8,394

Triclosans
activity is
not
substantially
affected by
organic
matter, but
may be
inhibited by
sequestratio
n of the
agent in
micelle
structures
formed by
surfactants
present in
some
formulations.
Most
formulations
containing
less than 2%
triclosan are
well
tolerated
and seldom
cause
allergic

reactions. containing
triclosan
A few
with a
reports
nonsuggest
antibacteri
that
al soap
providing and
HCWs with concluded
that the
a triclosan- former did
containing not
preparatio provide
any
n
additional
for
benefit.399
Concerns
hand
have been
antise
raised
psis
about the
has
use of
led to
triclosan,
decrea
because of
sed
the
infecti
developme
nt of
ons
bacterial
cause
resistance
d by
to low
MRSA.
concentrat
181,182
ions of
Triclos
biocide and
ans
crossresistance to
lack of
some
potent
antibiotics.
For example,
activit
Mycobacterium
y
smegmatis
mutations in
agains
inhA gene
t
leading
Gramto triclosan
negati
resistance are
ve
known to
bacilli
carry
has
resistance
resulte
also to
d in
isoniazid.400
occasi
Increased
onal
tolerance (i.e
report
increased
s of
MICs) to
conta
triclosan due
minat
to mutations
ed
in efflux
triclos
pumps has
an.398
A recent
study
compare
d an
antibact
erial
soap

been
reported in E.
coli and P.
aerugninosa.401
Laboratory
studies
involving
exposure

of some
microorga
nisms to
subinhibit
ory
concentrat
ions of
triclosan
have
resulted in
increased
triclosan
MICs.
However,
the clinical
relevance
of
increased
triclosan
MICs
generated
in the
laboratory
is unclear,
since
affected
strains
remain
susceptibl
e to in-use
concentrat
ions of 40
triclosan.
1,402
Further
research
dealing
with the
relationshi
p between
triclosan
use and
antimicrob
ial
resistance
mechanis
ms is
warranted
, and
surveillanc
e for
triclosanresistant
pathogens
in clinical
and
environme
ntal
settings is
needed.

36

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

11.10 Other
agents

409-417

More than 100

years after
Semmelweis
demonstrated
the impact of
rinsing hands
with a solution
of chlorinated
lime on
maternal
mortality
related to
puerperal
fever,
Lowbury and
colleagues403
studied the
efficacy of
rubbing hands
for 30
seconds with
an aqueous
hypochlorite
solution. They
found that the
solution was
no more
effective than
rinsing with
distilled water.
Rotter404
subsequently
studied the
regimen used
by
Semmelweis,
which called
for rubbing
hands with
a
4%
hypochlorite
solution405
until
the
hands were
slippery
(approximat
ely
5
minutes).
He
found
that
the
regimen
was
30
times more
effective
than a 1minute rub
using 60%
isopropanol.
However,
because
hypochlorite
solutions tend
to
be
very
irritating to the

skin when used

repeatedly and
have a strong
odour, they are
seldom
used
for
hand
hygiene today.
A number of
other agents
are being
evaluated by
the FDA for
use in
antiseptics
related to
health
care.198
However, the

efficacy of these
agents has not
been evaluated
adequately for
use in hand
hygiene
preparations
intended for use
by HCWs.
Further
evaluation of
some of these
agents may be
warranted.
Products that
utilize different
concentrations of
traditional
antiseptics (e.g.
low
concentrations of
iodophor) or
contain novel
compounds with
antiseptic
properties are
likely to be
introduced for
use by HCWs.
For example,
preliminary
studies have
demonstrated
that adding silvercontaining
polymers to an
ethanol carrier
(Surfacine)
results in a
preparation that
has persistent
antimicrobial
activity on animal
and human
skin.406 A unique
chlorhexidineloaded,
nanocapsulebased gel
showed
immediate
bactericidal
effect,
comparable to
isopropanolol
60% v/v against

aerobic bacteria;
surviving
anaerobic
bacteria were
significantly lower
compared with
ethanol-based gel
62% v/v.
Persistant
bactericidal effect
was observed
throughout the 3hour test period.
The immediate
and sustained
antibacterial
effect was
explained by an
efficient
chlorhexidine
carrier system
which improved
the drug targeting
to bacteria.407 The
clinical
significance of
these findings
deserves further
research. New
compounds with
good in vitro
activity must be
tested in vivo to
determine their
abilities to reduce
transient and
resident skin flora
on the hands of
caregivers.

11.11
Activity of
antiseptic
agents
against
sporeforming
bacteria
The increasing
incidence of C.
difficileassociated
diarrhoea in
health-care
facilities in
several
countries, and
the occurrence
in the USA of
human Bacillus
anthracis
infections
related to
contaminated
items sent
through the postal
system, have
raised concerns
about the activity
of antiseptic
agents against

spores. The
increasing
morbidity and
mortality of C.
difficileassociated
triclosan)
disease in the
used in
USA, Canada,
antiseptic
and some
handwash or
European
antiseptic
countries since
handrub
2001 has been
preparations
especially
attributed to more is reliably
sporicidal
frequent
outbreaks and the against
emergence of a Clostridium
new, more virulent spp. or
Bacillus
strain (ribotype
287,339,418,4
408
027). Epidemic spp.
19
Mechanical
strains differ
among countries: friction while
for instance, while washing
hands with soap
in Canada and
the Netherlands and water may
help physically
ribotype 027
remove spores
is
from the surface
predominant,
of contaminated
the United
hands.110,420,421
Kingdom
This effect
detected three
is not enhanced
different
when using
strains
(ribotype 001,
medicated
027 and 106)
soap.420 Contact
responsible for
precautions are
70% of C.
highly
difficile-associated recommended
diarrhoea.
during C. difficileassociated
Apart
fromoutbreaks, in
iodophors, but atparticular, glove
a
concentrationuse (as part of
remarkably highercontact
than the one usedprecautions) and
in antiseptics,373handwashing with
none
of
thea nonagents (includingantimicrobial or
alcohols,
antimicrobial soap
chlorhexidine,
and water
hexachlorophene, following glove
chloroxylenol, and
removal after
caring for patients
with
diarrhoea.422,423
Alcohol-based
handrubs can
then be
exceptionally
used after
handwashing in
these instances,
after making sure
that hands are
perfectly dry.
Moreover,
alcohol-based
handrubs, now
considered the
gold standard to
protect patients
from the multitude
of harmful
resistant and nonresistant

organisms
transmitted by
HCWs hands,
should be
continued to be
used in all other
instances

at the same
facility.
Discouraging
their
widespread
use, just
because of the
response to
diarrhoeal
infections
attributable to
C. difficile, will
only jeopardize
overall patient
safety in the
long term.
The widespread
use of alcoholbased handrubs
was repeatedly
given the major
blame for the
increase of C.
difficileassociated
disease
rates
because alcohol
preserves spores
and is used
in the laboratory
to select C.
difficile spores
from stools.424,425
Although alcoholbased handrubs
may not be
effective against
C. difficile, it has
not been shown
that they trigger
the rise of C.
difficile-associated
disease.426-429 C.
difficile-associated
disease rates
began to rise in
the USA long
before the wide
use of alcoholbased
handrubs.430,431
One outbreak with
the epidemic
strain REA-group
B1 ( ribotype 027)
was successfully
managed while
introducing
alcohol-based
handrub for all
patients other
than those with C.
difficile-associated
disease.427
Furthermore,
abandoning

alcohol-based
antimicrobial soap
handrub for
or antimicrobial
patients other
soap and water
than those with C. reduced the
difficile-associated amount of B.
disease would do atrophaeus (a
more harm than surrogate for B.
good, considering anthracis) on
the dramatic
hands, whereas
impact on overall an alcohol-based
infection rates
handrub was not
observed through effective.432
the recourse to
Accordingly,
handrubs at the HCWs with
point of care.320 suspected or
documented
A guide on
exposure to B.
how to deal
anthraciswith C.
contaminated
difficile
items should
outbreaks,
wash their hands
including
with a nonfrequently
antimicrobial or
asked
antimicrobial soap
questions
and water.

on hand
hygiene
practices, is
provided in
Appendix 2.

11.12
Reduced
susceptibility
of
A recent study
microorganis
demonstrated that ms to
washing hands
antiseptics
with either non-

37

Reduced
susceptibility
of bacteria to
antiseptic
agents can be
an intrinsic
characteristic
of a species,
or can be an
acquired
trait.433 A
number of
reports have
described
strains
of bacteria that
appear to have
acquired
reduced
susceptibility to
antiseptics such
as
chlorhexidine,
QAC, or
triclosan when
defined by MICs
established in
vitro.433-436
However, since
in-use
concentrations
of antiseptics
are often
substantially

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

resistant
bacterial
enzyme has
raised the
question of
whether
resistance
may develop
higher
more readily
than the
to this agent
MICs of
than to other
strains
antiseptic
with
agents.396
reduced
Under
antiseptic
laboratory
susceptibi
conditions,
lity, the
bacteria with
clinical
reduced
relevance
susceptibility
of the in
to triclosan
vitro
carry crossfindings
resistance to
may be
antibiotics.439,
inaccurat
440
Reduced
e. For
triclosan
example,
susceptibility
some
or resistance
strains of
was detected
MRSA
in clinical
have
isolates of
chlorhexi
methicillindine and
resistant S.
QAC
epidermidis
MICs that
and in MRSA,
are
respectively.44
several1,442
Of
fold
additional
higher
concern,
than
exposing
methicillin
Pseudomona
s strains
susceptibl
containing the
e strains,
MexAB-OprM
and some
efflux system
strains of
to triclosan
S. aureus
may select for
have
mutants that
elevated
are resistant
MICs to
to multiple
triclosan.4
antibiotics,
33,434,437
including
However,
fluoroquinolon
such
es.436,439,440
strains
Nevertheless,
were
a recent study
readily
failed to
inhibited
demonstrate
by in-use
a statistically
significant
concentra
association
tions of
between
these
elevated
antiseptic
triclosan
s.433,434
MICs and
Very high
reduced
MICS for
antibiotic
triclosan
susceptibility
were
among
reported by
staphylococci
Sasatsu
and several
and
species of
colleagues,
Gram438
and the
negative
description
bacteria.443
of a
Clearly, further
triclosan-

studies
are
necessary to
determine
if
reduced
susceptibility to
antiseptic
agents is of
epidemiologica
l importance,
and whether or
not resistance
to antiseptics

may influence
the prevalence
of antibioticresistant
strains.433
Periodic
surveillance
may be
needed to
ensure that
this situation
has not
changed.444

11.13
Relati
ve
efficac
y of
plain
soap,
antise
ptic
soaps
and
deterg
ents,
and
alcoho
ls
Comparing
the results of
laboratory
studies
dealing with
the in vivo
efficacy of
plain soap,
antimicrobial
soaps, and
alcoholbased
handrubs
may be
problematic
for various
reasons.
First,
different test
methods
produce
different
results,445
especially if
the
bacteriostatic
effect of a
formulation is
not
(or not

sufficiently)
abolished
either by
dilution or
chemical
neutralizer
s prior to
quantitativ
e
cultivation
of posttreatment
samples.
This leads
to results
that might
overstate
the efficacy
of the
formulation
,446
Second,
the
antimicrobi
al efficacy
of a hand
antiseptic
agent is
significantl
y different
among a
given
population
of
individuals.
315

Therefore,
the
average
reductions
of bacterial
release by
the same
formulation
will be
different
in
different
laboratori
es or in
one
laboratory
with
different
test
populatio
ns.447
Interlaboratory
results
will be
comparab
le only if
they are
linked up
with those
of a
reference
procedur
e
performe
d in
parallel
by the
same

individuals
in a crossover
designed test
and compared
intraindividually.
Summarizing
the relative
efficacy of
agents in each
study can
provide a
useful
overview of the
in vivo activity
of various
formulations
(Tables I.11.6
and I.11.8).
From there, it
can be seen
that antiseptic
detergents are
usually more
efficacious
than plain soap
and that
alcohol-based
rubs are more
efficacious
than antiseptic
detergents. A
few studies
show that
chlorhexidine
may be
as effective
as plain
soap against
MRSA, but
not as
effective as
alcohol and
povidone
iodine.448
Studies
conducted in
the
community
setting bring
additional
findings on
the topic of
the relative
efficacy of
different
hand
hygiene
products.
Some
indicate that
medicated
and plain
soaps are
roughly
equal in
preventing
the spread of
childhood
gastrointesti
nal and
upper

respiratory tract
infections or
impetigo249,449,4
50
. This
suggests that
the health
benefits from
clean hands
probably result
from the simple
removal of
potential
pathogens by
handwashing
rather than their
in situ
inactivation by
medicated
soaps. Other
studies clearly
demonstrated
the
effectiveness of
alcohol-based
handrubs used
for hand
hygiene in
schools in
reducing the
incidence of
gastrointestinal
and/or
respiratory
diseases and
absenteeism
attributable to
these
causes.451-454
In most
studies on
hygienic hand
antisepsis that
included plain
soap, alcohols
were more
effective than
soap (Tables
I.11.6 and
I.11.8). In
several trials
comparing
alcohol-based
solutions with
antimicrobial
detergents,
alcohol
reduced
bacterial
counts on
hands to a
greater extent
than washing
hands with
soaps or
detergents
containing
hexachlorophe

ne,
handrubbing
versus
povidoneconventional
iodine,
CHG(CHG) handwashing
or triclosan. with antiseptic
In a cross- soap showed
over study that the median
comparing percentage
plain soap reduction in
bacterial
with one
containing contamination
was
4% CHG,
unexpectedl significantly
y, the latter higher with
handrubbing
showed
higher final than with hand
CFU counts antisepsis with
after use of 4% CHG457
CHG-soap soap. In
another trial to
compared
compare the
with plain
soap, but the microbiological
comparative efficacy of
handrubbing
CFU log
with an
reduction
alcohol-based
was not
provided to solution and
handwashing
permit
conclusions with water and
concerning unmedicated
soap in HCWs
relative
efficacy.455 In from different
wards, with
another
clinical study particular
emphasis on
in two
transient flora,
neonatal
handrubbing
intensive
was more
care units
comparing efficacious
an alcohol than
rub with 2% handwashing
CHG-soap, for the
no difference decontaminatio
was found n of HCWs
hands.152
either in
In studies
infection
dealing with
rates or in
antimicrobialmicrobial
counts from resistant
organisms,
nurses
hands.456 Of alcohol-based
products
note, the
reduced the
ethanol
concentratio number of
n (61%) of multidrugthe sanitizer resistant
was low and pathogens
recovered
the
chemicals to from the hands
of HCWs more
neutralize
effectively than
CHG
washed from handwashing
with soap and
the hands
water.225,374,458
into the
An
sampling
fluids might observational
study was
not have
conducted to
been
appropriate. assess the
However, a effect of an
randomized alcohol-based
clinical trial gel handrub on
comparing infection rates
the efficacy attributable to
the three most
of

common
multidrugresistant
bacteria (S.
aureus,
K.
pneumoniae,
and P.
aeruginosa) in
Argentina.459
Two periods
were
compared, 12
months before
(handwashing
with soap and
water) and 12
months after
starting alcohol
gel use. The
second period
(alcohol gel
use) showed a
significant
reduction in the
overall
incidence rates
of K.
pneumoniae
with extendedspectrum betalactamase
(ESBL)
infections, in
particular
bacteraemias.
Nevertheless,
on the basis of
this study, the
authors could
not conclude
whether this
was a result of
alcohol gel
itself or an
increase in
hand hygiene
compliance.
The efficacy of
alcohols for
surgical hand
antisepsis has
been
reviewed in
numerous
48,268,271,280studies.
286,301,313,316,460-463
In

many of these
studies,
bacterial
counts on the
hands were
determined
immediately
after using the
product and
again 13
hours later.
The delayed
testing is
performed to
determine if
regrowth of
bacteria on

the hands is
inhibited
during
operative
procedures;
this has
been shown

to be
questionable
by in vivo
experiments
only if a
suitable
neutralizer is
38

used to stop
any prolonged
activity in the
sampling
fluids and on
the counting

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

plates.227 The relative efficacy of plain soap, antimicrobial soaps,

and alcohol-based solutions to reduce the number of bacteria
recovered from hands immediately after use of products for
surgical hand preparation is shown in Table I.11.9. A comparison
of five surgical hand antisepsis products two alcohol-based
handrubs and three handwashes (active ingredient triclosan,
CHG or povidone-iodine) by EN 12791, an in vivo laboratory
test, showed that preparations containing povidone-iodine
and triclosan failed the test, although all products passed the in
vitro suspension test of prEN 12054. Better results were
achieved with the alcohol-based handrubs.464 Alcohol-based
solutions were more effective than washing hands with plain
soap in all studies, and reduced bacterial counts on hands to a
greater extent than antimicrobial soaps or detergents in most
experiments.268,271,280-286,301,313,316,461-463 Table I.11.10 shows the

log10 reductions in the release of resident skin flora from clean

hands immediately and 3 hours after use of surgical handrub
products. Alcohol-based preparations proved more efficacious
than plain soap and water, and most formulations were superior
to povidone-iodine- or CHG-containing detergents. Among the
alcohols, a clear positive correlation with their concentration
is noticeable and, when tested at the same concentration, the
range of order in terms of efficacy is: ethanol is less efficacious
than isopropanol, and the latter is less active than n-propanol.
Table I.11.1
Examples of common water contaminants and their effects
Contaminant
Inorganic salts

Examples

Concerns

Hardness (dissolved compounds of

calcium and magnesium)
Heavy metals (metallic elements with
high atomic weights, e.g. iron, chromium,
copper, and lead)

Organic matter

Trihalomethanes

Inhibit activities of
cleaning and biocidal products;
can also cause the build-up of
scale over time or spotting on
a surface

Can inhibit the

activities of cleaners and
biocidal products; cause
damage to some surfaces
(e.g. corrosion); in some
cases, are toxic and
bioaccumulative

Microorganisms
Biocides

Proteins, lipids, polysaccharides

Source: reproduced with permission from

465
Dissolved gases McDonnell, 2007.
3
9

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.11.2
Waterborne pathogens and their significance in water supplies
Pathogen

Health significance

Persistence in water
supplies

Relative infectivity

Campylobacter jejuni, C. coli

High

Moderate

Moderate

Pathogenic Escherichia coli

High

Moderate

Low

Enterohaemorrhagic E. coli

High

Moderate

High

Legionella spp.

High

Multiply

Moderate

Non-tuberculosis mycobacteria

Low

Multiply

Low

Pseudomonas aeruginosa

Moderate

May multiply

Low

Salmonella typhi

High

Moderate

Low

Other salmonellae

High

Short

Low

Shigella spp.

High

Short

Moderate

Vibrio cholerae

High

Short

Low

Burkholderia pseudomallei

Low

May multiply

Low

Yersinia enterocolitica

High

Long

Low

Adenoviruses

High

Long

High

Enteroviruses

High

Long

High

Hepatitis A

High

Long

High

Hepatitis E

High

Long

High

Noroviruses and sapoviruses

High

Long

High

Rotaviruses

High

Long

High

Acanthamoeba spp.

High

Long

High

Cryptosporidium parvum

High

Long

High

Cyclospora cayetanensis

High

Long

High

Entamoeba histolytica

High

Moderate

High

Giardia lamblia

High

Moderate

High

Naegleria fowleri

High

May multiply

High

Toxoplasma gondii

High

Long

High

Dracunculus medinensis

High

Moderate

High

Schistosoma spp.

High

Short

High

Bacteria

Viruses

Protozoa

Helminths

Source: WHO Guidelines for drinking-water quality, 2006.228

40

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.11.3
Microbiological indicators for drinking-water quality according to 1882/2003/EC
Indicator

1882/2003/EC

Escherichia coli

0 CFU/100 ml
0 CFU/250 ml (for bottled water)

Pseudomonas aeruginosa

0 CFU/250 ml

Enterococci

0 CFU/250 ml

Total bacteria
22 0C

100 CFU/ml

36/37 0C

20 CFU/ml

Comment

Specified only for bottled water

Specified only for bottled water

CFU: colony-forming unit

Table I.11.4
Microbiological indicators for water quality in health-care settings in France
Indicator

Level

Frequency

Aerobic flora at 22 C and 36 C

No variation above a 10-fold compared to

the usual value at the entry point

1 control/100 beds/year with a minimum of

4 controls per year

Pseudomonas aeruginosa

< 1 CFU/100 ml

Quarterly

Total coliforms

< 1 CFU/100 ml

Quarterly

CFU: colony-forming unit

Source: adapted with permission from: Leau dans les tablissements de sant. Guide technique (Water in health-care facilities. A technical
guide), 2005.466

41

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.11.5
Virucidal activity of antiseptic agents
Reference

Test method

Viruses

Agent

Results

Enveloped viruses
Spire et al., 1984467

Suspension

HIV

19% EA

LR=2.0 in 5 min

Martin, McDougal &

Suspension

HIV

50% EA

LR>3.5

35% IPA

LR>3.7

Loskoski, 1985 468

Resnick et al., 1986

469

Suspension

HIV

70% EA

LR=7.0 in 1 min

Suspension

HIV

70% EA

LR= 3.25.5 in 30 s

Montefiori et al., 1990471

Suspension

HIV

70% IPA + 0.5% CHG

4% CHG

LR= 6.0 in 15 s
LR= 6.0 in 15 s

Wood & Payne 1998472

Suspension

HIV

Chloroxylenol
Benzalkonium chloride

Inactivated in 1 min
Inactivated in 1 min

Harbison & Hammer,

Suspension

HIV

Povidone-iodine

Inactivated

CHG

Inactivated

Lavelle et al., 1989474

Suspension

HIV

Detergent + 0.5%
chloroxylenol

Inactivated in 30 s

Bond et al., 1983475

Suspension/dried
plasma
Chimpanzee challenge

HBV

70% IPA

LR= 6.0 in 10 min

Kobayashi et al., 1984476

Suspension/plasma
Chimpanzee challenge

HBV

80% EA

LR= 7.0 in 2 min

Kurtz, 1979477

Suspension

HSV

95% EA
75% EA
95% IPA
70% EA + 0.5% CHG

LR>5.0 in 1 min
LR>5.0
LR>5.0
LR>5.0

Platt & Bucknall, 1985297

Suspension

RSV

35% IPA
4% CHG

LR>4.3 in 1 min
LR>3.3

Schurmann & Eggers,

Suspension

Influenza

95% EA

Undetectable in 30 s

Vaccinia

95% EA

Undetectable in 30 s

Influenza

95% EA

LR> 2.5

Vaccinia

95% EA

LR> 2.5

van Bueren, Larkin &

Simpson, 1994470

473

1989

1983309
Schurmann & Eggers,
1983309

Hand test

42

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.11.5
Virucidal activity of antiseptic agents (Cont.)
Reference

Test method

Viruses

Agent

Results

Non-enveloped viruses
Sattar et al., 1983478

Suspension

Rotavirus

4% CHG
10% Povidone-iodine
70% IPA/0.1% HCP

LR<3.0 in 1 min
LR>3.0
LR>3.0

Schurmann & Eggers,

1983309

Hand test

Adenovirus
Poliovirus
Coxsackie

95% EA
95% EA
95% EA

LR>1.4
LR=0.21.0
LR=1.11.3

Finger test

Adenovirus
Poliovirus
Coxsackie

95% EA
95% EA
95% EA

LR>2.3
LR=0.72.5
LR=2.9

Kurtz, 1979477

Suspension

ECHO virus

95% EA
75% EA
95% IPA
70% IPA+0.5%CHG

LR>3.0 in 1 min
LR<1.0
LR=0
LR=0

Mbithi, Springthorpe &

Sattar, 2000308

Fingerpad

HAV

70% EA
62% EA foam
Plain soap
4% CHG
0.3% Triclosan

87.4% reduction
89.3% reduction
78.0% reduction
89.6% reduction
92.0% reduction

Bellamy et al., 1993272

Fingertips

Bovine rotavirus

n-propanol+IPA
70% IPA
70% EA
2% Triclosan
Water (control)
7.5% povidone-iodine
Plain soap
4% CHG

LR=3.8 in 30 s
LR=3.1
LR=2.9
LR=2.1
LR=1.3
LR=1.3
LR=1.2
LR=0.5

Ansari et al., 1991257

Fingerpad

Human rotavirus

70% IPA

98.9% reduction in 10 s
77.1%

Plain soap
Ansari et al., 1989304

Fingerpad

Human rotavirus

70% IPA
Plain soap

80.3%
72.5%

Sattar et al., 2000305

Fingerpad

Rotavirus
Rhinovirus
Adenovirus

60% EA gel
60% EA gel
60% EA gel

LR>3.0 in 10 s
LR>3.0
LR>3.0

Steinmann et al.,

Fingerpad

Poliovirus

70% EA

LR=1.6 in 10 s

70% IPA

LR=0.8

Fingertips

Poliovirus

Plain soap

LR=2.1

80% EA

LR=0.4

307

1995

Davies, Babb & Bradley,

1993372

HIV = human immunodeficiency virus; EA = ethanol; LR = Log10 Reduction; IPA = isopropanol; CHG = chlorhexidine gluconate; HBV =
hepatitis B virus; RSV = respiratory syncytial virus; HSV = herpes simplex virus; HAV = hepatitis A virus.

43

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.11.6
Studies comparing the relative efficacy (based on log10 reductions achieved) of plain soap or antimicrobial soaps versus alcoholbased antiseptics in reducing counts of viable bacteria on hands
Reference

Skin
contamination

Assay
method

Time
(s)

Relative efficacy

Dineen & Hildick-Smith,

Existing hand flora

Fingertip agar culture

60

Plain soap < HCP < 50% EA foam

Ayliffe et al., 1975286

Existing hand flora

Handrub broth culture

Plain soap < 95% EA

Ayliffe, Babb &

Artificial contamination

Fingertip broth culture

30

Plain soap < 4% CHG < P-I < 70% EA =

313

1965

Quoraishi, 1978273

alc. CHG

Lilly & Lowbury 1978

321

Artificial contamination

Fingertip broth culture

30

Plain soap < 4% CHG < 70% EA

Existing hand flora

Handrub broth culture

120

Plain soap < 0.5% aq. CHG < 70% EA <

Artificial contamination

Fingertip broth culture

60-120

4% CHG < P-I < 60% IPA

Ojajarvi, 1980125

Artificial contamination

Fingertip broth culture

15

Plain soap < 3% HCP < P-I < 4% CHG

< 70% EA

Ulrich, 1982275

Artificial contamination

Glove juice test

15

P-I < alc. CHG

Bartzokas et al., 1983276

Artificial contamination

Fingertip broth culture

120

0.3-2% triclosan = 60% IPA = alc. CHG

< alc. Triclosan

Rotter, 1984315

Artificial contamination

Fingertip agar culture

60

Phenolic < 4% CHG < P-I < EA < IPA <

n-P

Blech, Hartemann &

Existing hand flora

Fingertip agar culture

60

Plain soap < 70% EA < 95% EA

Rotter et al., 1986277

Artificial contamination

Fingertip broth culture

60

Phenolic = P-I < alc. CHG < n-P

Larson, Eke & Laughon,

Existing hand flora

Sterile broth bag

15

Plain soap < IPA < 4% CHG = IPA-H =

Lilly, Lowbury &

Wilkins, 1979274

4% CHG < alc.CHG

Rotter, Koller &

Wewalka, 1980314

Paquin, 1985

316

221

1986

technique

alc. CHG

Ayliffe et al., 1988137

Artificial contamination

Fingertip broth culture

30

Plain soap < triclosan < P-I < IPA < alc.
CHG < n-P

Ehrenkranz & Alfonso,

Patient contact

Glove juice test

15

Plain soap < IPA-H

Leyden et al., 1991317

Existing hand flora

Agar plate/image
analysis

30

Plain soap < 1% triclosan < P-I < 4%

CHG < IPA

Kjolen & Andersen,

Artificial contamination

Fingertip agar culture

60

Plain soap < IPA < EA < alc. CHG

Rotter & Koller, 1992223

Artificial contamination

Fingertip broth culture

60

Plain soap < 60% n-P

Namura, Nishijima &

Existing hand flora

Agar plate/image

30

Plain soap < alc. CHG

199188

1992278

Asada, 1994279

analysis

Zaragoza et al., 1999318

Existing hand flora

Agar plate culture

N.S.

Plain soap < commercial alcohol

mixture

Paulson et al., 1999319

Artificial contamination

Glove juice test

20

Plain soap < 0.6% PCMX < 65% EA

320

Artificial contamination

Fingertip broth culture

30

4% CHG < plain soap < P-I < 70% EA

Cardoso et al., 1999

Existing hand flora = without artificially contaminating hands with bacteria; alc. CHG = alcohol-based chlorhexidine gluconate; aq. CHG =
aqueous chlorhexidine gluconate; 4% CHG = chlorhexidine gluconate detergent; EA = ethanol;
HCP = hexachlorophene soap/detergent; IPA = isopropanol; IPA-H = isopropanol + humectants; n-P = n-propanol;
PCMX = para-chloro-meta-xylenol detergent; P-I = povidone-iodine detergent; NS = not stated.
Note: Hexachlorophene has been banned worldwide because of its high rate of dermal absorption and subsequent toxic effects 70,366.

44

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.11.7
Antimicrobial activity and summary of properties of antiseptics used in hand hygiene
Antiseptics

Grampositive
bacteria

Gramnegative
bacteria

Viruses
enveloped

Viruses
nonenveloped

Mycobacteria

Fungi

Spores

Alcohols

+++

+++

+++

++

+++

+++

Chloroxylenol

+++

+++

++

++

+++

Iodophors

+++

+++

++

++

++

++

Triclosand

+++

++

Quaternary
ammonium
compoundsc

++

Antiseptics

Typical conc. in %

Speed of action

Residual activity

Use

Alcohols

60-70 %

Fast

No

HR

Chloroxylenol

0.5-4 %

Slow

Contradictory

HW

0.5-4%

Intermediate

Yes

HR,HW

3%

Slow

Yes

HW, but not

recommended

Iodophors

0.5-10 %)

Intermediate

Contradictory

HW

Triclosand

(0.1-2%)

Intermediate

Yes

HW; seldom

Slow

No

HR,HW;
Seldom;

Chlorhexidine
Hexachlorophene

Chlorhexidine
Hexachlorophene

Quaternary
ammonium

compoundsc

+alcohols

Good = +++, moderate = ++, poor = +, variable = , none =

HR: handrubbing; HW: handwashing
*Activity varies with concentration.
a
Bacteriostatic.
b
In concentrations used in antiseptics, iodophors are not sporicidal. c
Bacteriostatic, fungistatic, microbicidal at high concentrations.
d
Mostly bacteriostatic.
e
Activity against Candida spp., but little activity against filementous fungi.
Source: adapted with permission from Pittet, Allegranzi & Sax, 2007.479

45

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.11.8
Hygienic handrub efficacy of various agents in reducing the release of test bacteria from artificially-contaminated hands
Agent

Concentrationa
(%)

Test bacterium

Mean log reduction exposure time

(min)
0.5

n-Propanol

100
60

E. coli

5.0
3.7

40
70

2.0

5.8
5.5

50

Isopropanol

1.0

4.7

4.9

4.3
E. coli

4.9
4.8
3.5

60

4.4
4.3
4.2
4.0
S. marcescens

4.1

E. coli
50
Ethanol

80

3.4
E. coli

3.9

4.4

4.5

70

4.3

5.1

4.3

4.9

4.0

S. aureus

3.6

3.8

3.4

4.1

3.7
2.6

Tosylchloramide (aq. sol.)

60

S. saprophyticus

Povidone-iodine (aq. sol.)

2.0b

E. coli

4.2

Chlorhexidine diacetate (aq. sol.)

1.0b

E. coli

4.04.3

0.5b

E. coli

3.1

Chloro-cresol (aq. sol.)

1.0b

E. coli

3.6

Hydrogen peroxide

7.5

E. coli

3.6

If not stated otherwise, v/v.

m/v.
Sources: reprinted with permission from Rotter, 2004.480,481
b

46

3.5

3.8

4.5

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.11.9
Studies comparing the relative efficacy of plain soap or antimicrobial soap versus alcohol-containing products in reducing
counts of bacteria recovered from hands immediately after use of products for preoperative surgical hand preparation
Reference

Assay method

Relative efficacy

Fingertip agar culture

HCP < 50% EA foam + QAC

Fingertip agar culture

HCP < P-I < 50% EA foam + QAC

Gravens, 1973

Fingertip agar culture

HCP soap < EA foam + 0.23% HCP

Lowbury, Lilly & Ayliffe, 1974301

Broth culture

Plain soap < 0.5% CHG det. < 4% CHG det. < alc. CHG

Hand broth test

Plain soap < 0.5% CHG det. < 4% CHG det. < alc. CHG

Glove juice test

0.5% CHG det. < 4% CHG det. < alc. CHG

Glove juice test

P-I < CHG det. < alc. CHG

Fingertip agar culture

P-I = 46% EA + 0.23% HCP

Broth culture of hands

Plain soap < P-I < alc. CHG < alc. P-I

Aly & Maibach, 1979

Glove juice test

70% IPA = alc. CHG

Zaragoza et al., 1999316

Fingertip agar culture

Plain soap < 70% - 90% EA

Glove juice test, modified

Plain soap < triclosan < CHG det. < P-I < alc. CHG

Glove juice test

Plain soap < 2% triclosan < P-I < 70% IPA

Fingertip broth culture

70% IPA < 90% IPA = 60% n-P

Glove juice test

P-I < CHG det. < 70% EA

Glove juice test

4% CHG det. < CHG det./61% EA

Glove juice test

P-I < CHG det. < 70% EA

Dineen & Hildick-Smith, 1965313

Berman & Knight, 1969

461

268

Ayliffe et al., 1975286

Rosenberg, Alatary & Peterson, 1976
Pereira, Lee & Wade, 1997

281

Galle, Homesley & Rhyne, 1978

284

280

Jarvis et al., 1979

283

282

Larson et al., 1990

Babb, Davies & Ayliffe, 1991

271

Rotter, Simpson & Koller, 1998

463

Hobson et al., 1998

Mulberry et al., 2001

482

Furukawa et al., 2004

483

462

285

QAC = quaternary ammonium compound; alc. CHG = alcoholic chlorhexidine gluconate;

CHG det. = chlorhexidine gluconate detergent; EA = ethanol; HCP = hexachlorophene detergent; IPA = isopropanol; P-I
= povidone-iodine detergent.

47

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.11.10
Efficacy of surgical handrub solutions in reducing the release of resident skin flora from clean hands
Rub

Concentrationa (%)

Time (min)

Mean log reduction

Immediate

Persistent (3h)

2.9b

1.6b

2.7b

NA

2.5b

1.8b

2.3b

1.6b

2.9c

NA

2.0b

1.0b

1.1b

0.5b

90

2.4

1.4c

80

2.3c

1.2c

70

2.4b

2.1b

2.1b

1.0b

2.0c

0.7c

1.7c

NA

1.5b

0.8b

1.2

0.8

0.7b

0.2

0.8

NA

60

1.7

1.0

70 + 0.5

2.5b

2.7b

1.0

1.5

95

2.1

NA

85

2.4c

NA

80

1.5

NA

70

1.0

0.6

95 + 0.5

1.7

NA

77 + 0.5

2.0

1.5d

70 + 0.5

0.7

1.4

Chlorhexidine gluc. (aq. Sol., m/v)

0.5

0.4

1.2

Povidone-iodine (aq. Sol., m/v)

1.0

1.9b

0.8b

Peracetic acid (m/v)

0.5

1.9

NA

n-Propanol

Isopropanol

Isopropanol + chlorhexidine gluc. (m/v)

Ethanol

Ethanol + chlorhexidine gluc. (m/v)

60

NA = not available.
a

v/v unless otherwise stated.

Tested according to the Deutsche Gesellschaft fur Hygiene and Mikrobiologic (German Society of Hygiene and Microbiology).
Tested according to European Standard EN 12791.
d
After 4 hours.
Source: reprinted with permission from Rotter, 1999.48
b

48

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

12.
WHO-recommended handrub formulations
12.1.2.1 Volume of
production, containers

12.1 General remarks

To help countries and health-care facilities to achieve system
change and adopt alcohol-based handrubs as the gold standard
for hand hygiene in health care, WHO has identified formulations
for their local preparation. Logistic, economic, safety, and cultural
and religious factors have all been carefully considered by WHO
before recommending such formulations for use worldwide (see
also Part I, Section 14).

At present, alcohol-based handrubs are the only known means

for rapidly and effectively inactivating a wide array of
potentially harmful microorganisms on hands.60,221,329,484-487
WHO recommends alcohol-based handrubs based on the
following factors:

1.

evidence-based, intrinsic advantages of fast-acting and

broad-spectrum microbicidal activity with a minimal risk of
generating resistance to antimicrobial agents;

2.

suitability for use in resource-limited or remote areas

with lack of accessibility to sinks or other facilities for
hand hygiene (including clean water, towels, etc.);

3.

capacity to promote improved compliance with hand hygiene

by making the process faster and more convenient;

4.

economic benefit by reducing annual costs for hand

hygiene, representing approximately 1% of extra-costs
generated by HCAI (see also Part III, Section 3);488-490

5.

minimization of risks from adverse events because of

increased safety associated with better acceptability and

tolerance than other products (see also Part I, Section

14).491-498

Formulation I

To produce final
concentrations of ethanol
80% v/v, glycerol 1.45%
v/v, hydrogen peroxide

10-litre preparations:
glass or plastic bottles
with screw-threaded
stoppers can be used.

50-litre preparations:
large plastic (preferably
polypropylene,
translucent enough to
see the liquid level) or
stainless steel tanks with
an 80 to100 litre capacity
should be used to allow
for mixing without
overflowing.

(H2O2) 0.125% v/v.

Pour into a 1000 ml

graduated flask:

1)

ethanol
833.3 ml

2)
3)

ml

96%

v/v,

H2O2 3%, 41.7 ml

glycerol 98% ,14.5

Top up the flask to 1000 ml

with distilled water or water
that has been boiled and
cooled; shake the flask
gently to mix the content.

Formulation II
To produce final
concentrations of isopropyl
alcohol 75% v/v, glycerol
1.45% v/v, hydrogen
peroxide 0.125% v/v:
Pour into a 1000 ml
graduated flask:

For optimal compliance with hand hygiene , handrubs should be 1)

isopropyl
alcohol
readily available, either through dispensers close to the point of
(with a purity of 99.8%),
751.5 ml
care or in small bottles for on-person carriage.335,485
Health-care settings currently using commercially-available
handrubs should continue to use them, provided that they meet
recognized standards for microbicidal efficacy (ASTM or EN
standards) and are well accepted/tolerated by HCWs (see also
Implementation Toolkit available at http://www.who.int/ gpsc/en/). It
is obvious that these products should be regarded as acceptable,
even if their contents differ from those of the WHO-recommended
formulations described below. WHO recommends the local
production of the following formulations as an alternative when
suitable commercial products are either unavailable or too costly.

12.1.1 Suggested composition of alcohol-based handrub

formulations for local production
The choice of components for the WHO-recommended
handrub formulations takes into account cost constraints and
microbicidal activity. The following two formulations are

recommended for local production with a maximum of 50 litres

per lot to ensure safety in production and storage.

2)
3)

ml

H2O2 3%, 41.7 ml

glycerol 98%, 14.5

Top up the flask to 1000 ml

with distilled water or water
that has been boiled and
cooled; shake the flask
gently to mix the content.
Only pharmacopoeial quality
reagents should be used (e.g.
The International
Pharmacopoeia) and not
technical grade products.

12.1.2 Method for local

production

49

The tanks should be

calibrated for the
ethanol/isopropyl alcohol
volumes and for the final
volumes of either 10 or 50
litres. It is best to mark
plastic tanks on the outside
and stainless steel ones on
the inside.

12.1.2.2 Preparation

1)

The alcohol for the

chosen formulation is
poured into the large
bottle or tank up to the
graduated mark.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

the
distilled
or cold,
boiled
water.

5)
2)

H2O2 is
added
using
the
measuri
ng
cylinder.

3)

Glycerol
is
added
using a
measuri
ng
cylinder.
As the
glycerol
is very
viscous
and
sticks to
the
walls of
the
measuri
ng
cylinder,
it can
be
rinsed
with
some
sterile 6)
distilled
or cold
boiled
water to
be
added
and
then
emptied
into the
bottle/
tank.

4)

The
bottle/t
ank is
then
topped
up to
the
corresp
onding
mark of
the
volume
(10litre or
50litre) to
be
prepar
ed with
the
remain
der of

7)

Th
e
lid
or
the
scr
ew
cap
is
pla
ced
on
the
bott
le/t
ank
im
me
diat
ely
afte
r
mix
ing
to
pre
ven
t
eva
por
atio
n.
The
solution is
mixed by
gently
shaking
the
recipient
where
appropriat
e (small
quantities)
,or by
using a
wooden,
plastic or
metallic
paddle.
Electric
mixers
should not
be used
unless
EX
protected
because
of the
danger of
explosion.
After
mixing, the
solution is
immediatel
y divided
into
smaller

containers
(e.g. 1000,
500 or 100
ml plastic
bottles).
The bottles
should be
kept in
quarantine
for 72
hours. This
allows time
for any
spores
present in
the alcohol
or the new
or re-used
bottles to
be
eliminated
by H2O2.

12.1.2.3
Quality control
If concentrated
alcohol is
obtained from
local
production,
verify the
alcohol
concentration
and make the
necessary
adjustments in
volume to
obtain the final
recommended
concentration.
An
alcoholmeter
can be used to
control the
alcohol
concentration
of the final use
solution; H2O2
concentration
can be
measured by
titrimetry
(oxydoreduction
reaction by
iodine in acidic
conditions). A
higher level
quality control
can be
performed
using gas
chromatograph
y499 and the
titrimetric
method

to control the
alcohol and
the hydrogen
peroxide
content,

respectively. 1
Moreover,
the absence
2
of microbial
contaminati
on
(including
spores) can 3
be checked
by filtration,
according to
the
European
Pharmacop
eia
specification
s.500
For more
detailed
guidance
on
production
and
quality
control of
both
formulatio
ns, see
the
WHOrecomme
nded
hand
antisepsis
formulatio
n - guide
to local
production

(Impleme
ntation
Toolkit
available
at
http://www
.who.int/g
psc/ en/).

12.1.2.4
Labelling of
the bottles
The
bottles
should
be
labelle
d in
accord
ance
with
nation
al
guideli
nes.
Labels
should
include
the
followi
ng:

a
ls
o
b
e
i
n
d
ic
a
t
e
d
)
a
n
d
t
h
e
f
o
ll
o
w
i
n
g
s
t
a
t
e
m
e
n
t
s
:

Name of
institution
Date
of
production
and batch
number
C
o
m
p
o
s
it
i
o
n
:
e
t
h
a
n
o
l
o
r
i
s
o
p
r
o
p
a
n
o
l,
g
l
y
c
e
r
o
l
a
n
d
h
y
d
r
o
g
e
n
p
e
r
o
x
i
d
e
(
%
v
/
v
c
a
n

WHOrecommen
ded
handrub
formulatio
n

For
external
use only

Avoid
contact
with eyes

Keep out
of reach of
children

Use:
apply a
palmful
of
alcoholbased
handrub
and
cover all
surfaces
of
the
hands.
Rub
hands
until dry.
Flammab
le: keep
away
from

flame
and
heat.

12.1.2.5 H2O2
While alcohol
is the active
component in
the
formulations,
certain aspects
of other
components
should be
respected. All
raw materials
used should
be preferably
free of viable
bacterial
spores. The
low
concentration
of H2O2 is
incorporated in
the
formulations to
help eliminate
contaminating
spores in the
bulk solutions
and
excipients501,50
2
and is not an
active
substance for
hand
antisepsis.
While the use
of H2O2 adds
an important
safety aspect,
the use of 3
6% of H2O2 for
the production
might be
complicated by
its corrosive
nature and by
difficult
procurement in
some
countries.
Further
investigation is
needed to
assess H2O2
availability in
different
countries as
well as the
possibility of
using a stock
solution with a
lower
concentration.

12.1.2.6
Glycerol
Glycerol is
added to the

formulation as
a humectant to
increase the
acceptability of
the product.
Other
humectants or
emollients may
be used for
skin care,
provided that
they are
affordable,
available
locally, miscible
(mixable) in
water and
alcohol, nontoxic, and
hypoallergenic.
Glycerol has
been chosen
because

it is safe and
relatively
inexpensive.
Lowering the
percentage
of glycerol
may be
considered to
further
reduce
stickiness of
the handrub.

12.1.2.7 Other
additives to
the
formulations
It is strongly
recommended
that no
ingredients
other than
those specified
here be added
to the
formulations.
In the case of

any additions,
full
justification
must be
provided
together with
documented
safety of the
additive, its
compatibility
with the other
ingredients,
and all
relevant
details should
be given on
the product
label.
In general, it
is not
recommended

to add any
bittering
agents to
reduce the
risk of
ingestion of
the
handrubs.
Nevertheles
s, in
exceptional
cases
where the
risk of
ingestion
might be
very high
(paediatric
or confused
patients),
substances
such as
methylethyl
ketone and
denatonium
benzoate503
) may be
added to
some
household
products to
make them
less
palatable
and thus
reduce the
risk of
accidental or
deliberate
ingestion.
However,
there is no
published

information on
the
compatibility
and deterrent
potential of
such chemicals
when used in
alcohol-based
handrubs to
discourage
their abuse. It
is important to
note that such
additives may
make the
products toxic
and
add to
production
costs. In
addition, the
bitter taste may
be transferred
from hands to
food being
handled by
individuals
using handrubs
containing such
agents.
Therefore,
compatibility
and suitability,
as well as cost,
must be
carefully
considered
before deciding
on the use of
such bittering
agents.

50

A colorant
may be
incorporated
to
differentiate
the handrub
from other
fluids as long
as such an
additive is
safe and
compatible
with the
essential
components
of the
handrubs
(see also Part
I, Section
11.3).
However, the
H2O2 in the
handrubs
may tend to
fade any
colouring
agent used
and prior
testing is
recommende
d.
No data are
available to
assess the
suitability of
adding gelling
agents to the
WHOrecommende
d liquid
formulations,
but this

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

12.1.3
Production and
storage
Manufacture of
the WHOcould increase recommended
potentially both handrub
production
formulations is
difficulties and feasible in central
costs, and may pharmacies or
compromise
dispensaries.
antimicrobial
Whenever
possible and
efficacy.203,325
according to local
The addition of policies,
fragrances is not governments
recommended should encourage
because of the local production,
risk of allergic
support the
reactions.
quality
assessment
All handrub
process, and
containers
keep production
must be
costs as low as
labelled in
possible. Special
accordance
requirements
with
apply for the
national/inter
production and
national
stock piling of the
guidelines.
formulations, as
well as for the
To further reduce storage of the raw
the risk of abuse materials.
and to respect
cultural and
Because
religious
undiluted
sensitivities,
ethanol is highly
product
flammable and
containers may may ignite at
be labelled simply temperatures as
as antimicrobial low as 10C,
production
handrubs (see
facilities should
Part I, Section
directly dilute it
17.4).
to the abovementioned
concentration
12.1.2.
(Section 12.1.1).
8 Use
The flash points
of
of ethanol 80%
proper
(v/v) and
water
isopropyl alcohol
for the
75% (v/v) are
prepar
17.5C and 19C,
ation
respectively,
of the
(Rotter
formul
M, personal
ations
communication)
and special
While sterile
distilled water is attention should
be given to proper
preferred for
storage in tropical
making the
climates (see also
formulations,
Part I, Section
boiled and
23.6.1).
cooled tap
water may also Production and
be used as long storage facilities
should be ideally
as it is free of
air-conditioned or
visible
cool rooms. Open
particules.
flames and

smoking must be
strictly prohibited
in production and
storage areas.
Pharmacies and
small-scale
production
centres supplying
the WHOrecommended
handrub
formulations are
advised not to
manufacture
locally batches of
more than 50
litres at a time.
For safety
reasons, it is
advisable to
produce smaller
volumes and to
adhere to local
and/or national
guidelines and
regulations. The
production should
not be undertaken
in central
pharmacies
lacking
specialized air
conditioning and
ventilation.
National safety
guidelines and
local legal
requirements
must be adhered
to for the storage
of ingredients and
the final product.

12.1.4 Efficacy
It is the
consensus
opinion of
the WHO
expert group
that the
WHOrecommende
d handrub
formulations
can be used
both for
hygienic
hand
antisepsis
and for
presurgical
hand
preparation.

14).
In a recent
study
conducted
among ICU
12.1.4.1
HWs, the shortHygienic
term skin
handrub
tolerability and
acceptability of
The microbicidal the WHOactivity of the two recommended
WHOhandrub
recommended
formulations
formulations was were
tested by a WHO significantly
reference
higher than
laboratory
those of a
according to EN reference
standards (EN
product504.
1500) (see also Lessons learnt
Part I, section
about
10.1.1). Their
acceptability
activity was found and tolerability
to be equivalent to of the WHOrecommended
the reference
formulations in
substance
(isopropanol 60 % some sites
v/v) for hygienic where local
hand antisepsis. production has
taken place are
summarized
below (Section
12.1.4.2
Presurgical hand 12.2).

preparation

Both WHO12.1.6
Distribution
recommended
handrub
formulations were To avoid
contamination
tested by two
with sporeindependent
forming
reference
organisms,338
laboratories in
different European disposable bottles
should preferably
countries to
be used although
assess their
suitability for use reusable
sterilizable bottles
for pre-surgical
hand preparation, may reduce
according to the production costs
and waste
European
management. To
Standard EN
prevent
12791. The
evaporation,
results are
reported in Part I, containers should
have a maximum
Section 13.5.
capacity of 500 ml
on ward and 1
litre in operating
12.1.5 Safety
theatres, and
standards
possibly fit into a
wall dispenser.
With regard to
skin reactions, Leakage-free
pocket bottles
handrubbing
with a capacity of
with alcoholbased products no more than 100
ml should also be
is better
available and
tolerated than
distributed
handwashing
individually to
with soap and
water (see also HCWs, but it
should be
Part I, Section
emphasized that

the use of these

products should
be confined to
health care only.
The production or
re-filling unit
should follow
norms on how to
clean and
disinfect the
bottles (e.g.
autoclaving,
boiling, or
chemical
disinfection with
chlorine).
Autoclaving is
considered the
most suitable
procedure.
Reusable bottles
should never be
refilled until they
have been
completely
emptied and then
cleansed and
disinfected.
Cleansing and
disinfection
process for
reusable
handrub bottles:
empty bottles
should be
brought to a
central point to
be reprocessed
using standard
operating
procedures.
Bottles should
be thoroughly
washed with
detergent and
tap water to
eliminate any
residual liquid. If
they are heatresistant, bottles
should be
thermally
disinfected by
boiling in water.
Whenever
possible,
thermal
disinfection
should be
chosen in
preference to
chemical
disinfection,
since chemical
disinfection
might not only
increase costs
but also needs
an extra step to
flush out the
remains of the
disinfectant.
Chemical

disinfection
should include
soaking the

bottles in a
solution
containing 1000

ppm of chlorine
for a minimum of
15 minutes and
then rinsing

51
WHO GUIDELINES ON HAND
HYGIENE IN HEALTH CARE

with sterile/cooled
boiled water.505 After
thermal or chemical
disinfection, bottles
should be left to dry
completely upsidedown, in a bottle rack.
Dry bottles should be
closed with a lid and
stored, protected from
dust, until use.

12.2 Lessons
learnt from local
production of the
WHOrecommended
handrub
formulations in
different settings
worldwide
Since the Guide to
Local Production has
been disseminated
through the WHO
complementary sites
platform and pilot sites,
many settings around
the world have
undertaken local
production of the two
WHO-recommended
formulations.
A web-based survey
(http://www.surveymonkey
.com) was carried out to
gather information on the
feasibility, quality control
and cost of local
production, and the
acceptability and
tolerability of the
formulations by HCWs in
different countries.
Questions were designed
to collect information on
issues such as training
and numbers of personnel
involved in production, the
source and cost of each
component, quality
control of each
component and the final
product, equipment used
for

production, adequacy of
facility for preparation and
storage, and finally

distribution and end use.

There were also openended questions on
lessons learnt related to
each item. Responses
were obtained from
eleven sites located in
Bangladesh, Costa Rica,
Egypt, Hong Kong SAR,
Kenya, Mali, Mongolia,
Pakistan (two sites),
Saudi Arabia, and Spain.

12.2.1 Production facilities

and personnel
Production of a WHOrecommended handrub
formulation took place at
the pharmacy of the healthcare facility itself in Egypt,
Kenya, Mali, Mongolia, the
two sites in Pakistan, and
Spain. In Bangladesh,
Costa Rica, Hong Kong
SAR, and Saudi Arabia,
either private commercial or
government companies
were asked to manufacture
the product; in these
countries, it is intended that
the production will supply
numerous health-care
settings.
The quantity of handrub
produced ranged from 10
litres to 600,000 litres per
month. Qualified
pharmacists were involved
in the production at all
sites. However, in the case
of local production at the
hospital level and also in
some large-scale
production facilities (e.g. in
Bangladesh), this task was
added to the regular
workload as economic
constraints did not permit
to dedicate a staff member
only for this reason. Other
categories of workers were
also required for the
production, but varied in
numbers and
qualifications. The facilities
for preparation and storage
were considered adequate
by all but two sites (in Mali
and one in Pakistan).
Adequate ventilation and
temperature control and
fire safety signs were also
available at most sites.

12.2.2 Procurement of

components
All sites, except for the one
in Bangladesh and the two
located in Pakistan,
produced the WHOrecommended formulation
I, based on ethanol, mostly
because of easier
procurement (from local
suppliers in most cases)
and lower cost. In some
cases, ethanol was
derived from sugar cane or
wheat. In Pakistan,
isopropyl alcohol was used
because, although
cheaper, ethanol

is subject to licensing
restrictions and to strict
record-keeping. Glycerol
was procured by local
suppliers in most cases
while hydrogen peroxide
had to be imported in five
sites.

12.2.3 Equipment
Procurement of the
equipment for production
was relatively easy and not
particularly expensive in
most sites. Either plastic or
stainless steel containers
were used for mixing
except in Egypt where
glass containers were
used. In contrast, finding
adequate dispensers for
the final product use was
more problematic.
In Kenya and Mali, it was
not possible to purchase
suitable dispensers in the
country and they were
donated by Swiss
institutions. For HCWs,
100 ml pocket bottles are
in use in Hong Kong SAR,
Mali, Mongolia and
Pakistan; 500 ml wallmounted dispensers are
also available in Egypt,
Hong Kong SAR, Kenya,
Mongolia, Pakistan and
Spain. Bangladesh has
been using 100 ml glass
bottles and 500 ml plastic
bottles, Costa Rica 385 ml
bottles and Saudi Arabia 1
litre bottles or bags. For
long-term sustainability,
container moulds of both
bottles and caps, for final
use may have to be made
locally which may
represent a very high initial
cost. Pakistan was
successful in enlisting the
support of a private sector
company in making bottles
using new moulds.
Bangladesh too identified
local suppliers who are
able to make the desired
plastic dispensers.

The cleaning and

recycling process
proposed by WHO has
been put in place and is
working well in six sites.
Methods used for

disinfection varied and

included treatment with
chlorine or alcohol.

12.2.4 Quality control

The quality control of
alcohol concentrations
in the final product was
regularly performed by
alcoholmeter in all sites
but one. Hydrogen
peroxide was quality
checked at six sites
(Bangladesh, Costa
Rica, Mali, Mongolia,
Pakistan, and Saudi
Arabia).
Multiple samples from
seven sites (Costa
Rica, Egypt, Hong
Kong SAR, Mali,
Mongolia,
Pakistan,and Saudi
Arabia) were sent to
the University of
Geneva Hospitals,
Geneva, Switzerland,
for more sophisticated
quality checks by gas
chromatography499 and
the titrimetric method
to control the

alcohol and the hydrogen

peroxide content. Initial
results from four sites
showed either higher or
lower alcohol and/or H2O2
concentrations, but the
product was eventually
declared to conform to
acceptable ranges in all
sites. Quality was shown
to be optimal also for
three types of
formulations made in
Saudi Arabia in which
either a fragrance or
special humectants were
added to the WHO
formulation I.
Interestingly, samples
from Mali, which were
kept in a tropical climate
without air conditioning or
special ventilation, were
in accordance with the
optimal quality
parameters in all samples
even 19 months after

production.
The
site
located in Bangladesh
was able to perform gas
chromatography
and
titrimetry
for
quality
control
locally
and
reported optimal results
for all tests.
52

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

including
the pocket
bottle was
US$ 0.44
per 100 ml
of
formulation
12.2.5 Costs
II, and US$
0.50 per
Cost calculation 100 ml of
of the local
formulation
production of the I,

WHOrespectively.
recommended Prices of some
handrub
commerciallyformulations at available
the different sites handrubs may
has been quite be much
complex in the higher and
attempt to
vary greatly:
consider several US$ 2.50-5.40
aspects such as for a 100 ml
the cost of raw pocket bottle;
materials and
prices of gels
dispensers, the can be as high
recycling process as US$ 8 for a
(when
100 ml pocket
applicable), and bottle.
production staff Effective
salaries. The
actions to
cost of imported facilitate local
items was linked procurement
to the US$ and of some raw
fluctuated
ingredients for
markedly. Cost the production
also varied
of the WHOaccording to the recommended
supplier and the handrub
pack sizes. The formulations
cost of
would lead
equipment (if
very likely to a
any) to enable further
the facility to
reduction of
start production the overall
was not
cost of the end
considered in the product.
cost calculations
of the examples Studies are
below because it necessary to
varied
evaluate the
considerably
costbased on local effectiveness of
needs and
the local
sources.
production of
The production
cost (including
salaries but not
the dispenser)
per 100 ml was
US$ 0.37 and
US$ 0.30 for
formulation I in
Kenya and Mali
respectively
and US$ 0.30
for formulation
II in
Bangladesh.
In Pakistan
and Hong
Kong SAR,
the cost

the WHOrecommended
handrub
formulation in
the course of a
hand hygiene
promotion
campaign. As
an example, in
2005 the cost
of an alcoholbased hand
rinse originally
developed by
the pharmacy
of the
University of
Geneva
Hospitals and

currently
commercially
marketed, was
0.57 for a 100
ml pocket
bottle, 1.74
for

a 500 ml bottle,
and 3.01 for
a 1000 ml
bottle. A study
performed in
this institution
on the cost
implications of
a successful
hand hygiene
campaign
showed that
the total cost of
hand hygiene
promotion,
including the
provision of the
alcohol-based
handrub,
corresponded
to less than 1%
of the costs
associated with
HCAI.490

12.2.6 Issues
raised by the
survey
Several issues
related to the
expertise and
time availability of
personnel
involved in
production were
identified by the
survey
participants.
These included
the request for
additional training
in production
aspects for
pharmacists, the
need for existing
staff to take on
responsibilities in
addition to their
primary roles,
decisions to
include
production as
part of the job
description of
hospital
pharmacists, and
the question of
remuneration for
these additional
responsibilities.
Some participants
emphasized that

more attention
needs to be paid
to the
requirements for
preparation and
storage facilities,
production
especially if
production has to would be
be scaled up to beneficial and
WHO is
peripheral
exploring
hospitals. A
practical
purpose-built
production area solutions to
resolve this
with proper
issue.
humidity and
temperature
control according There were also
lessons learnt
to the
recommendations related to the
procurement of
for good
raw ingredients.
manufacturing
Sub-standard
practices is a
materials are
prerequisite for
available on the
production.
Several items of market and it is
equipment were important to
select local
inadequate in
sources with
some facilities,
care. It would be
particularly for
important to
scaling up.
Clearer guidance have specific
recommendation
on large-scale

s on the
chemical grade
of the
component and
acceptable
manufacturers.
However, actual
requirements
need to be
considered when
taking decisions
on quantities to
be purchased
and specific
attention should
be paid to the
risk of shortages
of supplies,
especially in
remote areas.
In some cases,
the possibility of
theft and
accidental
ingestion of the
alcohol-based
handrub made it
difficult to obtain
support from
hospital
administrators.
The survey
showed that in
many hospitals
the facilities
and the
equipment for
quality control
are inadequate,

especially as
far as testing
for hydrogen
peroxide is
concerned.
However the
centralization of
high-level
quality control
at the
University
Hospitals of
Geneva
overcame these
obstacles and
provided timely
and very helpful
support.
Nevertheless,
the availability
of this service
may be
reduced with
the expansion
of local
production to
more sites
around the
world. Indeed,
the fact that
some samples
failed to meet
the standard
required
concentrations
indicated the
importance of
the quality
check, and it
would be very
important to
identify other
reference
laboratories
able to perform
it.
Tolerability and
acceptability
information were
available from
four sites
(Bangladesh,
Hong Kong SAR,
Pakistan and
Saudi Arabia)
where, in general,
the WHOrecommended
formulations were
well appreciated
by HCWs. In
Hong Kong SAR
and Pakistan, the
WHOrecommended
formulations were
preferred to the
product
previously in use
because of better
tolerability. Hair
bleaching and

one case of
dermatitis were
the rare adverse
effects reported.
Issues related to
the unpleasant
smell of the final

product were
raised by HCWs
from all four
sites, but were
not a major
obstacle to
adoption. No
53

religious issues
related to the
alcohol content
were identified in
the survey.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

13.
Surgical hand preparation: state-of-the-art
13.1 Evidence for surgical hand preparation

outbreak of SSIs even

occurred when surgeons
who normally used an
antiseptic surgical scrub
preparation switched to a
non-antimicrobial
product.524

Historically, Joseph Lister (18271912)

demonstrated the effect of disinfection on the
Despite a large body of
reduction of surgical site infections (SSIs).506 At that
indirect evidence for the
time, surgical gloves were not yet available, thereby
need of surgical hand
making appropriate disinfection of the surgical site
of the patient and hand antisepsis by the surgeon even antisepsis, its requirement
more imperative.507 During the 19th century, surgical before surgical interventions
hand preparation consisted of washing the hands with has never been proven by a
antimicrobial soap and warm water, frequently with the randomized, controlled
clinical trial.525 Most likely,
use of a brush.508 In 1894, three steps were
suggested: 1) wash hands with hot water, medicated such a study will never be
soap, and a brush for 5 minutes; 2) apply 90% ethanol performed again nor be
for 35 minutes with a brush; and 3) rinse the hands acceptable to an ethics
with an aseptic liquid.508 In 1939, Price suggested a committee. A randomized
7-minute handwash
with soap, water, and a brush, followed by 70%
ethanol for 3 minutes after drying the hands with a
towel.63 In the second half of the 20th century, the
recommended time for surgical hand
preparation decreased from >10 minutes to 5 minutes.

Even today, 5-minute protocols are common.197 A

comparison of different countries showed almost as
many protocols as listed countries.513
The introduction of sterile gloves does not render
surgical hand preparation unnecessary. Sterile gloves
contribute to preventing surgical site contamination514
and reduce the risk of bloodborne pathogen
transmission from patients to the surgical team.515
However, 18% (range: 582%) of gloves have tiny
punctures after surgery, and more than 80% of cases
go unnoticed by
the surgeon. After two hours of surgery, 35% of all
gloves demonstrate puncture, thus allowing water
(hence also body fluids) to penetrate the gloves
without using pressure516 (see Part I, Section 23.1). A
recent trial demonstrated that punctured gloves
double the risk of SSIs.517 Double gloving decreases
the risk of puncture during surgery, but punctures are
still observed in 4% of cases after the
procedure.518,519 In addition, even unused gloves do
not fully prevent bacterial contamination of hands.520
Several reported outbreaks have been traced to
contaminated hands from the surgical team despite
wearing
sterile gloves.71,154,162,521-523

Koiwai and colleagues detected the same strain of

coagulase-negative staphylococci (CoNS) from the
bare fingers of

a cardiac surgeon and from a patient with

postoperative endocarditis with a matching
strain.522 A similar, more recent outbreak with CoNS
and endocarditis was observed by Boyce and
colleagues, strain identity being confirmed by
molecular methods.162 A cardiac surgeon with
onychomycosis became the source of an outbreak
of SSIs due to P. aeruginosa, possibly facilitated by
not routinely practising double gloving.523 One

509-512

clinical trial comparing

an alcohol-based
handrub versus a
chlorhexidine hand
scrub failed to
demonstrate a
reduction of SSIs,
despite considerably
better in vitro activity of
the alcohol-based
formulation.197
Therefore, even
considerable

improvements in
antimicrobial activity in
surgical hand hygiene
formulations are unlikely to
lead to significant
reductions of SSIs. These
infections are the result of
multiple risk factors related
to the patient, the surgeon,
and the health-care
environment, and the
reduction of only one
single risk factor will have
a limited influence on the
overall outcome.
In addition to
protecting the
patients, gloves
reduce the risk for the
HCW to be exposed to
bloodborne
pathogens. In
orthopaedic surgery,
double gloving has
been a common
practice that
significantly reduces,
but does not
eliminate, the risk of
cross-transmission
after glove punctures
during surgery.526

13.2 Objective of
surgical hand
preparation
Surgical hand preparation
should reduce the release
of skin bacteria from the
hands of the surgical team
for the duration of the
procedure in case of an
unnoticed puncture of the
surgical glove releasing
bacteria to the open
wound.527 In contrast to the

hygienic handwash or handrub, surgical hand

preparation must eliminate the transient and reduce
the resident flora.484,528,529
It should also inhibit growth of bacteria under the
gloved hand. Rapid multiplication of skin bacteria
occurs under surgical gloves if hands are washed
with a non-antimicrobial soap, whereas it occurs
more slowly following preoperative scrubbing with a
medicated soap. The skin flora, mainly coagulasenegative staphylococci, Propionibacterium spp., and
Corynebacteria spp., are rarely responsible for SSI,
but in the presence of a foreign body or necrotic
tissue even inocula as low as 100 CFU can trigger
such infection.530 The virulence of the
microorganisms, extent of microbial exposure, and
host defence mechanisms are key factors in the
pathogenesis of postoperative infection, risk factors
that are largely beyond the influence of the surgical
team. Therefore, products for surgical hand
preparation must eliminate the transient and

significantly reduce the

resident flora at the
beginning of an operation
and maintain the microbial
release from the hands
below baseline until the
end of the procedure.

The spectrum of
antimicrobial activity for
surgical hand preparation
should be as broad as
possible against bacteria
and fungi.529,531 Viruses are
rarely involved in SSI and
are not part of test
procedures for licensing in
any country. Similarly,
activity against sporeproducing bacteria is not
54

part of international testing

procedures.

13.3 Selection
of products for
surgical hand
preparation
The lack of
appropriate,
conclusive clinical
trials precludes
uniformly acceptable
criteria. In vitro and in
vivo trials with

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

contrast to

the USA
guidelines, only
the immediate
effect after the
hand hygiene
procedure and
healthy volunteers the level of
outside the
regrowth after 3
operating theatre hours under
are the best
gloved hands
evidence currently are measured.
available. In the The cumulative
USA, antiseptic effect over 5
preparations
days is not a
intended for use
requirement of
as surgical hand
EN 12791.

preparation
(based on the
Most guidelines
FDA TFM of 17
prohibit any
June 1994)198 are jewellery or
evaluated for their watches on the
ability
hands of the
to reduce the
surgical team
number of
(Table
bacteria released I.13.1).58,529,533
from hands: a)
Artificial
immediately after fingernails are an
scrubbing; b)
important risk
after wearing
factor, as they
surgical gloves
are associated
for 6 hours
with changes of
(persistent
the normal flora
activity); and c)
and impede
after multiple
proper hand
applications over hygiene.154,529
5 days
Therefore, they
(cumulative
should be
activity).
prohibited for the
Immediate and
surgical team or
persistent
in the operating
activities are
theatre.154,529,534
considered the
most important.
Guidelines in
13.4 Surgical
the USA
hand
recommend that antisepsis
agents used for using
surgical hand
medicated
preparation
soap
should
significantly
The different
reduce
active compounds
microorganisms included in
on intact skin,
commercially
contain a nonavailable handrub
irritating
formulations are
antimicrobial
described in Part
preparation, have I, Section 11. The
broad-spectrum most commonly
activity, and be
used products for
fast-acting and
surgical hand
persistent (see
antisepsis are
Part I, Section
chlorhexidine or
10).532 In Europe, povidone-iodineall products must containing soaps.
be at least as
The most active
efficacious as a agents (in order
reference surgical of decreasing
rub with nactivity) are
propanol, as
chlorhexidine
outlined in the
gluconate,
European Norm iodophors,
EN 12791. In
triclosan, and

plain
soap.282,356,378,529,5
35-537

Triclosancontaining
products have
also been tested
for surgical hand
antisepsis, but
triclosan is mainly
bacteriostatic,
inactive against P.
aeruginosa, and
has been
associated with
water pollution in
lakes.538,539
Hexachlorophene
has been banned
worldwide
because of its
high rate of
dermal absorption
and subsequent
toxic effects.70,366
Application

of chlorhexidine
or povidoneiodine result in
similar initial
reductions of
bacterial counts
(7080%),
reductions that
achieves 99%
after repeated
application.
Rapid regrowth
occurs after
application of
povidoneiodine, but not
after use of
chlorhexidine.54
0

Hexachlorophen
e and triclosan
detergents
show a lower
immediate
reduction, but a
good residual
effect.
These agents are
no longer
commonly used
in operating
rooms because
other products
such as
chlorhexidine or
povidone-iodine
provide similar
efficacy at lower
levels of toxicity,
faster mode of
action, or broader
spectrum of
activity. Despite
both in vitro and
in vivo studies
demonstrating
that it is less
efficacious than

chlorhexidine,
povidone-iodine
remains one of
the widely-used
products for
surgical hand
antisepsis,
induces more
allergic reactions,
and does not
show similar
residual
effects.271,463 At
the end of a
surgical
intervention,
iodophor-treated
hands can have
even more
microorganisms
than before
surgical
scrubbing. Warm
water makes
antiseptics and
soap work more
effectively, while
very hot water
removes more of
the protective
fatty acids from
the skin.
Therefore,
washing with hot
water should be
avoided. The
application
technique is
probably

less prone to
errors
compared with
handrubbing
(Table I.13.2)
as all parts of
the hands and
forearms get
wet under the
tap/ faucet. In
contrast, all
parts of the
hands and
forearms must
actively be put
in contact with
the alcoholbased
compound
during
handrubbing
(see below).

13.4.1 Required
time for the
procedure
Hingst and
colleagues
compared
hand bacterial
counts after 3minute and 5minute scrubs
with seven
different
formulations.37
8
Results
showed that
the 3-minute
scrub could be
as effective as
the 5-minute
scrub,
depending on
the formula of
the scrub
agent.
Immediate and
postoperative
hand bacterial
counts after 5minute and 10minute scrubs
with 4%
chlorhexidine
gluconate
were
compared by
OFarrell and
colleagues
before total hip
arthroplasty
procedures.512
The 10-minute
scrub reduced
the immediate

colony count
more than the
5-minute
scrub. The
postoperative
mean log
CFU count was
slightly higher
for the 5minute scrub
than for the 10minute scrub;
however, the
difference
between postscrub and
postoperative
mean CFU
counts was
higher for the
10-minute
scrub than the
5-minute scrub
in longer (>90
minutes)
procedures.
The study
recommended
a 5-minute
scrub before
total hip
arthroplasty.
A study by
OShaughnessy
and colleagues
used 4%
chlorhexidine
gluconate in
scrubs of 2, 4,
and 6-minutes
duration. A
reduction in postscrub bacterial
counts was found
in all three
groups. Scrubbing
for longer than 2
minutes did not
confer any
advantage. This
study
recommended a
4-minute scrub for
the surgical
teams first
procedure and a
2-minute scrub for
subsequent
procedures.541
Bacterial counts
on hands after 2minute and 3minute scrubs
with 4%
chlorhexidine
gluconate were
compared.542 A
statistically
significant
difference in
mean CFU counts
was found
between groups

with the higher

brushes
mean log
reduction in the 2- Almost all
minute group. The studies
investigators
discourage
recommended a the use of
2-minute
brushes.
procedure. Poon Early in the
and colleagues
1980s,
applied different Mitchell and
scrub techniques colleagues
suggested a
with a 10%
povidone-iodine brushless
surgical hand
formulation.543
scrub.544
Investigators
found that a 30- Scrubbing
second handwash with a
disposable
can be as
effective as a 20- sponge or
combination
minute contact
with an antiseptic sponge-brush
has been
in reducing
shown to
bacterial flora
reduce
and that

vigorous friction
scrub is not
necessarily
advantageous.
13.4.2 Use of

bacterial counts
on the hands as
effectively as
scrubbing with a
brush.511,545,546
Recently, even a

55

randomized,
controlled
clinical trial failed
to demonstrate
an additional
antimicrobial
effect by using a
brush.547 It is
conceivable that
a brush may be
beneficial on
visibly dirty
hands before
entering the
operating room.
Members of the
surgical team
who have
contaminated
their hands
before entering
the hospital may
wish to use a
sponge or brush
to render their
hands visibly
clean before
entering the
operating room
area.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

d with hand
antisepsis
using a
medicated
soap than
with an
alcoholbased
13.4.3
Drying of
handrub.548
hands
Boyce and
colleagues
Sterile
quantified
cloth
the
towels are epidermal
most
water
frequently content of
the dorsal
used in
surface of
operating
theatres to nurses
hands by
dry wet
hands after measuring
electrical
surgical
capacitance
hand
antisepsis. of the skin.
The
Several

water content
decreased
significantly
during the
washing
phase
compared with
the alcoholbased
handrub-in
phase.264
Most data
have been
13.4.4 Sidegenerated
effects of
outside the
surgical
hand scrub operating
room, but it is
conceivable
Skin
that these
irritation
results apply
and
for surgical
dermatitis
hand
are more
antisepsis as
frequentl
well.549
y
methods of
drying
have been
tested
without
significant
differences
between
techniques
.256

observed
after
surgical
hand
scrub
with
chlorhexi
dine than
after use
of
surgical
hand
antisepsi
s with an
alcoholbased
hand
rinse.197
Overall,
skin
dermatitis
is more
frequentl
y
associate

13.4.5
Potential for
recontaminatio
n
Surgical hand
antisepsis with
medicated soap
requires clean
water to rinse
the hands after
application of
the medicated
soap. However,
Pseudomonas
spp.,
377,529,558-561

specifically P.
aeruginosa, are
frequently
isolated from
taps/faucets in
hospitals.550.

Taps are
common
sources of P.
aeruginosa and
other Gramnegative
bacteria and
have even been
linked to
infections in
multiple
settings,
including
ICUs.551 It is
therefore
prudent to
remove tap
aerators from
sinks
designated for
surgical hand
antisepsis.551553
Even
automated
sensoroperated taps
were linked to
P. aeruginosa
contamination.5
54
Outbreaks or
cases clearly
linked to
contaminated
hands of
surgeons after
proper surgical
hand scrub
have not yet
been
documented.
However,
outbreaks
with
P.aerugino
sa were
reported as
traced to
members
of the
surgical
team
suffering
from
onychomyc
osis,154,523
but a link to
contaminat
ed tap
water has
never been
established
. In
countries
lacking
continuous
monitoring
of drinkingwater and
improper
tap
maintenan
ce,
recontamin
ation may
be a real

risk even
s is superior
after
to that of all
correct
other currently
surgical
available
hand
methods of
scrub.
preoperative
Of note,
surgical hand
one
preparation.
surgical
Numerous
hand
studies have
preparation demonstrated
episode with that
traditional
formulations
agents uses containing
approximatel 6095%
y 20 litres of alcohol alone,
warm water, or 5095%
or 60 litres when
and more for combined
the entire
surgical
team.555 This
is an
important
issue
worldwide,
particularly
in countries
with a limited
safe water
supply.

13.5
Surgical
hand
preparati
on with
alcoholbased
handrub
s
Several
alcoholbased
handrubs
have been
licensed
for the
commercia
l
market,531,5
56,557

frequently
with
additional,
long-acting
compound
s (e.g.
chlorhexidi
ne
gluconate
or
quaternary
ammonium
compound
s) limiting
regrowth of
bacteria on
the
gloved hand,
The
antimicrobial efficacy of
alcohol-

based
formulation

with small
amounts of a
QAC,
hexachlorophe
ne or
chlorhexidine
gluconate,
reduce
bacterial
counts on the
skin
immediately
post-scrub
more
effectively than
do other
agents.
The WHOrecommended
handrub
formulations
were tested by
two
independent
reference
laboratories in
different
European
countries to
assess their
suitability for
use for
surgical hand
preparation.
Although
formulation I
did not pass
the test in both
laboratories
and
formulation II
in only one of
them, the
expert group
is,
nevertheless,
of the opinion
that the
microbicidal
activity of
surgical
antisepsis is
still an
ongoing issue
for research
as due to the
lack of
epidemiologic
al data there is
no indication
that the
efficacy of npropanol
(propan-1-ol)
60 % v/v as a
reference in
EN 12791

finds a
clinical
correlate. It
is the
consensus
opinion of
the WHO
expert
group that
the choice
of npropanol
is
inappropri
ate as the
reference
alcohol for
the
validation
process
because
of its
safety
profile and
the lack of
evidencebased
studies
related to
its
potential
harmfulne
ss for
humans.
Indeed,
only a few
formulatio
ns
worldwide
have
incorporat
ed npropanol
for hand
antisepsis.
Considerin
g that other
properties
of the WHO
recommend
ed
formulation
s, such as
their
excellent
tolerability,
good
acceptance
by HCWs
and low
cost are of
high
importance
for a
sustained
clinical
effect, the
above
results are
considered
acceptable
and it is the

consensus
opinion of the
WHO expert
group that the
two
formulations
can be used
for surgical
hand
preparation.
Institutions
opting to use
the WHOrecommended
formulations
for surgical
hand
preparation
should ensure
that a
minimum of
three
applications
are used, if
not more, for
a

period of 3 to
5 minutes. For
surgical
procedures of
more than a
two hours
duration,
ideally
surgeons
should
practise a
second
handrub of
approximately
1 minute, even
though more
research is
needed on this
aspect.
Hand-care
products should
not decrease
the
antimicrobial
activity of the
handrub. A
study by
Heeg562 failed
to demonstrate
such an
interaction, but
manufacturers
of a handrub
should provide
good evidence
for the absence
of
interaction.563
It is not
necessary to
wash hands
before handrub
unless hands
are visibly
soiled or

dirty.562,564 The
hands of the
surgical team
should be
clean upon
entering the
operating
theatre by
washing with a
non-medicated
soap (Table
I.13.1). While
this handwash
may eliminate
any risk of
contamination
with bacterial
spores,
experimental
and
epidemiological
data failed to
demonstrate
an additional
effect
of
washing
hands before
applying
handrub
in
the
overall
reduction of
the resident
skin flora.531
The activity of
the handrub
formulation
may even be
impaired
if
hands
are not
completely
dried before
applying the
handrub or by
the washing
phase
itself.562,564,565
A simple
handwash
with soap and
water before
entering the
operating
theatre area
is highly
recommende
d to eliminate
any risk of
colonization
with bacterial
spores.420
Nonmedicated
soaps are
sufficient,566
and the
procedure is
necessary
only upon
entering the
operating
theatre:
repeating
handrubbing
without prior

handwash or recommended
scrub is
before
56

switching to the
next procedure.

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

the handrub.
Once the
forearms and
hands have been
treated with an
emphasis on the
forearms
usually for
13.5.1
Techniqu
approximately
e for the
1 minute the
applicatio
second part of
n of
the surgical
surgical
handrub
hand
should focus
preparati
on the hands,
on using
following the
alcoholidentical
based
technique as
handrub
outlined for
the hygienic
The application
handrub. The
technique has not
hands should
been
be kept above
standardized
the elbows
throughout the
during this
world. The WHO
step.
approach for
surgical hand
preparation
13.5.2 Required
requires the six
time for the
basic steps for the
procedure
hands as for
hygienic hand
For many years,
antisepsis, but
surgical staff
requires
frequently
additional steps
scrubbed their
for rubbing the
hands for 10
forearms (Figure
minutes
I.13.1). This
preoperatively,
simple procedure
which frequently
appears not to
led to skin
require training, damage. Several
though two
studies have
studies provide
demonstrated that
evidence that
scrubbing for 5
training
minutes reduces
significantly
bacterial counts
improves bacterial as effectively as a
killing.531,567 The 10-minute
hands should be scrub.284,511,512 In
wet from the
other studies,
alcohol-based rub scrubbing for 2 or
during the whole 3 minutes reduced
procedure, which bacterial counts to
requires
acceptable
approximately 15 levels.378,380,460,529,
ml depending on 541,542
Surgical
the size of the
hand antisepsis
hands. One study
using an alcoholdemonstrated that
based handrub
keeping the
required 3
hands wet with
minutes, following
the rub is more
the reference
important
method outlined in
than the volume EN 12791. Very
used.568 The size recently, even 90
of the hands and seconds of rub
forearms
have been shown
ultimately
to be equivalent to
determines the
a 3-minute rub
volume required with a product
to keep the skin containing a
area wet during mixture of iso- and
the entire time of

n-propanol and
mecetronium
etilsulfate557 when
tested with
healthy volunteers
in an in vivo
experiment. These
results were
corroborated in a
similar study
performed under
clinical conditions
with 32
surgeons.569
Alcohol-based
hand gels should
not be used
unless they pass
the test EN 12791
or an equivalent
standard, e.g.
FDA TFM 1994,
required for
handrub
formulations.533
Many of the
currently available
gels for hygienic
handrub do not
meet the
European
standard EN
1500.203 The
technique to apply
the alcohol-based
handrub defined
by EN 1500
matches the one
defined by EN
12791. The latter
requires an
additional rub of
the forearms
that is not
required for the
hygienic handrub
(Figure I.13.1).
At least one gel
on the market
has been tested
and introduced
in a hospital for
hygienic hand
antisepsis and
surgical hand
preparation that
meets EN
12791,570 and
several gels
meet the

FDA
TFM
standard.482 As
mentioned
above,
the
minimal killing is
not defined and,
therefore,
the
interpretation of
the effectiveness
remains elusive.
In summary,
the time

required for
surgical
alcohol-based
handrubbing
depends on
the compound
Manufacturers
used. Most
recommendatio
commercially
ns should be
available
based on in
products
vivo evidence
recommend a
at least,
3-minute
considering
exposure,
that clinical
although the
effectiveness
application
testing is
time may be
unrealistic.
longer for
some
formulations,
but can be
13.6
shortened to
Surgical
1.5 minutes for
handscrub
a few of them.
with
The
medicated
manufacturer
soap or
of the product
surgical
must provide
hand
recommendations preparatio
as to how long the n with
product must be alcoholapplied.

based
formulatio
ns

Both methods are

suitable for the
prevention of
SSIs. However,
although
medicated soaps
have been and
are still used by
many surgical
teams worldwide
for presurgical
hand preparation,
it
is important to
note that the
antibacterial
efficacy of
products
containing high
concentrations
of alcohol by far
surpasses that
of any
medicated soap
presently
available (see
Part I, section
13.5). In
addition, the
initial reduction
57

of the resident
skin flora is so
rapid and
effective that
bacterial
regrowth to
baseline
on the gloved
hand takes more
than six hours. 227
This makes the
demand for a
sustained effect
of a product
superfluous. For
this reason,
preference should
be given to
alcohol-based
products.
Furthermore,
several factors
including rapid
action, time
savings, less
side-effects, and
no risk of
recontamination
by rinsing hands
with water, clearly
favour the use of
presurgical
handrubbing.
Nevertheless,
some surgeons
consider the time

taken for surgical

handscrub as a
ritual for the
preparation of
the
intervention571
and a switch
from handscrub
to handrub must
be prepared with
caution. In
countries with
limited
resources,
particularly when
the availability,
quantity or
quality of water
is doubtful, the
current panel of
experts clearly
favours the use
of alcohol-based
handrub for
presurgical hand
preparation also
for this reason.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.13.1
Steps before starting surgical hand preparation
Key steps
Keep nails short and pay attention to them when washing your hands most microbes on hands come from beneath the fingernails. Do
not wear artificial nails or nail polish.
Remove all jewellery (rings, watches, bracelets) before entering the operating theatre.
Wash hands and arms with a non-medicated soap before entering the operating theatre area or if hands are visibly soiled.
Clean subungual areas with a nail file. Nailbrushes should not be used as they may damage the skin and encourage shedding of
cells. If used, nailbrushes must be sterile, once only (single use). Reusable autoclavable nail brushes are on the market.
Table I.13.2
Protocol for surgical scrub with a medicated soap
Procedural steps
Start timing. Scrub each side of each finger, between the fingers, and the back and front of the hand for 2 minutes.
Proceed to scrub the arms, keeping the hand higher than the arm at all times. This helps to avoid recontamination of the hands by
water from the elbows and prevents bacteria-laden soap and water from contaminating the hands.
Wash each side of the arm from wrist to the elbow for 1 minute.
Repeat the process on the other hand and arm, keeping hands above elbows at all times. If the hand touches anything at any time,
the scrub must be lengthened by 1 minute for the area that has been contaminated.
Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm back
and forth through the water.
Proceed to the operating theatre holding hands above elbows.
At all times during the scrub procedure, care should be taken not to splash water onto surgical attire.
Once in the operating theatre, hands and arms should be dried using a sterile towel and aseptic technique before donning gown and
gloves.

5
8

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Figure I.13.1
Surgical hand preparation technique with an alcohol-based handrub formulation
59

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Figure I.13.1
Surgical hand preparation technique with an alcohol-based handrub formulation (Cont.)
6
0

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

14.
Skin reactions related to hand hygiene
There are two major types of skin reactions associated with hand hygiene. The first and most common type
includes symptoms that can vary from quite mild to debilitating, including dryness, irritation, itching, and even
cracking and bleeding. This array of symptoms is referred to as irritant contact dermatitis. The second type of
skin reaction, allergic contact dermatitis, is rare and represents an allergy to some ingredient in a hand
hygiene product. Symptoms of allergic contact dermatitis can also range from mild and localized to severe and
generalized. In its most serious form, allergic contact dermatitis may be associated with respiratory distress and
other symptoms of anaphylaxis. Therefore it is sometimes difficult to differentiate between the two conditions.
HCWs with skin reactions or complaints related to hand hygiene should have access to an appropriate referral
service.
14.1 Frequency and pathophysiology of irritant
contact dermatitis

occurs more quickly.577

Damage to the skin also
changes
skin
flora,
resulting in more frequent
colonization
by
staphylococci and Gramnegative bacilli.79,219

Irritant contact dermatitis is extremely common among nurses,

ranging in prevalence surveys from 25% to 55%, and as many as
85% relate a history of having skin problems.572,573 Frequent and
repeated use of hand hygiene products, particularly soaps and
Although alcohols are safer
other detergents, is an important cause of chronic irritant contact
than detergents,262 they can
dermatitis among HCWs.574 Cutaneous adverse reaction was
infrequent among HCWs (13/2750 exposed HCWs) exposed to an cause dryness and skin
alcohol-based preparation containing chlorhexidine gluconate and irritation.48,578 The lipiddissolving effect of alcohols is
skin emollient during
inversely related to their
a hand hygiene culture change, multimodal programme;548 it
concentration,577 and ethanol
represented one cutaneous adverse event per 72 years of HCW
exposure. The potential of detergents to cause skin irritation varies tends to be less irritating than
n-propanol or isopropanol.578
considerably and can be reduced by the addition of humectants.
Irritation associated with antimicrobial soaps may be attributable to Numerous reports confirm that
alcohol-based formulations are
the antimicrobial agent or to other ingredients of the formulation.
Affected HCWs often complain of a feeling of dryness or burning, well tolerated and often
associated with better
skin that feels rough, and erythema, scaling or fissures. An
example of a hand skin self-assessment tool is given in Appendix 3. acceptability and tolerance
than other hand hygiene
In addition, two similar protocols
504,548,579-584
to assess skin tolerance and product acceptability by HCWs after products.
use of an alcohol-based handrub are included in the
In general, irritant contact
Implementation Toolkit of the WHO Multimodal Hand Hygiene
dermatitis is more commonly
Improvement Strategy.575 The method is based on: 1) objective
reported with iodophors220
evaluation of dermal tolerance by an investigator using a validated
Other antiseptic agents that
scale; 2) subjective evaluation by the HCW of his/ her own skin
may cause
conditions and of the product characteristics. The simpler protocol
irritant contact dermatitis, in
is meant to be used to assess a single product in the short term
order of decreasing
(35 days after use) and in the longer term (1 month after use); it
frequency, include
is easy to implement under ordinary conditions. A more
chlorhexidine, chloroxylenol,
investigational protocol has been designed
triclosan, and alcohol-based
to make a fast-track comparison of two or more products using a
products. Skin that is
double-blind, randomized, cross-over methodology.504
damaged by repeated
exposure to detergents may
Hand hygiene products damage the skin by causing denaturation be more susceptible to
of stratum corneum proteins, changes in intercellular lipids (either irritation by all types of hand
depletion or reorganization of lipid moieties), decreased
antisepsis formulations,
corneocyte cohesion and decreased stratum corneum waterincluding alcohol-based
binding capacity.574,576 Among these, the main concern is the
preparations.585 Graham and
depletion of the lipid barrier that may be consequent to contact
colleagues reported low
with lipid-emulsifying detergents and lipid-dissolving alcohols.577
rates
Frequent handwashing leads to progressive depletion of surface
of cutaneous adverse
lipids with resulting deeper action of detergents into the superficial reactions to an alcoholskin layers. During dry seasons and in individuals with dry skin,
based handrub (isopropyl
this lipid depletion
alcohol 70%) formulation
61

containing chlorhexidine
(0.5%) with emollient.548
Information regarding the
irritancy potential of
commercially prepared
hand hygiene products,
which is often determined
by measuring the
transepidermal water loss
of persons using the
preparation, may be
available from the
manufacturer. Other factors
that may contribute to
dermatitis associated with
frequent hand cleansing
include using hot water for
handwashing, low relative
humidity (most common in

winter months in the

northern hemisphere),
failure to use
supplementary hand lotion
or cream, and perhaps the
quality of paper
towels.586,587 Shear forces
associated with wearing or
removing gloves and
allergy to latex proteins
may also contribute to
dermatitis of the hands of
HCWs.577
In a recent study conducted
among ICU HCWs, the shortterm skin tolerability and
acceptability of the WHOrecommended alcohol-based
formulations (see Section 12)
were significantly higher than
those of a reference
product.504 Risk factors
identified for skin alteration
following handrub use were
male sex, fair and very fair
skin, and skin alteration
before use.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

14.2
Aller
gic
cont
act
derm
atitis
relat
ed to
hand
hygie
ne
prod
ucts

reactions
to
antiseptic
agents
including
QAC,
iodine or
iodophor
s,
chlorhexi
dine,
triclosan,
chloroxyl
enol and
alcohols2
85,330,332,33
9,588,592-597

have
been
reported,
as well
as
possible
Allergic
toxicity in
reactions
to products relation
applied to to dermal
absorptio
the skin
n of
(contact
products.
allergy)

may
present as
delayed
type
reactions
(allergic
contact
dermatitis)
or less
commonly
as
immediate
reactions
(contact
urticaria).
The most
common
causes of
contact
allergies
are
fragrances
and
preservativ
es, with
emulsifiers
being less
common.58
8-591
Liquid
soaps,
hand
lotion,
ointments
or creams
used by
HCWs may
contain
ingredients
that cause
contact
allergies.58
9,590

Allergic

598,599

Allergic
contact
dermatitis
attributab
le to
alcohol-based
handrubs is
very
uncommon.
Surveillance at
a large hospital
in Switzerland
where a
commercial
alcohol-based
handrub has
been used for
more than 10
years failed to
identify a single
case of
documented
allergy to the
product.484 In
late 2001, a
Freedom of
Information
Request for
data in the
FDAs Adverse
Event
Reporting
System
regarding
adverse
reactions to
popular
alcohol-based
handrubs in the
USA yielded
only
one reported
case of an
erythematous

rash reaction
attributed to
such a
product (J. M.
Boyce,
personal
communicatio
n). However,
with the
increasing
use of such
products by
HCWs, it is
likely that true
allergic
reactions to
such products
will
occasionally be
encountered.
There are a few
reports of
allergic
dermatitis resulting from contact
with ethyl alcohol

and one

report of
ethanolrelated
contact
urticaria
syndrome.331
More recently,
Cimiotti and
colleagues
reported
adverse
reactions
associated
with an
alcohol-based
handrub
preparation. In
most cases,
nurses who
had
symptoms
were able to
resume use of
the product
after a brief
hiatus.332 This
study raises
the alert for
possible skin
reactions to
alcohol-based
handrub
preparations.
In contrast, in
a double-blind
trial by Kampf
and
colleagues582
of 27 persons
with atopic
dermatitis,
there were no
significant
differences in
the tolerability
of alcoholbased
handrubs
when
compared

600-602

with normal strategies for

controls.
minimizing
Allergic
reactions to
alcoholbased
formulation
s may
represent
true allergy
to the
alcohol, or
allergy to
an impurity
or aldehyde
metabolite,
or allergy to
another
product
constituent.
330
Allergic
contact
dermatitis
or
immediate
contact
urticarial
reactions
may be
caused by
ethanol or
isopropanol
.330 Allergic
reactions
may be
caused by
compounds
that may be
present as
inactive
ingredients
in alcoholbased
handrubs,
including
fragrances,
benzyl
alcohol,
stearyl or
isostearyl
alcohol,
phenoxyeth
anol,
myristyl
alcohol,
propylene
glycol,
parabens,
or
benzalkoniu
m
chloride.330,491,5
88,603-606

hand hygienerelated irritant

contact
dermatitis
among HCWs:
selecting less
irritating hand
hygiene
products;
avoiding
certain
practices that
increase the
risk of skin
irritation; and
using
moisturizing
skin care
products
following hand
cleansing.607

14.3.1
Selecting less
irritating
products
Because
HCWs must
clean hands
frequently, it
is important
for healthcare facilities
to provide
products that
are both
efficacious
and as safe
as possible
for the skin.
The
tendency
of products to
cause skin
irritation and
dryness is a
major factor
influencing their
acceptance and
ultimate use by
HCWs.137,264,608611

For example,
concern about
the drying
effects of alcohol
was a major
cause of poor
acceptance of
alcohol-based
handrubs in
hospitals.313,612
Although many
hospitals have
provided HCWs
with plain soaps
in the hope of
minimizing
dermatitis,
frequent use of
such products
has been
associated with
even greater
skin damage,
dryness and
irritation than
some antiseptic
preparations.220,
262,264

14.3
Methods to
reduce
adverse
effects of
agents
There are
three
primary

One
strategy for
reducing
exposure of
HCWs to
irritating soaps
and detergents
is to promote the
use of alcoholbased handrubs
containing
humectants.

Several
donning gloves
studies have while hands
demonstrated are still wet
that such
from either
products are washing or
tolerated
applying
better by
alcohol
HCWs and
increases the
are
risk of skin
associated
irritation. For
with a better these reasons,
skin condition HCWs should
when
be reminded
compared
not to wash
with either
their hands
plain or
before or after
antimicrobial applying
soap.60,262,264,3 alcohol and to
26,329,486 ,
577,613,614

allow their
With hands to dry

completely
before donning
gloves. A
recent study
demonstrated
that HCW
education
regarding
compliance.61 proper skin
5
In settings care
management
where the
water supply was effective in
preventing
is unsafe,
waterless
occupational
rubs, the
shorter time
required for
hand
antisepsis
may increase
acceptability
and

hand
skin
antisepsis
disorders.618
presents
No product,
additional
however, is
advantages free
of
over soap and potential
water.616

risk. Hence,
it is usually
necessary
14.3.2
to
provide
Reducing an
skin irritation alternative
for use by
Certain hand individuals
hygiene
with
practices can sensitivity or
increase the reactions to
hand
risk of skin the
irritation and hygiene
product
should be
avoided. For available in
the
example,
institution.
washing
hands
regularly with
14.3.3 Use of
soap and
moisturizing
water
immediately skin care
products
before or
after using
an alcohol- The effects of
hand hygiene
based
products on
product is
skin vary
not only
unnecessary, considerably,
but may lead depending
upon factors
to
dermatitis.617 such as the
Additionally, weather and
environmental

conditions. For
example, in
tropical
countries and
during the
summer
months in
temperate
climates, the
skin remains
more
moisturized
than in cold,
dry
environments.
The effects of
products also
vary by skin
type. In one
recent study,
nurses with
darker skin
were rated as
having
significantly
healthier
skin and
less skin
irritation
than nurses
with light
skin, both
by their own
selfassessment
as well as
by observer
rating.619
Results of a
prevalence
survey of 282
Chinese
hospital
nurses
suggested
that hand
dermatitis was
less common
among this
group when
compared
with those in
other parts of
the world.620
In contrast,
the reported
prevalence of
dermatitis was
53.3% in a
survey of 860
Japanese
nurses, and
the use of
hand cream
was
associated
with a 50%
reduction.621
The need for
moisturizing
products will
thus vary
across healthcare settings,
62

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

geographical locations and respective climate conditions,

and individuals.
For HCWs at risk of irritant contact dermatitis or other adverse
reactions to hand hygiene products, additional skin moisturizing
may be needed. Hand lotions and creams often contain
humectants, fats, and oils that increase skin hydration and
replace altered or depleted skin lipids that contribute to the
barrier function of the skin.576,622 Several controlled trials have
shown that regular use of such products can help prevent

and treat irritant contact dermatitis caused by hand

hygiene products.623-627
Importantly, in a trial by McCormick and colleagues,624 improved
skin condition resulting from the frequent and scheduled use of
an oil-containing lotion led to a 50% increase in hand cleansing
frequency among HCWs. These investigators emphasized

the need to educate HCWs regarding the value of regular,

frequent use of hand-care products. However, most hand
moisturizing agents are not sterile and thus may easily
become contaminated; they have been associated also with
outbreaks in the neonatal ICU setting.628 In particular, if the
lotion is poured from a large bottle into smaller bottles, the
smaller containers should be washed and disinfected
between uses and not topped up.
Recently, barrier creams have been marketed for the
prevention of hand hygiene-related irritant contact dermatitis.
Such products are absorbed into the superficial layers of
the epidermis and are designed to form a protective layer that
is not removed by standard hand cleansing. Evidence of the
efficacy of such products, however, is equivocal.623,624,629
Furthermore, such products are expensive, so their use in
health-care settings, 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. 630
More recently, an examination glove coated with aloe vera
resulted in improved skin integrity and decreased erythema in
30 women with occupational dry skin.631 Nevertheless, such
products cannot yet be recommended as field trials, larger
sample sizes, and cost analyses are needed.
In addition to evaluating the efficacy and acceptability of handcare 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,204,632 as well as the fact
that, as previously mentioned, most of these products are not
sterile and can easily become contaminated.

63

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

15.
Factors to consider when selecting hand hygiene
products
To achieve a high rate of hand hygiene adherence, HCWs need education, clear guidelines, some understanding
of infectious disease risk, and acceptable hand hygiene products. 60,197,492,608,609,613,633,634 The selection of hand
hygiene products 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 and prevention
professionals, occupational disease professionals, administrative staff, pharmacists, and behavioural scientists)
and efforts to evaluate factors related to hand hygiene products and to conduct clinical pilot projects to test these
factors.48,58,351,607,610,635,636 The major determinants for product selection are antimicrobial profile, user acceptance,
and cost. A decision-making tool for the selection of an appropriate product is available within
the Implementation Toolkit (http://www.who.int/gpsc/en/). The antimicrobial efficacy of hand hygiene agents is
provided by in vitro and in vivo studies (see Part I, Section 10) which are reproducible and can be generalized.
Pilot studies aiming to help select products at the local level should mainly concentrate on tolerance and user
acceptability issues. Other aspects such as continuous availability, storage, and costs should also be taken into
account on a local basis, so as to guarantee feasibility and sustainability.
skin reactions;
hygiene compliance. After
careful evaluation of suitable
hand hygiene agents, HCWs
Pilot testing to assess acceptability is strongly recommended
should be given the option to
before final selection, aiming at fostering a system change and
choose themselves the
involving the users in the selection of the product they like most
product for use at their
and therefore are most likely to use. Characteristics that can
institution. Freedom of
affect HCWs acceptance of a hand hygiene product include
choice at an institutional
dermal tolerance and skin reactions to the product, and its
level was rated the second
characteristics such as fragrance, consistency, and
most important feature
colour,220,493,504,598,610 Structured, self-administered questionnaires may reported by HCWs to
be useful tools to assess HCWs acceptability of hand hygiene products. improve hand hygiene
A standardized and validated survey
compliance in the audit of a
to evaluate acceptability and tolerability among HCWs is available successful promotion
within the Implementation Toolkit (http://www.who. int/gpsc/en/).
programme in Victoria,
Such tools should be adapted to the local setting because of
Australia.494 Prior to product
differences in sociocultural backgrounds, climate and
pilot testing, the appropriate
environmental conditions, and clinical practices among users. Skin administrative decisionreactions to hand hygiene products may be increased by low
makers in the institution
relative humidity. For example, dry weather during winter months
should determine which
in the northern hemisphere should be taken into account during
products have demonstrated
pilot testing, and the introduction
efficacy and which ones can
of new products during dry and cold periods with low relative
be purchased at the best
humidity should be avoided. For an efficient test, more than one
cost. Only products that have
product should be compared, if possible with products already in
already been identified as
use. Each product should be tested by several users for at least
efficacious and affordable
23 weeks. A fast track method comparing different products
should be tested by HCWs.
(including the WHO formulations) was tested and validated in high
intensity users, such as nurses in intensive care, emergency
rooms or postoperative rooms, by the First Global Patient Safety
15.2 Selection factors
Challenge team.504 The detailed protocol can be obtained from
WHO upon request. If comparison is not possible, at least the pre- Factors to be taken into
selected product should be tested for tolerance and acceptance
consideration for product
with the above-mentioned tool. Dryness and irritation should be
selection include:
assessed with sufficient
numbers of HCWs to ensure that the results can be generalized. If 1 relative efficacy of
more than one new product is to be tested, either a period with the
antiseptic agents (see
routine product or, preferably, a minimum of a 2-day washout period
Part I, Section 10) and
504,579
should be observed between test periods.
When considering
consideration for
the replacement of a product, the new product should be at least as
selection of products for
good as the previous one. An inferior product could be responsible
hygienic hand antisepsis
for a decrease in hand
and surgical hand

15.1 Pilot testing

preparation;

2
64

dermal

tolerance

and

3
4

cost issues;

practical
considerations such
as availability,
convenience and
functioning of
dispenser, and ability
to prevent
contamination;

time for drying (consider

that different products are
associated with different
drying times; products that
require longer drying times
may affect hand hygiene
best practice);

freedom of choice by
HCWs
at
an
institutional level after
consideration of the
above-mentioned
factors.

aesthetic preferences
of HCWs and patients
such as fragrance,
colour, texture,
stickiness, and ease
of use;

15.2.1 Dermal tolerance and

skin reactions
Several studies
have published
methods to
evaluate dermal
tolerance such as
dryness or
irritation220,577,
either by selfassessment or by
expert clinical

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

a minor

skin irritant effect

compared with
handwashing
with soap and
water.548,583

evaluation197,221,264,32
6,327,329,405,495,504,608,610,6
13,636

(see Part I,

Section

15.2.2 Aesthetic
preferences
Fragrance.

14). Some studies

Products with a
have confirmed
strong fragrance
that these
may lead to
assessment
discomfort and
techniques
correlate well with respiratory
symptoms in
other
some HCWs
physiological
measures such as allergic to
perfume or
transepidermal
fragrances. Many
water loss or
patients complain
desquamation,
about perfumed
tests which are
products,
not practical to
especially in
use in clinical
settings.264,326,405,4 oncology.
95,549,577,613,636
An Therefore,
consideration
example of a
should be given
tolerability
to selecting a
assessment
framework for use product with mild
or no added
in the clinical
setting is included fragrances.
in Appendix
3220,504,572 and is Consistency
part of the WHO (texture).
Handrubs are
alcohol-based
available as
handrub
gels, solutions
tolerability and
or foams.
acceptability
Dermal
survey
(Implementation tolerance and
Toolkit available at efficacy were
http://www.who. not considered
int/gpsc/en/) (see as they are not
affected by
also Part I,
Section 14).
consistency.203,
Dermal tolerance 495 Although
is one of the main more
parameters
expensive than
leading to the
solutions, gels
product
have recently
acceptability by become the
HCWs that
most popular
influences directly type of alcoholthe compliance
based handrub
with hand
preparation in
hygiene. It is
many
demonstrated that countries. Due
dermal tolerance to their
of alcohol-based formulations,
handrubs is
some gels may
related to the
produce a
addition and the feeling of
quality of
humectant
emollient in the
build-up, or
product;504,580,627 the hands may
even alcohols,
feel slippery or
frequently used in oily
alcohol-based
with repeated
handrubs, are
use. This
known to generatedifference in

consistency has
not been
associated with
better objective
tolerance or
higher
compliance with
hand cleansing in
a controlled
study.579 A
prospective
intervention study
and a
comparison study
have shown that
the use of a gel
formulation was
associated with
better skin
condition,
superior
acceptance, and
a trend towards
improved
compliance.493,496
Nevertheless, it is
worth recalling
that first
generations of
gel formulations
have reduced
antimicrobial
efficacy
compared with
solutions.205,218 A
recent study
suggests that the
antibacterial
efficacy of
alcohol-based
gels may depend
mainly on
concentration
and type of
alcohol in the
formulation.496
Solutions
generally have a
consistency
similar to water
while some are
slightly viscous.
They often dry
more quickly
than gels or
foams (a
potential
advantage) and
may be less
likely to produce
a feeling of
humectant
build-up. They
are more likely
to drip from the
hands onto to
the floor during
use, and it has
been reported
that these drips
have created
spots on the

floor under the

dispensers in
some hospitals.
Solutions often
have a stronger
smell of alcohol
than do
gels.495,636

manufacturers of
foams
recommend the
Foams are used use of a relatively
large amount of
less frequently
product for each
and are more
application, and
expensive.
HCWs should be
Similar to gels,
they are less
reminded to
likely to drip from follow the
the hands onto
manufacturers
the
recommendation.
floor during
application,
but may
15.2.3 Practical
considerations
produce
stronger
Product
build-up
accessibility.
feeling with
Several
repeated use
studies
and may take
suggest that
longer to dry.
the frequency
Some
of hand
cleansing is
determined by
the
accessibility of
hand hygiene
facilities.335,486,
492,493,497,498,637639

A reliable
supplier
(industrial or
local at the
health-care
facility) is
essential to
ensure

a
continuo
us
supply of
products.
If
industrial
products
are not
available
or are
too
expensiv
e,
products
may be
produced within
the local setting
(see also Part I,
Section 12). WHO
identified and
validated two
different alcoholbased
formulations, and
a Guide to Local
Production
(Implementation
Toolkit, available

at
http://www.who.int
/gpsc/en/).
However, even if
a simple method
is proposed, it is
difficult to regulate
the quality control
of locally made
products, and
more
sophisticated but
feasible methods
to monitor quality
are needed.

Issues related to
infrastructure
necessary to
ensure
continuous
access to hand
hygiene products
and equipment
are specifically
dealt with in Part
I, Section 23.5.
Risk of
contamination.
Alcohol-based
rubs have a
low risk of
contamination,
338
but soap
contamination
is more
common.160,640
-644
Multipleuse bar soap
should be
avoided
because it is
difficult to
store bar soap
dry at a sink,
with a
subsequent
increase in the
risk of
contamination.
640-642
Although
liquid soaps
are generally
preferred over
bar soaps for
handwash, the
risk for either
intrinsic643 or
extrinsic160,644
microbial
contamination still
exists.

15.2.4 Cost
The promotion
of hand
hygiene is
highly cost
effective (see
Part III, Section
3), and the
introduction of

a waterless
products by
system for
HCWs is even
hand hygiene
more important.
is a costAn inexpensive
effective
product with
measure.329,645,
undesirable
646
While the
characteristics
cost of hand
may discourage
hygiene
hand hygiene
products will
among HCWs and
continue to be
the resulting poor
an important
compliance will
issue for
not be cost
departments
effective.
responsible for
purchasing
Financial
such products, the
strategies to
level of
support
acceptance of

programmes

65

designed to
improve hand
hygiene
across a
nation may
benefit from a
centralized
design and
production of
supporting
materials.
This strategy
may be more
cost effective
to the overall
health
economy
(see also Part
III, Section 3).

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

16.
Hand hygiene practices among health-care
workers and adherence to recommendations
16.1 Hand hygiene practices among healthcare workers
Understanding hand hygiene practices among
HCWs is essential in planning interventions in
health care. In
observational studies conducted in hospitals, HCWs
cleaned their hands on average from 5 to as many as
42 times
219,262,264,611,613,623,624,647-655
per shift and 1.715.2 times per
hour (Table I.16.1). 79,137,217The average frequency of hand
hygiene
episodes fluctuates with the method used for monitoring
(see Part III, Section 1.1) and the setting where the
observations were conducted; it ranges from 0.7 to 30
episodes per hour (Table I.16.1). On the other hand, the
average number of opportunities for hand hygiene per
HCW varies markedly between hospital wards; nurses in
paediatric wards, for example, had an average of eight
opportunities for hand hygiene per hour of patient
care, compared with an average of 30 for nurses in
ICUs.334,656 In some acute clinical situations, the patient is
cared for by several HCWs at the same time and, on
average, as many as 82 hand hygiene opportunities per
patient per hour of care have been observed at postanaesthesia care unit admission.652 The number of
opportunities for hand hygiene depends largely on the
process of care provided: revision of protocols for patient
care may reduce unnecessary contacts and,
consequently, hand hygiene opportunities.657
In 11 observational studies, the duration of hand
cleansing episodes by HCWs ranged on average from
as short as 6.6 seconds to 30 seconds. In 10 of these
studies, the hand hygiene technique monitored was
handwashing,79,124,135,213-216,218,572,611 while handrubbing
was

monitored in one study.457.In addition to washing their

hands for very short time periods, HCWs often failed to
cover all surfaces of their hands and fingers.611,658 In
summary, the number of hand hygiene opportunities
per hour of care may be very high and, even if the hand
hygiene compliance is high too, the applied technique
may be inadequate.

16.2 Observed adherence to hand cleansing

Adherence of HCWs to recommended hand hygiene
procedures has been reported with very variable
figures, in some cases unacceptably poor, with mean
baseline rates ranging from 5% to 89%, representing
an overall average of
60,334,648,652,666,667,683,685-687
38.7% (Table
I.16.2).60,140,215,216,334,335,485,486,492,493,496,497,613,633,637,648-

did not include detailed

information about the
methods and criteria
used. Some studies
assessed compliance
with hand hygiene

concerning the same patient,

and an increasing
number have
recently evaluated
hand hygiene
compliance after
contact with the
patient
environment.

60,334,648,652,654,657,670,682,
683,686,687,691,698,700-702,704,707-709,711 ,712

A number of investigators
reported improved
adherence after
implementing various
interventions, but most
studies had short follow-up
periods and did not
establish if improvements
were of long duration. Few
studies reported sustained
improvement as a
consequence of the longrunning implementation of
programmes aimed at
promoting optimal
adherence to hand
hygiene policies.60,494,657,713-719

16.3 Factors affecting

adherence
Factors that may
influence hand hygiene
include risk factors for
non-adherence
identified in
epidemiological studies
and reasons reported
by HCWs for lack of
adherence to hand
hygiene
recommendations.
Risk factors for poor
adherence to hand
hygiene have been
determined objectively in
several observational
studies or interventions to
improve
adherence.608,656,663,666,720725
Among these, being a
doctor or a nursing
assistant, rather than a
nurse, was consistently
associated with reduced
adherence. In addition,
compliance with hand
cleansing may vary among
doctors from different
specialities.335 Table I.16.3
lists the major factors
identified in observational
studies of hand hygiene
behaviour in health care.

651,654,655,657,659-711

It should be pointed out that the

methods for defining adherence (or non-adherence)
and the methods for conducting observations varied
considerably in the reported studies, and many articles

In a landmark study,656 the

investigators identified
hospitalwide predictors of

poor adherence to recommended hand hygiene measures (on average, 22

during routine patient care. Predicting variables included opportunities per patientprofessional category, hospital ward, time of day/week, and hour). The highest
type and intensity of patient care, defined as the number of adherence rate (59%) was
opportunities for hand hygiene per hour of patient care. In observed in paediatrics,
2834 observed opportunities for hand hygiene, average
where the average intensity
adherence was 48%. In multivariate analysis, nonof patient care
adherence was the lowest among nurses compared with was lower than elsewhere
other HCWs and during weekends. Non-adherence was (on average, eight
higher in ICUs compared with internal medicine, during
opportunities per patientprocedures that carried a high risk
hour). The results of this
of bacterial contamination, and when intensity of patient
study suggested that full
care was high. In other words, the higher the demand for adherence to previous
hand hygiene, the lower the adherence. The lowest
guidelines was unrealistic
adherence rate (36%) was found in ICUs, where
and that easy access to
indications for hand hygiene were typically more frequent hand hygiene at the point
66

of patient care, i.e. in

particular through alcoholbased handrubbing, could
help
improve adherence,615,656,720
Three recent publications
evaluating the implementation
of the CDC hand hygiene
guidelines58 in the USA tend to
concur with these results and
considerations.726-728 Various
other studies have confirmed
an inverse relation between
intensity of patient care and
adherence to hand
hygiene.60,334,335,493,649,652,653,656,689,729
,730

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

been assessed
or quantified in
observational
studies.608,663,666,
720,722-724
Table
I.16.3 lists the
most frequently
reported
reasons that are
possibly, or
effectively,
associated with
poor adherence.
Some of these
barriers are
discussed in
Part I, Section
14 (i.e. skin
irritation, no
easy access to
hand hygiene
supplies), and in
Part I, Section
23.1 (i.e. impact
of use of gloves
on hand hygiene
practices).

Perceived
barriers to
adherence with
hand hygiene
practice
recommendations
include skin
irritation caused
by hand hygiene
agents,
inaccessible hand
hygiene supplies,
interference with
HCWpatient
relationships,
patient needs
perceived as a
priority over hand
hygiene, wearing
of gloves,
forgetfulness, lack
of knowledge of
Table I.16.1
guidelines,
Frequency of hand
insufficient time hygiene actions
for hand hygiene, among health-care
workers
high workload
and understaffing,
and the lack of
scientific
information
showing a
definitive impact
of improved
hand hygiene on
HCAI
rates.608,656,663,666,722725,729,731,732 Some

of the perceived
barriers to
adherence with
hand hygiene
guidelines have

o
y
Girard, Amazian & Fabry
n
.
Reference
Noritomi et al.l
y
*
Ayliffe et al.
Rosenthal et al.
*
218
Broughall
Pittet et al.652 r
Winnefeld et al.
e
H
Harbarth et al.
p
a
McCormick, Buchman & Maki
Larson, Albrecht
o & OKeefe
n
Boyce, Kelliher & Vallande
655 r
d
Girou et al.
t
r
Boyce, Kelliher
& Vallande
*
e
u
Ojajarvi, Makela & Rantasalo
d
b
H
b
Larson et al.
a
i
i
n
Larson et al.
n
n
d
g
Berndt et al.
w
t
Larson et al.
a
h
o
s
e
n
Larson et al.
h
l
Lam, Lee &
i Lau
s
y
n
t
Taylor611
g
u
r
Gould649
d
e

Lack of
knowledge of
guidelines for
hand hygiene,
lack of
recognition of
hand hygiene
opportunities
during patient
care, and lack of
awareness of
the risk of crosstransmission of
pathogens are
barriers to good
hand hygiene
practices.
Furthermore,
some HCWs
believed that
they washed
their
hands when
necessary even
when
observations
indicated that
they did
not.218,220,666,667,676,733
Additional
perceived
barriers to hand
hygiene
behaviour are
listed in Table
I.16.3. These
are relevant not
only on the

institutional level,
but also to
particular HCWs
or HCW groups.

p
o
r
t
e

d
i
n

t
h
e
s

t
u
d
y
.
67

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.16.2
Hand hygiene adherence by health-care workers (1981June 2008)

Reference

Year

Setting

Before/
after
contact

Adherence
baseline
(%)

Adherence
after
intervention
(%)

Intervention

Preston, Larson &

1981

ICU

16

30

More convenient sink locations

Albert & Condie660

1981

ICU

41

Preston, Larson &

1981

ICU

28

Larson661

1983

All wards

45

Kaplan &

1986

SICU

51

Mayer et al.633

1986

ICU

63

92

Performance feedback

Donowitz662

1987

PICU

31

30

Wearing overgown

1989

MICU

B/A

14/28 *

73/81

Feedback, policy reviews, memo,

posters

DeCarvalho et al.734

1989

NICU

A/B

75/50

Graham665

1990

ICU

32

45

Alcohol-based handrub introduced

1990

ICU

A**

81

92

In-service first, then group feedback

1990

ICU

B/A**

22

30

1991

SICU

51

Lohr et al.669

1991

Pedi
OPDs

49

49

Signs, feedback, verbal reminders to

doctors

Raju & Kobler670

1991

Nursery
& NICU

B/A ***

28

63

Feedback, dissemination of literature,

results of environmental cultures

Larson et al.671

1992

NICU/
others

29

Doebbeling et al.659

1992

ICU

NS

40

Stamm

492

Stamm 492

McGuckin497

Conly et al.

663

Dubbert et al.666
Simmons et al.

667

Pettinger &
Nettleman668

Zimakoff et al.

672

1993

ICUs

40

Meengs et al.216

1994

Emerg
Room

32

Lund et al.215

1994

All wards

32

Wurtz, Moye &

1994

SICU

22

38

Automated handwashing machines

Jovanovic637
Pelke et al.

673

available
1994

NICU

62

60

No gowning required

1994

ICUs
Wards

A
A

30
29

Shay et al.674

1995

ICU
Oncol
Ward

56

Berg, Hershow &

1995

ICU

NS

63

Lectures, feedback, demonstrations

Tibballs676

1996

PICU

B/A

12/11

13/65

Overt observation, followed by

feedback

Slaughter et al.677

1996

MICU

41

58

Routine wearing of gowns and gloves

Gould

649

675

Ramirez

68

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.16.2
Hand hygiene adherence by health-care workers (1981June 2008) (Cont.)

Reference

Year

Setting

Before/
after
contact

Adherence
baseline
(%)

Adherence
after
intervention
(%)

Intervention

Dorsey, Cydulka

1996

Emerg

54

64

Signs/distributed review paper

Emerman

678

Dept

Larson et al.684

1997

ICU

B/A**

56

83

Lectures based on previous

questionnaire on HCWs beliefs,
feedback, administrative support,
Automated handwashing machines
available

Watanakunakorn,

1998

All wards

30

1998

Paediat-

B/A

52/49

74/69

Feedback, films, posters, brochures

Wang & Hazy679

Avila-Aguero et

al.680

ric wards

Kirkland,

1999

MICU

B/A

12/55

2000

All wards

B/A**
and ***

48

67

Posters, feedback, administrative

support, alcohol rub

Weinstein681
Pittet et al.60
Maury et al.485

2000

MICU

42

61

Alcohol handrub made available

486

2000

MICU
CTICU

B/A
B/A

10 / 22
4 / 13

23 / 48
7 / 14

Education, feedback, alcohol gel made

available

Muto, Sistrom &

2000

Medical

A***

60

52

Education, reminders, alcohol gel made

Bischoff et al.

Farr

682

Girard, Amazian &

wards

available

2001

All wards

B/A

62

67

Education, alcohol gel made available

Karabey et al685

2002

ICU

B/A**

15

Hugonnet, Perneger
& Pittet334

2002

MICU/
SICU
NICU

B/A**
and ***

38

55

Posters, feedback, administrative

support, alcohol rub

Harbarth et al.686

2002

PICU /
NICU

B/A**
and ***

33

37

Posters, feedback, alcohol rub

Rosenthal et al.651

2003

All wards
3 hospitals

B/A

17

58

Education, reminders, more sinks made

available

Brown et al.687

2003

NICU

B/A**
and ***

44

48

Education, feedback, alcohol gel made

available

Pittet et al.652

2003

PACU

B/A**
and ***

19.6

Ng et al.735

2004

NICU

B/A***

40

53

Education, reminders

Pittet et al.335

2004

Doctors
in all
wards

B/A**
and ***

57

Kuzu et al.683

2005

All wards

B/A**
and ***

39

Arenas et al.689

2005

Haemodialysis
units

B/A and
***

B 13.8
Ar 35.6

Saba et al.690

2005

Haemodialysis
units*

B/A

26

Fabry613

69

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.16.2
Hand hygiene adherence by health-care workers (1981June 2008) (Cont.)

Reference

Year

Setting

Before/
after
contact

Adherence
baseline
(%)

Adherence
after
intervention
(%)

Intervention

Larson, Albrecht &

OKeefe654

2005

Pediatric
ER and
PICU

B/A

38.4

Jenner et al.691

2006

Medical,
surgical
wards

B/A

Maury et al.692

2006

MICU

NS

47.1

55.2

Announcement of observations
(compared to covert observation at
baseline)

Furtado et al.693

2006

2 MSICUs

B/A

22.2 / 42.6

das Neves et al.694

2006

NICU

B/A

62.2

61.2

Posters, musical parodies on radio,

slogans

Hayden et al.140

2006

MICU

B/A

29

43

Wall dispensers, education, brouchures,

buttons, posters

Sacar et al.695

2006

Hospitalwide

B/A

45.1

Berhe, Edmond &

2006

MICU,

B/A

31.8 / 50

39 / 50.3

Performance feedback

Bearman696

SICU

Girou et al.655

2006

Rehab
institution-wide

B/A

60.8

Eckmanns et al.736

2006

ICU

B/A

29

45

Announcement of observations
(compared to covert observation at
baseline)

Santana et al.698

2007

MSICU

B/A

18.3

20.8

Introduction of alcohol-based handrub

dispensers, posters, stickers, education

Swoboda et al.699

2007

IMCU

19.1

25.6

Voice prompts if failure to handrub

Novoa et al.700

2007

Hospitalwide

B/A

20

Barbut et a.496

2007

MICU

B/A

53 / 63 / 68

3 different handrub products

Trick et al.701

2007

3 study
hospitals, one
control,
hospitalwide

23 / 30 / 35
/ 32

46 / 50 / 43
/ 31

Increase in handrub availability,

education, poster

Dedrick et al.702

2007

ICU

45.1

Noritomi et al.650

2007

Multidisciplinary
ICU

B/A

27.9

Pan et al.703

2007

Hospitalwide

B/A

19.6

70

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.16.2
Hand hygiene adherence by health-care workers (1981June 2008) (Cont.)

Reference

Year

Setting

Before/
after
contact

Adherence
baseline
(%)

Adherence
after
intervention
(%)

Intervention

Hofer et al.704

2007

Hospitalwide,
paediatric
hospital

B/A

34

Raskind et al.705

2007

NICU

89

100

Education

Traore et al.493

2007

MICU

B/A

32.1

41.2

Gel versus liquid handrub formulation

Pessoa-Silva

2007

NICU

B/A

42

55

Posters, focus groups, education,

et al.657

questionnaires, review of care protocols

Khan & Siddiqui

706

2008

Anaesthesia

62

Rupp et al.707

2008

ICU

B/A

38 / 37

69 / 68

Introduction of alcohol-based handrub

gel

Ebnother et al.708

2008

All wards

B/A

59

79

Multimodal intervention

Haas & Larson709

2008

Emerg
department

B/A

43

62

Introduction of wearable personal

handrub dispeners

Venkatesh et al.710

2008

Hematology unit

B/A

36.3

70.1

Voice prompts if failure to handrub

Duggan et al.711

2008

Hospitalwide

B/A

84.5

89.4

Announced visit by auditor

ICU = intensive care unit; SICU = surgical ICU; MICU = medical ICU; MSICU = medical/surgical ICU;
PICU = paediatric ICU; NICU = neonatal ICU; Emerg = emergency; Oncol = oncology; CTICU = cardiothoracic ICU; PACU = postanaesthesia care unit: OPD = outpatient department; NS = not stated.
* Percentage compliance before/after patient contact.

1*
1**
1***

Hand hygiene opportunities within the same patient also counted.

After contact with inanimate objects.
Use of gloves almost universal (93%) in all activities.

71

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.16.3
Factors influencing adherence to hand hygiene practices

Factors for poor adherence / low compliance

1.

References

Observed risk factors for poor adherence to recommended hand hygiene practices
Doctor status (rather than a nurse)

Pittet & Perneger, 1999737

Pittet, 2000738
Pittet et al., 200060
Lipsett & Swoboda, 2001730
Hugonnet, Perneger & Pittet, 2002334
Rosenthal et al., 2003651
Zerr et al., 2005715
Pan et al., 2007703

Nursing assistant status (rather than a nurse)

Pittet & Perneger, 1999737

Pittet, 2000738
Lipsett & Swoboda, 2001730
Hugonnet, Perneger & Pittet, 2002334
Rosenthal et al., 2003651
Arenas et al., 2005689
Novoa et al., 2007700
Pan et al., 2007703

Physiotherapist

Pan et al., 2007703

Technician

Pittet et al., 200060

Male sex

Pittet, 2000738
Rosenthal et al., 2003651

Working in intensive care

Pittet & Perneger, 1999737

Pittet, 2000738
OBoyle, Henly & Larson, 2001729
Hugonnet, Perneger & Pittet, 2002334
Rosenthal et al., 2003651
Pittet et al., 2004335

Working in surgical care unit

Lipsett & Swoboda, 2001730

Pittet et al., 2004335
Zerr et al., 2005715

Working in emergency care

Pittet et al., 2004335

Working in anaesthiology

Pittet et al., 2004(Pittet, 2004 #261}

Working during the week (vs. weekend)

Pittet & Perneger, 1999737

Pittet, 2000738

Wearing gowns/ gloves

Thompson et al., 1997739

Khatib et al., 1999740
Pittet, 2000738
Pessoa-Silva et al., 2007657

Before contact with patient environment

Zerr, 2005715

After contact with patient environment e.g. equipment

Zerr, 2005715
Pessoa-Silva et al., 2007657

Caring of patients aged less than 65 years old

Pittet et al., 2003652

Caring of patients recovering from clean/clean-contaminated surgery in

postanaesthesia care unit

Pittet et al., 2003652

Patient care in non-isolation room

Arenas et al., 2005689

Duration of contact with patient (< or equal to 2 minutes)

Dedrick et al., 2007702

Interruption in patient-care activities

Harbarth et al., 2001653

Automated sink

Larson et al., 1991217

Pittet, 2000738
72

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.16.3
Factors influencing adherence to hand hygiene practices (Cont.)

Factors for poor adherence / low compliance

References

Activities with high risk of cross-transmission

Pittet & Perneger, 1999737

Pittet, 2000738
Pittet et al., 200060
Hugonnet, Perneger & Pittet, 2002334
Pan et al., 2007703

Understaffing or overcrowding

Haley & Bregman, 1982741

Pittet & Perneger, 1999737
Harbarth et al., 1999185
Pittet, 2000738
Pittet et al., 200060
OBoyle, Henly & Larson, 2001729
Kuzu et al., 2005683

High patient-to-nurse ratio and more shifts per day

(for haemodialysis unit)

Arenas et al., 2005689

High number of opportunities for hand hygiene per hour of patient care

Pittet & Perneger, 1999737

Pittet, 2000738
Pittet et al., 200060
OBoyle, Henly & Larson, 2001729
H Hugonnet, Perneger & Pittet, 2002
334

Pittet et al., 2003652

Kuzu et al., 2005683
Pan et al., 2007703
Pessoa-Silva et al., 2007657
B.

Self-reported factors for poor adherence to hand hygiene

Handwashing agents cause irritations and dryness

Larson & Killien, 1982608

Larson, 1985742
Pettinger & Nettleman, 1991668
Heenan, 1992743
Zimakoff et al., 1992609
Larson & Kretzer, 1995722
Kretzer & Larson, 1998724
Huskins et al., 1999744
Pittet, 2000738
Pittet et al., 200060
Patarakul et al., 2005745

Sinks are inconveniently located or shortage of sinks

Larson & Killien, 1982608

Kaplan & McGuckin, 1986497
Pettinger & Nettleman, 1991668
Heenan, 1992743
Larson & Kretzer, 1995722
Kretzer & Larson, 1998724
Huskins et al., 1999744
Pittet, 2000738
Pittet et al., 200060

Lack of soap, paper towel, handwashing agents

Heenan, 1992743
Huskins et al., 1999744
Pittet, 2000738
Pittet et al., 200060
Suchitra & Lakshmi Devi, 2007746

73

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.16.3
Factors influencing adherence to hand hygiene practices (Cont.)

Factors for poor adherence / low compliance

References

Often too busy or insufficient time

Larson & Killien, 1982608

Pettinger & Nettleman, 1991668
Heenan, 1992743
Williams et al., 1994747
Larson & Kretzer, 1995722
Voss & Widmer, 1997615
Kretzer & Larson, 1998724
Boyce, 1999720
Pittet & Perneger, 1999737
Weeks, 1999748
Bischoff et al., 2000486
Pittet, 2000738
Pittet et al., 200060
Dedrick et al., 2007702
Suchitra & Lakshmi Devi, 2007746

Patient needs take priority

Kretzer & Larson, 1998724

Pittet, 2000738
Patarakul et al., 2005745

Hand hygiene interferes with HCW-patient relationship

Larson & Kretzer, 1995722

Kretzer & Larson, 1998724
Pittet, 2000738

Low risk of acquiring infection from patients

Pittet, 2000738

Wearing of gloves or belief that glove use obviates the need for hand hygiene

Pittet & Perneger, 1999737

Pittet, 2000738
Pittet et al., 200060

Lack of institutional guidelines/ lack of knowledge of guidelines and protocols

Larson & Killien, 1982608

Pettinger & Nettleman, 1991668
Larson & Kretzer, 1995722
Kretzer & Larson, 1998724
Boyce & Pittet, 200258
Rosenthal, Guzman & Safdar, 2005716
Suchitra & Lakshmi Devi, 2007746

Lack of knowledge, experience and education

Larson & Killien, 1982608

Pettinger & Nettleman, 1991668
Suchitra & Lakshmi Devi, 2007746

Lack of rewards/ encouragement

Larson & Killien, 1982608

Pettinger & Nettleman, 1991668
Suchitra & Lakshmi Devi, 2007746

Lack of role model from colleagues or superiors

Larson & Killien, 1982608

Pettinger & Nettleman, 1991668
Muto, Sistrom & Farr, 2000682
Pittet, 2000738
Pittet et al., 200060
Suchitra & Lakshmi Devi, 2007746

Not thinking about it, forgetfulness

Larson & Kretzer, 1995722

Kretzer & Larson, 1998724
Pittet, 2000738
Pittet et al., 200060
Patarakul et al., 2005745

Scepticism about the value of hand hygiene

Pittet, 2000738
Pittet et al., 200060
Boyce & Pittet, 200258

Disagreement with recommendations

Pittet, 2000738

Lack of scientific information of definitive impact of improved hand hygiene on HCAI

rates

Weeks, 1999748
Pittet, 2000738
Pittet et al., 200060
74

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.16.3
Factors influencing adherence to hand hygiene practices (Cont.)

Factors for poor adherence / low compliance

3.

A.

References

Additional perceived barriers to appropriate hand hygiene

Lack of active participation in hand hygiene promotion at individual or institutional
level

Larson & Kretzer, 1995722

Kretzer & Larson, 1998724
Larson et al., 2000713
Pittet, 2000738
Pittet et al., 200060
Pittet & Boyce, 2001749
Pittet, 2001750

Lack of institutional priority for hand hygiene

Pittet, 2000738
Pittet et al., 200060
Pittet, 2001750

Lack of administrative sanction of non-compliers or rewarding of compliers

Kelen et al., 1991751

Jarvis, 1994721
Kretzer & Larson, 1998724
Boyce, Kelliher & Vallande, 2000264
Pittet, 2000738
Pittet & Boyce, 2001749
Pittet, 2001750

Lack of institutional safety climate/ culture of personal accountability of HCWs to

perform hand hygiene

Larson & Kretzer, 1995722

Kretzer & Larson, 1998724
Larson et al., 2000713
Pittet, 2000738
Pittet et al., 200060
Pittet & Boyce, 2001749
Pittet, 2001750
Goldmann, 2006752

Factors for good adherence/ improved compliance

References

Observed factors for improved compliance

Pittet & Perneger, 1999737
Bischoff et al., 2000486
Maury, 2000485
Pittet et al., 200060
Earl, 2001753
Girard, Amazian & Fabry, 2001613
Harbarth et al., 2002686
Hugonnet, Perneger & Pittet, 2002334
Mody et al., 2003754
Brown et al., 2003687
Lam, Lee & Lau, 2004 648
Pittet et al., 2004335
Johnson et al., 2005494
Zerr et al., 2005715
Hussein, Khakoo & Hobbs, 2007755
Pessoa-Silva et al., 2007657
Trick et al., 2007701
Rupp et al., 2008707

Introduction of widely accessible alcohol-based handrub

(e.g. bedside handrub, small bottles/pocket-sized handrub); or combined with a
multimodal multidisciplinary approach targeted at individual and institution levels.

Multifaceted approach to improve hand hygiene

(e.g. education, training, observation, feedback, easy access to hand
hygiene supplies (sinks/ soap/ medicated detergents), sink automation,
financial incentives, praises
by superior, admonishment of suboptimal performance,
administrative support, prioritization to infection control needs, active
participation at institutional level)

2.

Conly et al., 1989663 Dubbert et

al., 1990666 Larson et al., 1997684
Rosenthal et al., 2003651 Won et
al., 2004756
Rosenthal, Guzman & Safdar, 2005716

interventional study*)
Predictive factors for hand hygiene
compliance (by observational study /

(i) Status of HCW

r HCW status (with attending doctors

Nondocto
75

as reference group)
2008711

Duggan et al.,

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.16.3
Factors influencing adherence to hand hygiene practices (Cont.)

Factors for good adherence/ improved compliance

References

Respiratory therapist (with nurses as reference group)

Harbarth et al., 2001653

Harbarth et al., 2002686

(ii) Type of patient care

Dedrick et al., 2007702

Swoboda et al., 2007699

Under precaution care (perceived as greater risk of transmission to HCWs themselves)

care of patient under contact precautions
care of patient in isolation room
Completing care/ between patients

Pessoa-Silva et al., 2007657

(iii) Activities perceived as having a high risk of cross-contamination or crossinfection to HCWs

Lipsett & Swoboda, 2001730

Harbarth et al., 2001653
Harbarth et al., 2002686
Kuzu et al., 2005683
Jenner et al., 2006700
Pessoa-Silva et al., 2007657
Trick et al., 2007701
Haas & Larson, 2008709

(e.g. after direct patient contact; before wound care; before/after contact with invasive
devices or aseptic techniques; before/after contact with body fluid secretions;
contact with nappies/diapers; or assessed by level of dirtiness of tasks)

(iv) Type of unit

Intensive care unit
Neonatal ICU
Acute haemiodialysis unit

3.

Novoa et al., 2007700

Harbarth et al., 2001653
Arenas et al., 2005689

(v) During the 3-month period after an announced accreditation visit

Duggan et al., 2008711

(vi) Strong administrative support

Rosenthal et al., 2003651

Determinants/ predictors/ self-reported factors for good adherence to hand hygiene (by questionnaire or focus group
study) Normative beliefs
Peer behaviour (role model)/
perceived expectation from colleagues (peer pressure)

Wong & Tam, 2005757

Whitby, McLaws & Ross, 2006725
Sax et al., 2007732

Being perceived as role model (for doctors)/

with good adherence by colleagues

Pittet et al., 2004335

Perceived positive opinion / pressure from superior or important referent others e.g.
senior doctors, administrators

Seto et al., 1991758

Pittet et al., 2004335
Pessoa-Silva et al., 2005731
Whitby, McLaws & Ross, 2006725
Sax et al., 2007732

Control beliefs
Perception that hand hygiene is easy to perform/ easy access to alcohol-based
handrub

Pittet et al., 2004335

Sax et al., 2007732

Perceived control over hand hygiene behaviour

Pessoa-Silva et al., 2005731

Attitudes
Awareness of being observed

Pittet et al., 2004335

Positive attitude towards hand hygiene after patient contact

Pittet et al., 2004335

Perceived risk of infection (level of dirtiness) during patient contact/ perceived high
public health threat

Parker et al., 2006254

Whitby, McLaws & Ross, 2006725

Beliefs in benefits of performing hand hygiene/ protection of HCWs from infection

Shimokura et al., 2006759

Whitby, McLaws & Ross, 2006725

Translation of community hand washing behaviour (behaviour developed in early

childhood) into healthcare settings (for nurses in handwashing)

Whitby, McLaws & Ross, 2006725

76

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.16.3
Factors influencing adherence to hand hygiene practices (Cont.)

Factors for good adherence/ improved compliance

References

Others

4.

Female sex

Sax et al., 2007732

HCW status technician

Shimokura et al., 2006759

Previous training

Sax et al., 2007732

Participation in previous hand hygiene campaign

Sax et al., 2007732

Patient expectation (for doctors)

Sax et al., 2007732

Factors for preferential recourse to handrubbing vs handwashing

Doctors e.g. critical care (with nurses as reference group)

Pittet et al., 200060

Hugonnet, Perneger & Pittet, 2002334
Dedrick et al., 2007702
Trick et al., 2007701

Activities with high risk of cross-transmission/ level of dirtiness

Hugonnet, Perneger & Pittet, 2002334

Kuzu et al., 2005683

High activity index (>60 opportunities per hour)

Hugonnet, Perneger & Pittet, 2002334

77

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

17.
Religious and cultural aspects of hand hygiene
There are several reasons why religious and cultural issues should be considered when dealing with the topic of
hand hygiene and planning a strategy to promote it in health-care settings. The most important is that these
Guidelines, issued as a WHO document, are intended to be disseminated all over the world and in settings where
very different cultural and religious beliefs may strongly influence their implementation. Furthermore, the
guidelines consider new aspects of hand hygiene promotion, including behavioural and transcultural issues.
Within this framework, a WHO Task Force on Religious and Cultural Aspects of Hand Hygiene was created to
explore the potential influence of transcultural and religious factors on attitudes towards hand hygiene practices
among HCWs and to identify some possible solutions for integrating these factors into the hand hygiene
improvement strategy. This section reflects the findings of the Task Force.
With the increasingly diverse
populations accompanying
these changes, very diverse
cultural beliefs are also more
prevalent than ever. This
evolving cultural topography
demands new, rapidly
acquired knowledge and
Philanthropy, generally inherent in any faith, has often been the highly sensitive, informed
motivation for establishing a relationship between the mystery of insights of these differences,
life and death, medicine, and health care. This predisposition has not only among patients but
often led to the establishment of health-care institutions under
also among HCWs who are
religious affiliations. Faith and medicine have always been
subject to the same global
integrated into the healing process as many priests, monks,
forces.
theologians and others inspired by religious motivations studied,
researched, and practised medicine. In general, religious faith has It is clear that cultural and
often represented an outstanding contribution to highlighting the to some extent, religious
ethical implications of health care and to focusing the attention of factors strongly influence
health-care providers on both the physical and spiritual natures of attitudes to inherent
human beings.
community handwashing

In view of the vast number of religious faiths worldwide, only

the most widely represented have been taken into
consideration (Figure I.17.1).760 For this reason, this section is
by no means exhaustive. Some ethno-religious aspects such
as the followers of local, tribal, animistic or shamanistic
religions were also considered.

Well-known examples already exist, however, of health

interventions where the religious point of view had a critical
impact on implementation or even interfered with it. 761,762
Research has already been conducted into religious and cultural
factors influencing health-care delivery, but mostly in the field of
mental health or in countries with a high influx of immigrants
where unicultural care is no longer appropriate.49,763 In a recent
world conference on tobacco use, the role of religion in
determining health beliefs and behaviours was raised; it was
considered to be a potentially strong motivating factor to promote
tobacco control interventions.764 A recent review enumerates
various potential positive effects of religion on health, as
demonstrated by studies showing its impact
on disease morbidity and mortality, behaviour, and lifestyles as
well as on the capacity to cope with medical problems. 765
Beyond these particular examples, the complex association

which, according to
behavioural theories (see
Part I, Section 18), are likely
to have an impact on
compliance with hand
cleansing during health care.

In general, the degree of

HCWs compliance with
hand hygiene as a
fundamental infection
control measure in a public
health perspective may
depend on their belonging
to a community-oriented,
rather than an individualoriented society. The
between religion, culture, and health, in particular hand existence of a wide
hygiene practices among HCWs, still remains an essentially awareness of everyones
unexplored, speculative area.
contribution to the common
good, such as health of the
In the increasingly multicultural, globalized community that is
community, may certainly
health-care provision today, cultural awareness has never been foster HCWs propensity to
more crucial for implementing good clinical practice in keeping
adopt good hand hygiene
with scientific developments. Immigration and travel are more
habits. For instance, hand
common and extensive than ever before as a result of the
cleansing as a measure of
geopolitically active forces of migration, asylum-seeking and, in preventing the spread of
Europe, the existence of a broad, borderless multi-state Union.
disease is clearly in
harmony with the
fundamental Hindu value of

non-injury to others
(ahimsa) and care for their
well-being (daya).
Another interesting aspect may
be to evaluate optional
methods of hand cleansing
which exist in some cultures
according to deep-seated
beliefs or available resources.
As an example, in the Hindu
culture, hands are rubbed
vigorously with ash or mud and
then rinsed with water. The
belief behind this practice is
that soap should not be used
as it contains animal fat. If
water is not available, other
substances such as sand are
used to rub the hands. In a
scientific study performed in
Bangladesh to assess faecal
coliform counts from postcleansing hand samples,

hand cleansing with mud

and ash was demonstrated
to be as efficient as with
soap.766
In addition to these
general considerations,
some specific issues to
be investigated in a
transcultural and
transreligious context are
discussed.
Based on a review of the
literature and the
consultation of religious
authorities, the most
important topics identified
were the importance of
hand hygiene in different
religions, hand gestures in
different religions and
cultures, the interpretation
of the concept of visibly
dirty hands, and the use of
alcohol-based handrubs and
alcohol prohibition by some
religions.

78

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

populations, both
inherent and
elective hand
hygiene practices
are deeply
influenced by
cultural and
17.1
religious factors.
Importance of Even though it is
hand hygiene very difficult to
in different
establish whether
religions
a strong inherent
attitude towards
Personal hygiene hand hygiene
is a key
directly
component of
determines
human well-being an increased
regardless of
elective
religion, culture or behaviour, the
place of origin.
potential
impact of
Human healthrelated behaviour, some
however, results religious
from the influence habits is worth
of multiple factors considering.
Hand hygiene can
affected by the
be practised for
environment,
hygienic reasons,
education, and
ritual reasons
culture.
during religious

According to
behavioural
theories725,767
(see Part I,
Section 18),
hand cleansing
patterns are
most likely to be
established in
the first 10 years
of life. This
imprinting
subsequently
affects the
attitude to hand
cleansing
throughout life,
in particular,
regarding the
practice called
inherent hand
hygiene,725,767
which reflects
the instinctive
need to remove
dirt from the
skin. The
attitude to
handwashing in
more specific
opportunities is
called elective
handwashing
practice725 and
may much more
frequently
correspond to
some of the
indications for
hand hygiene
during healthcare delivery.
In some

ceremonies, and
symbolic reasons
in specific
everyday life
situations
(seeTable I.17.1).
Judaism, Islam
and Sikhism, for
example, have
precise rules for
handwashing
included in the
holy texts and this
practice
punctuates several
crucial moments of
the day. Therefore,
a serious,
practising believer
is a careful
observer of these
indications, though

it is well known
that in some
cases, such as
with Judaism,
religion underlies
the very culture of
the population in
such a way that
the two concepts
become almost
indistinguishable.
As a
consequence of
this, even those
who do not
consider
themselves
strong believers
behave according
to religious
principles in

everyday life.
However, it is very
difficult to
establish if
inherent725 and
elective725
behaviour in hand
hygiene, deepseated in some
communities, may
influence HCWs
attitude towards
hand cleansing
during health-care
delivery. It is likely
that those who
are used to caring
about hand
hygiene in their
personal lives are
more likely to be
careful in their
professional lives
as well, and to
consider hand
hygiene as a duty
to guarantee
patient safety. For
instance, in the
Sikh culture, hand
hygiene is not
only a holy act,
but an essential
element of daily
life. Sikhs will
always wash their
hands properly
with soap
and water before
dressing a cut or a
wound. This
behaviour is
obviously
expected to be
adopted by HCWs
during patient
care. A natural
expectation, such
as this one, could
also facilitate
patients ability to
remind the HCW
to clean their
hands without
creating the risk of
compromising
their mutual
relationship.
Of the five basic
tenets of Islam,
observing
regular prayer
five times daily is
one of the most
important.
Personal
cleanliness is
paramount to
worship in
Islam.763
Muslims must
perform

methodical
ablutions before
praying, and
clear instructions
are given in the
Quran as to
precisely how
is required to
these should be maintain
carried out.768
scrupulous
The Prophet
personal
Mohammed
hygiene at five
always urged
intervals
Muslims to wash throughout the
hands frequently day, aside
and especially
from his/her
after some clearly
usual routine
defined tasks
of bathing as
(Table I.17.1).769
specified in
Ablutions must be
the Quran.
made in freely
These habits
running (not
transcend
stagnant) water
Muslims of all
and involve
races, cultures
washing the
and ages,
hands, face,
emphasizing
forearms, ears,
nose, mouth and the
feet, three times importance
each. Additionally, ascribed to
correct
hair must be
dampened with ablutions.770
water. Thus,
every observant With the
Muslim
exception of
the ritual
sprinkling of
holy water on
hands before
the
consecration
of bread and
wine, and of
the
washing of hands
after touching the
holy oil (the latter
only in the
Catholic Church),
the Christian faith
seems to belong
to the third
category of the
above
classification
(Table I.17.1)
regarding hand
hygiene
behaviour. In
general, the
indications given
by Christs
example refer
more to spiritual
behaviour, but the
emphasis

on this specific
point of view
does not imply
that personal
hygiene and
body care are
not important
in the
Christian way

of life.
Similarly, there
are no specific
indications
regarding
hand hygiene
in daily life in
the Buddhist
faith, nor
during ritual
occasions,
apart from the
hygienic act of
washing hands
after each
meal.
Similarly, specific
indications
regarding hand
hygiene are
nonexistent in the
Buddhist faith. No
mention is made
of hand cleansing
in everyday life,
nor during ritual
occasions.
According to
Buddhist habits,
only two
examples of
pouring water
over hands can
be given, both
with symbolic
meaning. The first
is the act of
pouring water on
the hands of the
dead before
cremation in order
to demonstrate
forgiveness to
each other,
between the dead
and the living. The
second, on the
occasion of the
New Year, is the
young persons
gesture of pouring
some water over
the hands of
elders to wish
them good health
and a long life.
Culture might
also be an
influential factor
whatever the
religious
background. In
certain African
countries (e.g.
Ghana and some
other West
African
countries) hand
hygiene is
commonly
practised in

specific
situations of
daily life
according to
some ancient
traditions. For
instance, hands
must always be
washed before
raising anything
to ones lips. In
this regard, there
is a local
proverb: when a
young person
washes well his
hands,

above-mentioned
hypothesis that
community
behaviour
influences HCWs
professional
behaviour has
been
corroborated by
scanty scientific
evidence until
now (see also
Part I, Section
18). In particular,
no data are
available on the
impact of
he eats with the religious norms
on hand hygiene
elders.
Furthermore, it is compliance in
customary
to health-care
provide facilities settings where
for
hand religion is very
aspersion
(a deep-seated.
bowl of water This
with
special is a very
leaves) outside interesting area
the house door for research in a
to
welcome global
visitors and to perspective,
allow them to because this
wash their face kind of
and
hands information could
before
even be very useful to
enquiring
the identify the best
purpose of their components of a
programme for
visit.
hand hygiene
Unfortunately, the promotion. It
79

could be
established that,
in some
contexts,
emphasizing the
link between
religious and
health issues
may be very
advantageous.
Moreover, an
assessment
survey may also
show that in
populations with
a high religious
observance of
hand hygiene,
compliance with
hand hygiene in
health

care will be
higher than in
other settings
and, therefore,
does not need
to be further
strengthened or,
at least,
education
strategies
should be
oriented
towards
different aspects
of hand hygiene
and patient
care.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

hands
together
either as a
form of
greeting, as
well as in
prayer.

17.2 Hand
gestures in There are many
different
hand gestures
religions in Mahayana
and
and Tibetan
cultures
Buddhism. In
Hand use
and
specific
gestures
take on
considera
ble
significan
ce in
certain
cultures.77
1
The
most
common
popular
belief
about
hands, for
instance
in Hindu,
Islam,
and some
African
cultures,
is to
consider
the left
hand as
unclean
and
reserved
solely for
hygienic
reasons,
while it is
thought
culturally
imperative
to use the
right hand
for offering,
receiving,
eating, for
pointing at
something
or when
gesticulating
.

In the
Sikh and
Hindu
cultures,
a specific
cultural
meaning
is given to
the habit
of folding

Theravada
Buddhist
countries,
putting two
hands together
shaped like a
lotus flower is
representative
of the flower
offered to pay
respect to the
Buddha,
Dhamma
(teaching)
and Sangha
(monk).
Walking
clockwise
around the
relic of the
Buddha or
stupa is also
considered to
be a proper
and positive
form of
respect
towards the
Buddha.
Washing
hands in a
clockwise
movement is
suggested
and goes
well with the
positive
manner of
cheerful and
auspicious
occasions.
Studies have
shown the
importance
of the role of
gesture
in teaching and
learning and
there is certainly
a potential
advantage to
considering this
for the teaching
of hand
hygiene, in
particular, its
representation
in pictorial
images for
different

cultures.772,773 In
multimodal
strategies to
promote hand
hygiene, posters
placed in key
points in healthcare settings
have been
shown to be
very effective
tools to remind
HCWs to
cleanse their
hands.58,60
Efforts to
consider
specific hand
uses and
gestures
according to
local customs in
visual posters,
including
educational and
promotional
material, may
help to convey
the intended
message more
effectively and
merits further
research.

17.3 The
concept of
visibly dirty
hands
Both the
CDC
guidelines58
and the
present
WHO
guidelines
recommend
that HCWs
wash their
hands with
soap and
water when
visibly soiled.
Otherwise,
handrubbing
with an
alcoholbased rub is
recommende
d for all other
opportunities
for hand
hygiene
during
patient care
as it is faster,
more
effective,
and better
tolerated by
the skin.

Infection
control
practitioner
s find it
difficult to
define
precisely
the
meaning of
visibly
dirty and to
give
practical
examples
while
schooling
HCWs in
hand
hygiene
practices.
In a
transcultura
l
perspective
, it could be
increasingly
difficult to
find a
common
understandi
ng of this
term. In
fact,
actually
seeing dirt
on hands
can be
impeded by
the colour
of the skin:
it is, for
example,
more
difficult to
see a spot
of blood or
other
proteinaceo
us material
on very
dark skin.
Furthermor
e, in some
very hot
and humid
climates,
the need to
wash hands
with fresh
water may
also be
driven by
the feeling
of having
sticky or
humid skin.
According
to some
religions,
the concept
of dirt is not
strictly

visual, but
reflects a
wider
meaning
which refers
to interior and
exterior
purity.774,775 In
some
cultures, it
may be
difficult to
train HCWs to
limit
handwashing
with soap and
water to some
rare situations
only. For
instance,
external and
internal
cleanliness is
a scripturally
enjoined
value in
Hinduism,
consistently

listed among
the cardinal
virtues in
authoritative
Hindu texts
(Bhagavad
gita, Yoga
Shastra of
Patanjali).
Furthermor
e, in the
Jewish
religion, the
norm of
washing
hands
immediatel
y after
waking in
the morning
refers to
the fact that
during the
night, which
is
considered
one sixtieth
of death,
hands may
have
touched an
impure site
and
therefore
implies that
dirt can be
invisible to
the naked
eye.
Therefore,
the concept
of dirt does
not refer
only to
situations in
which it is
visible. This
understanding
among some
HCWs may
lead to a
further need to
wash hands
when they feel
themselves to
be impure and
this may be an
obstacle to the
use of alcoholbased
handrubs.

The cultural
issue of
feeling
cleaner after
handwashing
rather than

after
alcoholhandrubbin based
g was
handrub
recently
s and
raised
alcohol
within the prohibiti
context of a on by
widespread some
hand
religions
hygiene
campaign in According to
Hong Kong scientific
and might evidence
be at the
arising from
basis of the efficacy and
lack of long- cost
term
effectiveness,
sustainabilit alcohol-based
y of the
handrubs are
excellent
currently
results of
considered the
optimal
gold standard
hand
approach. For
hygiene
this purpose,
compliance WHO
achieved
recommends
during the specific
Severe
alcohol-based
Acute
formulations
Respiratory taking into
Syndrome account
pandemic antimicrobial
(W H Seto, efficacy, local
personal
production,
communicat distribution,
ion).
and cost
issues at
From a
country level
global
worldwide (see
perspective, also Part I,
the above
Section 12).
consideratio
ns highlight
the
importance
of making
every
possible
effort to
consider the
concept of
visibly
dirty in
accordance
with racial,
cultural and
environment
al factors,
and to
adapt it to
local
situations
with an
appropriate
strategy
when
promoting
hand
hygiene.

17.4
Use of

In some
religions,
alcohol use is
prohibited or
considered
an offence
requiring a
penance
(Sikhism)
because it is
considered to
cause mental
impairment
(Hinduism,
Islam) (Table
I.17.1). As a
result, the
adoption of
alcoholbased
formulations
as the gold
standard for
hand hygiene
may be
unsuitable or
inappropriate
for some
HCWs, either
because of
their

reluctance to
have contact
with alcohol,
or because of
their concern
about alcohol
ingestion or
absorption via
the skin.
Even the
simple
denomination
of the product
as an
alcoholbased
formulation
could become
a real
obstacle in
the
implementatio
n of WHO
recommendat
ions.
In some
religions, and
even within the
same religious
affiliation,
various
degrees of
interpretation
exist
concerning
alcohol
prohibition.
According to
some other
faiths, on the
contrary, the
problem does
not exist (Table
I.17.1). In
general, in
theory, those
religions with
an alcohol
prohibition in
everyday life
demonstrate a
pragmatic
vision which is
followed by the
acceptance of
the most
valuable
approach in
the
perspective
of optimal
patient-care
delivery.
Consequentl
y, no
objection is
raised
against the
use of
alcoholbased
products for

environme
ntal
cleaning,
disinfectio
n, or hand
hygiene.
This is the

most
common
approach in
the case of
faiths such
as Sikhism
and
80

Hinduism.
For
example, in
a
fundamental
Hindu
textbook, the

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Shantiparva
n, it is
explicitly
stated that it
is not sinful
to drink
alcohol for
medicinal
purposes.
In Buddhism,
obstacles to the
use of alcohol in
health care are
certainly present,
but from a
completely
different
perspective.
According to the
law of kamma,
the act or the
intention to kill
living creatures is
considered a
sinful act. As
microorganisms
are living beings,
killing them with
an alcohol-based
handrub may
lead to demerit.
According to
Expositor
(1:128), the five
conditions for the
act of killing are:
a living being;
knowledge that it
is a being;
intention of
killing; effort; and
consequent
death.
Nevertheless,
considering that
HCWs for the
most part have
good intentions
in their work,
namely, to
protect patients
from pathogen
transmission, the
result of this
sinful action does
not bear heavy
consequences.
Therefore, when
comparing
a human
patients life
with a
bacteriums
life, most
people

adhering to the
Buddhist
kamma agree
that a patients
life is more
valuable.
Furthermore,
according to
Phra
Depvethee, a
Thai Buddhist
monk and
scholar, the
consequences
of killing
depends on
the size and
good
contribution of
that being.776
The Islamic
tradition poses
the toughest
challenge to
alcohol use.
Fortunately, this is
also the only
context where
reflection on
alcohol use in
health care has
begun. Alcohol is
clearly designated
as haram
(forbidden) in
Islam because it
is a substance
leading to sukur,
or intoxication
leading to an
altered state of
mind. For
Muslims, any
substance or
process leading
to a disconnection
from a state of
awareness or
consciousness (to
a state in which
she or he may
forget her or his
Creator) is called
sukur, and this is
haram. For this
reason, an
enormous taboo
has become
associated with
alcohol for all
Muslims. Some
Muslim HCWs
may feel
ambivalent about
using alcoholbased handrub
formulations.
However, any
substance that
man can
manufacture or

develop in order
to alleviate illness
or contribute to
better health is
permitted by the
Quran and this
includes alcohol
used as a medical
agent. Similarly,
cocaine is
permitted as a
local anaesthetic
(halal, allowed)
but is inadmissible
as a recreational
drug (haram,
forbidden).
To understand
Muslim HCWs
attitudes to
alcohol-based
hand cleansers
in an Islamic
country, the
experience
reported by
Ahmed and
colleagues at
the King Abdul
Aziz Medical
City (KAAMC)
in Riyadh,
Kingdom of
Saudi Arabia,
is very
instructive.770
At the KAAMC,
the policy of
using alcohol
handrub is not
only permitted,
but has been
actively
encouraged in
the interest of
infection
control since
2003. No
difficulties or
reluctance
were
encountered in
the adoption of
alcoholcontaining
hand hygiene
substances.
Though Saudi
Arabia is
considered to
be the historic
epicentre of
Islam, no state
policy or
permission or
fatwa (Islamic
religious edict)
were sought
for approval of
the use of
alcoholcontaining

handrubs,
given that
alcohol has
long been a
component
present in
results indicate a
household
very strong
cleaning
adoption of the
agents and
strategy,
other materials
including a
for public use,
preference for
including
handrubbing
perfume,
instead of
without
handwashing,
legislated
which has led to
restriction
a significant
within the
increase of hand
Kingdom. In all
these instances, hygiene
compliance
the alcohol
among HCWs
content is
permitted becauseand a reduction
of HCAI rates in
it is not for
777
ingestion. In 2005, ICUs. This
the Saudi Ministry example shows
of Health pledged that positive
its commitment to attitudes to the
the WHO Global medicinal
benefits of
Patient Safety
alcohol, coupled
Challenge, and
with a
most hospitals
across the country compassionate
have joined in a interpretation of
national campaign Quranic
implementing the teachings, have
WHO multimodal resulted in a
readiness to
Hand Hygiene
adopt new hand
Improvement
Strategy centred hygiene policies,
even within an
on the use of
Islamic Kingdom
alcohol-based
which is
handrub at the
legislated by
point of care.
Sharia (Islamic
Given this high
level commitment, law).
WHO selected
hospitals in Saudi
Arabia in 2007 for
the testing of the
present
Guidelines.
Preliminary

The risk of
accidental or
intentional
ingestion of
alcohol-based
preparations is
one of the
arguments
presented by
sceptics
concerning the
introduction of
these products
because of
cultural or
religious reasons.
Even if this is a
potential problem,
it is important to
highlight that only
a few cases have
been reported in
the
literature.599,778-781
In specific
situations,
however,
this unusual

complication of
hand hygiene
should be
considered and
security measures
planned to be
implemented (see
Part I, Section
23.6.2). Another
concern regarding
the use of handrub
formulations by
HCWs is the
potential systemic
diffusion of alcohol
or its metabolites
following skin
absorption or
airborne inhalation.
Only a few
anecdotal and
unproven cases of
alcohol skin
absorption leading
to clinical
symptoms are
reported in the
literature.779,780 In
contrast, reliable
studies on human
volunteers clearly
demonstrate that
the quantity of
alcohol absorbed
following
application is
minimal and well
below toxic levels
for humans.599,782784

In a study
mimicking use in
large quantities and
at a high
frequency,783 the
cutaneous
absorption of two
alcohol-based
handrubs with
different alcohol
components
(ethanol

and isopropanol)
was carefully
monitored.
Whereas
insignificant
levels of ethanol
were measured in
the breath and
serum of
a minority of
participants,
isopropanol was
not detected (see
Part I, Section
23.6.2). Finally,
alcohol smell on
skin may be an
additional barrier
to handrubbing,
and further
research should
be conducted to
eliminate this

smell from
handrub
preparations.

17.5 Possible
solutions
In addition to
targeting
areas for
further
research,
possible
solutions may
be identified
(Table I.17.2).
For example,
from
childhood,
the inherent
nature of
hand hygiene
which is
strongly
influenced by
religious
habits and
norms in
some
populations
could be
shaped in
favour of an
optimal
elective
behaviour
towards hand
hygiene.

Indeed, some
studies have
demonstrated
that it is
possible to
successfully
educate
children of
school age to
practise
optimal hand
hygiene for
the
prevention of
common
paediatric
communityacquired
infections.449,
454,785

When
preparing
guidelines,
international
and local
religious
authorities
should be
consulted and
their advice
clearly
reported. An
example is the
statement
issued by the
Muslim
Scholars
Board of the
81

Muslim World
League during
the Islamic Fiqh
Councils 16th
meeting held in
Mecca, Saudi
Arabia, in
January 2002:
It is allowed to
use medicines
that contain
alcohol in any
percentage that
may be
necessary for
manufacturing
if it cannot be
substituted.
Alcohol may be
used as an
external wound
cleanser, to kill
germs and in
external
creams and
ointments.786
In hand
hygiene
promotion
campaigns in
health-care
settings where
religious
affiliations
prohibiting the
use of alcohol
are

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

represented, educational strategies should include focus

groups on this topic to allow HCWs to raise their concerns
openly regarding the use of alcohol-based handrubs, help
them to understand the scientific evidence underlying this
recommendation, and identify possible solutions to overcome
obstacles (Table I.17.2). Results of these discussions could be
summarized in an information leaflet to be produced and
distributed locally. It has been suggested to avoid the use of
the term alcohol in settings where the observance of related
religious norms is very strict and rather use the term antiseptic
handrubs. However, concealing the true nature of the product
behind the use of a non-specific term could be construed as
deceptive and considered unethical; further research is thus
needed before any final recommendation can be made.
Medical practices different from Western medicine, such as
traditional medicines, should be explored for further
opportunities to promote hand hygiene in different cultural
contexts. For instance, traditional Chinese medicine
practitioners are very open to the concept of hand hygiene.
During a usual traditional Chinese medicine consultation, both
inpatient and outpatient, there can be a vast array of direct
contacts with the patient. These include various kinds of
physical examination such as the routine taking of the pulse and
blood pressure for almost all patients, but may also involve
various kinds of massages and examination of the oral cavities
or other orifices, and contact can be often more intense than in
Western medicine. In this context, the potential for using

an alcohol-based handrub is tremendous for the practitioner,

given the high frequency of hand hygiene actions, and there
is a definite avenue for further research in this setting.
Finally, the opportunity to involve patients in a multimodal
strategy to promote hand hygiene in health care should be
carefully evaluated (see Part V). Despite its potential value, this
intervention through the use of alcohol-based handrubs may be
premature in settings where religious norms are taken literally;
rather, it could be a subsequent step, following the achievement
of awareness and compliance among HCWs.

8
2

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.17.1
Hand hygiene indications and alcohol prohibition in different religions
Religion

Buddhism

Christianity

Hinduism

Islam

Judaism

Orthodox
Christianity

Sikhism

Specific indications for hand

hygiene

Type of
cleansinga

Alcohol prohibition
Existence

Reason

Potentially
affecting use of
alcohol-based
handrub

After each meal

Yes

Yes, but
surmountable

To wash the hands of the deceased

It kills living
organisms
(bacteria)

At New Year, young people pour

water over elders hands

Before the consecration of bread

and wine

No

No

After handling Holy Oil (Catholics)

During a worship ceremony (puja)

(water)

Yes

It causes mental
impairment

No

End of prayer (water)

After any unclean act (toilet)

Before and after any meal

Repeating ablutions at least three

times with running water before
prayers (5 times a day)

Yes

Before and after any meal

It causes
disconnection from
a state of spitritual
awareness or
consciousness

Yes, but
surmountable.
Very advanced and
close scrutiny of
the problem

After going to the toilet

After touching a dog, shoes or a

cadaver

After handling anything soiled

Immediately after waking in the

morning

No

No

Before and after each meal

Before praying

Before the beginning of Shabbat

After going to the toilet

After putting on liturgical

vestments before beginning the
ceremony

No

No

Before the consecration of bread

and wine

Early in the morning

Yes

Yes, but probably

surmountable

Before every religious activity

Before cooking and entering the

community food hall

Unacceptable
behaviour as
disrespectful of the
faith
Considered as an
intoxicant

After each meal

After taking off or putting on shoes

H = hygienic; R = ritual; S = symbolic.

83

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.17.2
Religious and cultural aspects of hand hygiene in health care and potential impact and/or solutions
Topic

Potential impact and/or solutions

Hand hygiene practices

Both inherent and elective hand hygiene practices are deeply influenced by cultural and
religious factors
Area for research: potential impact of some religious habits on hand hygiene compliance
in health care

Hand gestures

Consider specific gestures in different cultures to be represented in posters and other

promotional material for educational purposes in multimodal hand hygiene campaigns

The concept of visibly dirty hands

Consider different skin colour, different perceptions of dirtiness and climiate variations
when educating HCWs on hand hygiene indications

Prohibition of alcohol use

Consultation of local clergy and wise interpretation of holy texts

Focus groups on this topic within education strategies
Use of the most appropriate term for alcohol-based handrubs
Careful evaluation of patient involvement
Area for research: quantitative studies on potential toxicity of accidental ingestion and
inhalation or skin absorption of alcohol related to alcohol-based handrubs; elimination of
alcohol smell

Figure I.17.1
Most widely represented religions worldwide, 2005760

Christianity

2.1

billion, 33%

Islam
21%

1.5 billion,
Hinduism
900 Million, 14%

Buddhism
376 Million, 6%
Judaism

Ethno-Religions

14 Million, 0.2%

300 Million, 6%
Sikhism
23 Million, 0.4%

Source: http://www.adherents.com/Religions_By_Adherents.html, accessed 26 February 2009

84

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

18.
Behavioural considerations
18.1 Social sciences and health behaviour
Hand hygiene behaviour varies significantly among HCWs within
the same unit, institution494,656,688 or country,787 thus suggesting that
individual features could play a role in determining behaviour.
Social psychology attempts to understand these features, and
individual factors such as social cognitive determinants may
provide additional insight into hand hygiene
behaviour.724,767,788,789

18.1.1 Social cognitive variables

Over the last quarter of the 20th century, it was stated that
social behaviour could be best understood as a function of
peoples perceptions rather than as a function of real life
(objective facts, etc.).790 This assumption gave birth to several
models which were based on social cognitive variables and tried
to better understand human behaviour. The determinants that
shape behaviour are acquired through the socialization process
and, more importantly, are susceptible to change for which
reason they are the focus of behavioural models. In other areas
of health-care promotion, the application of social
cognitive models in intervention strategies has regularly resulted in
a change towards positive behaviour.790 Some of the so-called
social cognitive models applied to evaluate predictors of health
behaviour include: Health Belief Model (HBM); Health Locus of
Control (HLC); Protection Motivation Theory (PMT); Theory of
Planned Behaviour (TPB); and Self-efficacy Model (SEM). The
cognitive variables used in these models are:

1
2
3

knowledge;

outcome expectancy: an individuals expectation that a

given behaviour can counteract or increase a threat and
how one perceives the threat;

motivation;
intention: a persons readiness to behave in a given
way, which is considered to be the immediate
antecedent of behaviour;

perception of threat: based on the perceived risk/

susceptibility and the perceived severity of the
consequences;

perceived behavioural control (self-efficacy): the

perception that performance of a given behaviour is within
ones control;

subjective norm: beliefs about the expectations of an

important referent towards a given behaviour;790,791

behavioural norm: an individuals perception of the

behaviour of others;792 subjective and behavioural norms
represent the perceived social pressure towards a certain
behaviour.

18.1.2 Modelling human behaviour

Current models and theories that help to explain human
behaviour, particularly as they relate to health education, can be
classified on the basis of being directed at the individual

(intrapersonal), interpersonal,
or community levels. The
social cognitive models
mentioned above deal with
intrapersonal and
interpersonal determinants of
behaviour. Among the
community-level models, the
Theory of Ecological
Perspective (also referred to
as the Ecological Model of
Behavioural Change) can
successfully result in
behavioural change. This
theory is based on two key
ideas: (i) behaviour is viewed
as being affected by and
affecting multiple levels of
influence; and (ii) behaviour
both influences and is
influenced by the social
environment. Levels of
influence for health-related
behaviour and conditions
include intrapersonal
(individual), interpersonal,
institutional and community
factors.758

Intrapersonal factors are

individual characteristics
that influence behaviour
such as knowledge,
attitudes, beliefs and
personality traits.These
factors are contained in
social cognitive
determinants.790
Interpersonal factors include
interpersonal processes and
primary groups, i.e. family,
friends and peers, who
provide social identity,
support and role definition.
HCWs, like others in the
wider community, can be
influenced by or are
influential in their social
environments. Behaviour is
often influenced by peer
group pressure,688,732 which
indicates that responsibilities
for each HCWs individual
group should be clearly
recognized and defined.
Community factors are social
networks and norms that exist
either formally or informally
between individuals, groups
and organizations. For

example, in the hospital, the community level would be the

ward.758 Community-level models are frameworks for
understanding how social systems function and change, and how
communities and organizations can be activated.
The conceptual framework of community organization models is
based on social networks and support, focusing on the active
participation and development of communities that can help
evaluate and solve health problems. Lower hand hygiene rates in
non-nursing staff during ward-specific observations may, in part,
be the result of inconsistent influences from
the immediate social or community environment for those doctors,
student HCWs, and agency nursing staff who move in and out or
between subspecialities. Public policy factors include local
policies that regulate or support practices for disease prevention,
control and management. The role of local community-based

communication through wardbased liaison or link infection

control nurses should be
considered when attempting
to have HCWs adopt a core
infection control policy.

18.1.3 Application of social

sciences to the infection
control field
Few studies have applied
social sciences to assess
HCWs behaviour related to
85

infection control practices.

Seto identified three fields of
study in the behavioural
sciences with some degree
of relevance to the field of
infection control: social
psychology, organizational
behaviour and consumer
behaviour.788 By applying a
basic concept from each
field,

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Curry &
Cole796
applied the
Theory of
Ecological
Perspective
Seto and
and reported
colleagues their
demonstrat experience in
ed the
the medical
potential
and surgical
value of
ICUs in a
these
large teaching
theories to hospital
achieve
experiencing
staff
an increased
compliance patient
with
colonization
rate with
different
VRE. Their
infection
intervention
control
policies in consisted of a
multifaceted
the
758, approach to
hospital.
the problem,
788,793
considering
the five levels
So
of influence
cial
(individual,
cog
interpersonal,
niti
institutional,
ve
community,
mo
and
del
administrative
s
factors). They
hav
implemented
e
in-service
bee
education and
n
developed
app
references,
lied
policies, and
to
programmes
eva
directed at
luat
each of the
e
five levels of
HC
influence. The
Ws
Health Belief
cog
Model was
niti
employed for
ve
assessment
det
of beliefs and
er
intervention
min
design. The
ant
authors
s
observed a
tow
significant
ard
decrease in
s
the number of
han
patients with
d
active
hyg
surveillance
ien
cultures or
e

behaviour3

35,729,731,732,7
94,795

and
are
discussed
in the next
section
(Part I,
Section
18.2).

clinical
isolates
positive for
VRE within six
months in
both ICUs,
and the
benefit
seemed to
persist even

two years
later.

18.2
Behavioural
aspects of
hand
hygiene
The inability
over two
decades to
motivate HCW
compliance
with hand
cleansing722,738
suggests that
modifying
hand hygiene
behaviour is a
complex task.
Human healthrelated
behaviour is
the
consequence
of multiple
influences
from our
biology,
environment,
education, and
culture. While
these
influences are
usually
interdependent
, some have
more effect
than others;
when the
actions are
unwise, they
are usually the
result of tradeoffs with
acknowledged
or denied
consequences.
Thus, this
complexity of
individual,
institutional
and
community
factors must
be considered
and
investigated
when
designing
behavioural
interventions.7
20,724,732,789

Researc
h into
hand
hygiene
using
behavio
ural

theory
has
primar
ily
focuse
d on
the
individ
ual,
althou
gh this
may
be
insuffi
cient
to
effect
sustai
ned
chang
e.
OBoyl
e and
collea
gues7

unit was
significantly
and negatively
associated
with observed
adherence to
hand hygiene
recommentati
ons (r=-33). In
a neonatal
ICU, a
perceived
positive
opinion of a
senior staff
member
towards hand
hygiene and
the perception
of control over
hand hygiene
behaviour
were
independently
associated
29
with the
intention to
investi
perform hand
gated
hygiene
the
among
possib
le
HCWs.731
associ
Perceived
ation
behavioural
of
control and
cognitive
intention were
factors and significant
nursing unit predictors of
workload
hand hygiene
with hand behaviour in
hygiene
another
compliance, study.794
the first-ever
attempt
Focus
using a well- group
established data725
behavioural suggested
model. The that hand
three major hygiene
motivating patterns
factors were are likely
predictive of to be
firmly
intention,
and while establishe
d before
intention
the age of
related to
9 or 10
self-reported
estimates of
compliance,
the
relationship
was not
strong
(r=0.38).
Intention to
wash hands
did not
predict
observed
handwashin
g behaviour.
However,
the intensity
of activity of
the nursing

years,
probably
beginning at
the time of
toilet training.
They are
patterns of a
ritualized
behaviour
carried out to
be, in the
main, selfprotective
from
infection.
However, the
drivers to
practise hand
cleansing
both in the
community
and in the
health-care
setting are
not overtly
microbiologic
ally based
and appear
seriously
influenced by
the emotional
concepts of
dirtiness
and
cleanliness.
725,797
This
same
behaviour
pattern

has previously
been
recognized in
developing
countries,798
and Curtis &
Biran have
postulated
that the
emotion of
disgust in
humans is an
evolutionary
protective
response to
environmental
factors that
are perceived
to pose a risk
of infection.799
Yet in most
communities,
this motivation
results in
levels of hand
hygiene that
are, in
microbiologica
l terms,

suboptimal elective hand

hygiene
for ideal
protection.80 practice,
0,801

An
individuals
hand
hygiene
behaviour is
not
homogenou
s and can
be classified
into at least
two types of
practice.725
Inherent
hand
hygiene
practice,
which drives
the majority
of
community
and HCW
hand
hygiene
behaviour,
occurs when
hands are
visibly
soiled, sticky
or gritty.
Among
nurses, this
also
includes
occasions
when they
have
touched a
patient who
is regarded
as
unhygienic
either
through
appearance,
age or
demeanour,
or after
touching an
emotionally
dirty area
such as the
axillae, groin
or
genitals.725
This
inherent
practice
appears to
require
subsequent
handwashin
g with water
or with soap
and water.
The other
element to
hand
hygiene
behaviour,

represents
those
opportunities
for hand
cleansing not
encompassed
in the inherent
category. In
HCWs, this
component of
hand hygiene
behaviour
would include
touching a
patient such
as taking a
pulse or blood
pressure, or
having contact
with an
inanimate
object around
a patients
environment.
This type of
contact is
similar to
many common
social
interactions
such as
shaking
hands,
touching for
empathy, etc.
As such, it
does not
trigger an
intrinsic need
to cleanse
hands,
although it may
lead to hand
contamination
in the healthcare
environment
with the risk of
crosstransmission of
organisms. It
therefore
follows that it is
this component
of hand
hygiene which
is likely to be
omitted by
busy HCWs.
Compliance
with hand
cleansing
protocols is
most
frequently
investigated
in nurses, as
this group
represents
the majority

of HCWs in
hospitals and
the category
of HCWs with
the highest
number of
opportunities
for hand
hygiene.59,60,6
56
However, it
is also well
documented
that doctors
are usually
less
compliant
with practices
recommende
d for hand
hygiene than
are
other
HCWs.60,608,656
Yet these
clinicians are
possibly the
peer facilitators
of hand
hygiene
compliance for
nurses,725 with
different groups
acting as peer
facilitators for
other
HCWs.335,732
Behavioural
modelling725
suggests that
the major
influence on
nurses
handwashing
practices in
hospitals is the
translation

of their
community
attitudes into
the health-care
setting. Thus,
activities that
would lead to
inherent
community
handwashing
similarly induce
inherent
handwashing in
the health-care
setting. The
perceived
protective
nature of this
component of
hand hygiene
behaviour
means that it
will be carried
out whenever
nurses believe
that hands are
physically or
emotionally
soiled,

regardless of perceived
barriers, and behaviour of
will require peers and
washing with other influential
water. This social groups,
model
together with a
indicates that nurses own
other factors attitude
including
towards hand
86

hygiene, have
much less
effect on
inherent hand
hygiene
behavioural
intent.725

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

considered as
being relatively
easy to perform
is likely to be
elective hand
hygiene
opportunities.
Elective
Whether the
community
hand hygiene
opportunity the
behaviour has
HCW is
been shown to
presented with
have a major
impact on nurses is elective or
inherent, the
with regard to
their intention to primary
motivator to
undertake
undertake
elective init is selfhospital hand
725
cleansing. Other protection.
Therefore,
important
future cognitive
facilitators of
programmess
nurses electing
to practise hand aiming to
modify HCWs
hygiene are
hand hygiene
attitude and
behaviour
an expectation
should consider
of compliance
adjusting the
not by their
benefits to
nursing peers,
include selfbut by doctors
protection and
and
patient
7
administrators.
protection.
25
Nurses and
doctors were
The nursing
more likely to
behaviour
report high
model
levels of
predicts a
compliance if
positive
they believed
influence
that their own
by senior
peer group also
administrat
complied.732
ors and
Reduction in
doctors on
effort required
the hand
to undertake
hygiene
hand hygiene
compliance of
has no
nurses but,
influence on
surprisingly, there
inherent hand
was no influence
hygiene
by senior nurses
behaviour and
on junior nurses.
only minimal
Lankford and
impact on
colleagues802
elective hand
found that poor
hygiene
725
hand hygiene
intent. Yet,
practices in
the strongest
senior medical
predictor of
and nursing staff
self-reported
could provide a
compliance by
negative
nurses and
influence on
doctors who
others, while
had previously
Pittet and
been exposed
colleagues335
to hand
reported that
hygiene
campaigns was doctors
perception of
the belief that
being role models
the practice
to other
was relatively
colleagues had a
easy to
732
positive influence
perform.
on their
Hand hygiene
compliance,
behaviour

independent of
system
constraints and
hand hygiene
knowledge.
All influences in
the model for
nursing hand
hygiene
behaviour725 act
independently of
behavioural
intent. This
suggests that
the effective
component of
the Geneva
programme,60
which has
demonstrated
significantly
improved and
sustained hand
hygiene
compliance over
a period of
several
years.60,490 was
not only the
introduction of
an alcohol-based
handrub per se,
but were those
components of
the programme
that directly
promoted the
desired
behaviour: peer
support from
high-level
hospital
administrators
and clinicians789
and the
perception that
ones colleagues
adherence
behaviour was
good.732

Results of a
behaviour
modification at
an organizational
level further
support these
conclusions.
Larson and
colleagues713
described a
significant
increase in
handwashing
compliance in a
teaching hospital
sustained over a
14-month period.
The focus of this
behaviour-based
programme was
directed to
induce an
organizational

cultural change
towards optimal
handwashing
with senior
clinical and
administrative
18.2.1 Factors
staff overtly
supporting and influencing
behaviour
promoting the
intervention.
Patterns of
The dynamic of hand hygiene
behaviour are
behavioural
developed and
change is
complex and
established in
multifaceted.60,713, early life. As
725,789
It involves a most HCWs do
not begin their
combination of
education,
careers until
motivation, and their early
system change.789 twenties,
Wide
improving
dissemination of compliance
hand hygiene
means
guidelines alone is modifying a
not sufficient
behaviour
motivation for a pattern that has
change in hand
already been
hygiene
practised for
728
behaviour. With
decades and
our current
continues to be
knowledge, it
reinforced in
can be
community
suggested that
situations.
programmes to
improve hand
Self-protection:
hygiene
this is not invoked
compliance in
on a true
HCWs cannot
microbiological
rely solely on
awareness, but basis, but on
emotive
must take into
sensations
account the
major barriers to including feelings
of
altering an
individuals pre- unpleasantness,
discomfort, and
existing hand
disgust. These
hygiene
sensations are
behaviour.
not normally
associated with
the majority of
patient contacts
within the healthcare setting.
Thus, intrinsic
motivation to
cleanse hands
does not occur on
these occasions.

18.2.2 Potential
target areas for
improved
compliance
Education.
While HCWs
must be
schooled in
how, when
and why to
clean hands,
emphasis on

the derivation
of their

community and
occupational
hand hygiene
behaviour
patterns may
assist in altering
attitudes.
Motivation.
Influenced by
role modelling
and perceived
peer pressure
by senior
medical,
nursing, and
administrative
staff,
motivation
requires overt
and continuing
support
of hand hygiene
as an
institutional
priority by the
hospital
administration.78
9
This will, in
due course, act
positively at
both the
individual and
organizational
levels. Such
support must be
embedded in an
overall safety
climate directed
by a top-

level
management
committee, with
visible safety
programmes, an
acceptable level
of work stress, a
tolerant and
supportive
attitude towards
reported
problems, and a
belief in the
efficacy of
preventive
strategies.

Reinforcement of
appropriate hand
hygiene
behaviour
Cues to action
such
as
cartoons
and
even alcoholbased rub itself
appropriately
located at the
point of care
should continue

to be employed. of engaging the

public is
required before
Patient
empowerment.
its widespread
While involvement application will
of patients in hand result in
hygiene
acceptance.
programmes for
Possible
HCWs has been obstacles to be
demonstrated to be addressed
effective803-806 and include cultural
also incorporated in constraints, the
a national
barrier of patient
programme,807 one dependency on
campaign found
caregivers, and
less than a third of the lack of
patients and public applicability of
wanted to be
this tactic to
involved.808 Further ventilated,
study of the
unconscious
approach
and/or seriously
87

ill patients who

are often at most
risk of crossinfection.656
Furthermore,
whether patients
reminding
HCWs that they
have to clean
their hands
before care
would interfere
with the patient
caregiver
relationship
remains to be
properly
assessed in
different
sociocultural and
care situations.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

hand hygiene
will require that
a decision be
made, at least
at the
organizational
level as for
System
many social
change
behaviours, as
to whether
Structural. these other
As
promotional
successful facets of hand
behavioural hygiene are
hand
then supported
hygiene
by law or
promotion
marketing.
programme Rewards and/or
s induce
sanctions for
increased
acceptable or
compliance, unacceptable
the
behaviour may
convenienc prove
e and time- necessary and
saving
effective in both
effects of
the short and
cosmetically long term,
acceptable given both the
alcoholduration of prebased
existing hand
handrubs
hygiene
will prove of behaviour
further
inappropriate to
benefit.
the health-care
However,
setting and its
inherent
continued
hand
reinforcement
hygiene
in
behaviour
the community.
will always This approach
persist and has been
will continue successfully
to
applied in many
requi
countries to
re
other public
hand
health issues
wash
such as
ing
smoking and
with
driving under
water
the influence of
and
alcohol, but
soap;
further studies
are necessary
henc
to assess its
e,
application to
the
hand hygiene
acce
promotion.
ssibili
Alternatively,
ty of
the philosophy
sinks
of marketing
must
may be
still
considered;
be
such an
caref
approach takes
ully
particular
consi
consideration of
dere
self-interest,
d.
which may be
extremely
Philosophical
pertinent given
. Heightened
that selfinstitutional
protection
priority for
continues to be

the primary
motivational
force behind all
hand hygiene
practice. The
value of active
participation at
the institutional
level and its
impact on
HCWs
compliance
with hand
hygiene have
been
demonstrated
in several
studies.60,651,713

Patterns of
hand hygiene
both in the
community
and in health
care
represent a
complex,
socially
entrenched
and ritualistic
behaviour. It
is thus not
surprising
that single
interventions
have failed to
induce a
sustained
improvement
in HCW
behaviour.
Multi-level,
multimodal
and
multidisciplina
ry strategies,
responding to
these
behavioural
determinants,
would seem
to hold most
promise.59,60,6
84,789

occupational
groups and in
varying ethnic
and
professional
groups is
18.2.3
essential to
Research ensure that
implementatithese findings
on
are constant
and the
Confirmation
implications
of
that flow from
behavioural
them are
determinant
universally
s of hand
relevant.
hygiene in
all other
The impact in
health-care

practice of
each
behavioural
factor
influencing
hand hygiene
must be
carefully
measured and
considered, so
as to design
cost-effective
motivational
programmes
suitable for
both high- and
low-resource
health-care
settings.

8
8

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

19.
Organizing an educational programme to
promote hand hygiene
Education of HCWs is an inherent component of the work of the infection control team. Through education, the
infection control team can influence inappropriate patient-care practices and induce improved ones. Traditionally, a
formal education programme is relied on to introduce new infection control policies successfully in health
care. It is now recognized that for hand hygiene, however, education alone may not be sufficient. There are also
reports that a unique teaching session is unlikely to be successful and, even after positive change is noted, it
might not be maintained.705,809 HCWs attitudes and compliance with hand hygiene are extremely complex and
multifactorial,738,750,789,810,811 and studies indicate that a successful programme would have to be multidisciplinary
and multifaceted.684,701,750,767
This offers a distinct
Education is important and critical for success and represents one advantage because studies
of the cornerstones for improvement of hand hygiene practices. 812 have shown that guidelines
are in themselves an
It is therefore an essential component of the WHO multimodal
effective means of
Hand Hygiene Improvement Strategy together with other
influencing behaviour
elements, in particular, the building of a strong and genuine
regarding infection control.832
institutional safety culture which is inherently linked
to education. The reasons why education is important can be However, the wide
dissemination of guidelines
summarized as follows.
alone is insufficient to
change clinical practice.728 It
Successful hand hygiene programmes reported in the literature
inevitably have an educational component.60,651,676,684,813,814 They are is important to realize that
not all consistently successful and their impact is not always
HCWs compliance can be
sustainable. Some811 appear to have only a short-term influence,
extremely low when
666,705,740,809
particularly the one-time educational interventions.
It is
guidelines are simply
important to emphasize that educational programmes alone are
inadequate for long-lasting improvement, and other behaviourcirculated down the hospital
modifying strategies must be included in a multifaceted approach in hierarchy: research indicates
that the compliance rate can
order to achieve change.657,684,701,750,767,809,815,816
be as low as 20%.793 When
There is also clear evidence that adequate physical facilities
monitored, compliance with
for hand cleansing could affect the success of the programme MRSA precautions was only
itself and must certainly be in place.335,810,817 However, these
28% in a teaching hospital833;
considerations do not negate the critical role of the formal
compliance was as low as
education programme for achieving better adherence to hand 8% during
hygiene.
the evening shift and 3%
during the night shift. The
Surveys and studies on HCWs have shown that valid
success of the implementation
information and knowledge about hand hygiene do influence
process depends on the
good practices.335,814,818-820 This is consistent with the finding
effectiveness of the education
that informational power is the most influential social power
programme, and careful
in infection control.821 An educational programme providing
planning is essential.

accurate and pertinent facts is therefore indispensable for

success.
Educational programmes have been reported as an essential
ingredient for success in other infection control strategies,
including the control of ventilator-associated pneumonia822-825
reducing needlestick injuries,826 and the implementation of
isolation precautions.423,827 There are also reports on the
effective use of education for hand hygiene promotion
strategies outside the acute hospital care setting.449,828-830 It is
important, therefore, to continue to use the formal education
programme as one feature of the implementation strategy for
hand hygiene improvement in health care.
It is noteworthy that robust hand hygiene guidelines are now
available for infection control teams around the world. 58,831

If a formal education
programme is organized to
introduce the guidelines, the
effects would be more
assured, especially when
there is firm administrative
support.728 The programme
must
be well designed701 and the
use of a prepackaged
educational toolkit will aid
uptake.1,834,835 The WHO
Implementation Toolkit
(available at
http://www.who.int/gpsc/en/)
offers a blueprint for
practitioners interested in
hand hygiene
improvement.836

In this section, guidance is

given on the planning
process of the education
programme, together with
a guideline review scheme
that could help in
developing an effective
strategy for
implementation.

19.1 Process for

developing an
educational
programme
when
implementing
guidelines
It is important that all
audiences are
considered when
developing and
implementing
educational
programmes. Inclusion
of the elements
suggested in this
section should be
promoted in all
settings, including in
undergraduate
programmes.
Prerequisite conditions:
submitting a customized
guideline according to
updated knowledge; local
resources and goals for
endorsement; and
instructions for
implementation.
1. Customize the
recommendations to meet
the requirements of the
health-care facility. The
central part of this scheme
is a method for reviewing
guidelines before
implementation.837,838

Following this review, the infection control team will obtain

essential information for the formulation of the education

programme (Figure I.19.1).

An infection control
89

guideline

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

consists
generally of
a list of
recommend
ations on
appropriate
patient-care
practices.
In the
education
programme
, instead of
covering all
the
recommend
ations in a
similar
fashion for
all
categories
of HCWs, a
better
strategy is
to focus on
patient-care
practices
that require
adaptations
,
particularly
those

that would
meet
resistance
from
HCWs. The
review
scheme
seeks to
anticipate
the
educational
needs so
that the
infection
control
team can
plan
accordingly.
This might
highlight
some of the
recommend
ations that
are deemed
to be
critically
important
for success
or, on the
other hand,
choose to
exclude
recommend
ations that
are not

relevant for
the institution.
The
document
should
provide
specific
information
such as the
actual person
to contact for
queries and
the precise
location of the
supply of
hand
antisepsis
products. A
final draft of
the guideline
will often
require
endorsement
for
implementatio
n from the
management
of the
institution or
from the
infection
control
committee.
Importantly,
institutional
experts need
to be
knowledgeabl
e about
evidencebased
information
regarding
hand
hygiene.
2. Categorize
all
recommenda
tions into the
four types of
practice
described
below in
Section
19.1.1. This
task should
be performed
with the help
of a panel of
experienced
HCWs in the
institution. It
is
recommende
d that a
senior
infection
control
professional
in the
hospital
conducts the

initial
review.837
Other senior
nurses in the
institution
should also
be coopted
for this
exercise.
Using this
scheme,
studies have
shown that
front-line
senior nurses
in the hospital
are accurate
in predicting
actual
practices on
the wards. A
survey
comparing
their
predictions
with practices
reported on
the wards
showed a
significant
correlation.837

(1) work with

the
institution
to provide
the
necessary
resources
for nonestablishe
d
practices
detailed in
the
recomme
ndations
(lack of
resources
). The
infection
control
team must
ensure
that these
resources
are
actually
available
for the
wards
when the
guideline
is
introduced
.

(2)identif
y
reason
s for
HCW
resista

nce
to
nonesta
blis
hed
prac
tice
(HC
W
resi
stan
ce).
The
easi
est
met
hod
will
be
to
conv
ene
a
focu
s
grou
p
cons
istin
g of
HC
Ws
from
the
relevan
t
wards.
Discus
sions
can be
followe
d, if
necess
ary, by
a
simple
survey
of the
key
issues
identifi
ed by
the
focus
group.
It is
also
worth
while to
gather
informa
tion on
the
determi
nants
of good
adhere
nce to
hand
hygien
e so
that

these
points
can be
emphasiz
ed in the
education
al
program
me. A
good
example
of such
research
is
reported
by Sax
and
colleague
s.732

3. Measure
baseline rates
before the
introduction of
the new
guideline. The
infection rate
may be
included, but
by itself it may
be difficult to
document
improvement
because large
numbers are
usually
needed. Other
structural,
process or
outcome
indicators may
be measured,
and it is also
pragmatic to
obtain the
compliance
rate or
evidence of
behavioural
change. This
involves
assessing the
level of several
key practices
before
introduction of
the guideline,
e.g.
observations
for hand
hygiene
compliance
rates before
and after
patient contact,
or the amount
of antisepsis
product used in
the institution.
4. Formulate
and execute

an
educational
programme
focusing on
the resistance
factors of
nonestablished
practice
(HCW
resistance).
Presenting a
standardized
technique for
hand hygiene
such as the
five
moments will
be an
advantage.1

Many
techniques7
88,839
for
persuasion,
such as the
use of
opinion
leaders758
and
participatory
decisionmaking
have been
described,
and
successful
application
in the
health-care
facility
context has
been
reported.788,
839
The use
of these
persuasion
intervention
s could be
timeconsuming
and should
be reserved
only for
programme
s requiring
attitude
change, i.e.
the nonestablished
practice
(HCW
resistance)
recommend
ations.

nt in the
institutio
n or is
already
standard
practice.
An
example
is the
washing
of hands
that are
visibly
dirty or
contami
nated
with
proteina
ceous
material,
or are
visibly
soiled
with
blood or
other
body
fluids.
Even
without
an
official
guidelin
e for
hand
hygiene,
many
healthcare
facilities
will
usually
already
have
such a
practice
in place.

(2) No
19.1.1
Categorizati
on of
recommend
ations in
the
guidelines
in order to
identify
educational
needs

(1) Establ
ished
practi
ce. A
policy
for the
practic
e is
alread
y
prese

nest
abl
ish
ed
pra
cti
ce
(ea
sy
im
ple
me
nta
tio
n).
It is
ex
pe
cte
d
tha
t
HC

Ws
wo
uld
agr
ee
wit
h
the
rati
on
ale
of
the
rec
om
me
nd
atio
n
an
d
als
o
tha
t
res
our
ces
for
impleme
ntation, if
needed,
are
already
in place.
Therefor
e, the
practice
should
be easily
impleme
nted by
the usual
educatio
nal
program
me of inservice
lectures
or
posters.
An
example
is hand
antisepsi
s before
inserting
peripher
al
vascular
catheter
s or
other
invasive
devices,
as most
HCWs
will not
object to
such a
reasona
ble
practice.
Azjen &

Fishbe
in
have
shown
that,
under
such
circum
stance
s,

the
desire
d
behavi
our will
often
follow
the
intent.
840

Studie
s have
shown
that
where
there
is
agree
ment
for a
patient
-care
practic
e, a
standa
rd
educat
ional
progra
mme
of
lecture
s or
poster
s will
be
effecti
ve.793

(3) Nonesta
blish
ed
pract
ice
(diffi
cult
impl
eme
ntati
on:
lack
of
reso
urce
s).
For
this
categ
ory, it
is
antici
pate
d

that
implem
entatio
n would
be
difficult
mainly
becaus
e of the
lack of
resourc
es. An
exampl
e is the
need to
provide
a
sufficie
nt
supply
of
alcohol
-based
handru
b for
use in
areas
of high
workloa
d and
highintensit
y
patient
care so
that it is
availabl
e at the
entranc
e to the
patient
s room
or at
the
bedsid
e and
other
conveni
ent
location
s. A list
of

such
resource
s should
be
compile
d for the
new
guidelin
e, and
the
infection
control
team
must
ensure
that
these
material
s are in
place
before

launchin
g the
impleme
ntation
program
me.

(4) Nonestablishe
d practice
(difficult
implement
ation:
HCW
resistance)
.
Implement
ation is
difficult in
this
category
because
HCW
resistance
is
expected
to be high.
An
example is
the
recommen
dation for
hand
antisepsis
after glove
removal as
many
HCWs
may
consider
their hands
to be
clean,
having
been
protected
by the
wearing of
gloves.
The
successful
implement
ation of the
new
guideline
usually
hinges on
this
category of
nonestablishe
d practices
(HCW
resistance)
.
Disagreem
ent from
HCWs is
anticipated
, and a
programm
e of
persuasion

is
needed
to
institute
the
required
change.
It will be
worth
while for
the
infection
control
team to

understan
d the
reasons
for
resistanc
e, and
both
quantitati
ve and
qualitative
studies
may be
required
to elicit
90

these
factors.
Special
studies or
surveys
may be
carried
out on the
various
barriers to
hand
hygiene
that have
been

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

does not always

fall naturally within
the care flow.
Ideally, hand
hygiene should be
an automated
behaviour that the
identified in HCW is able to
the
analyse and
literature.
adjust according
After
to each specific
understandi care situation.

ng the
reasons for
resistance,
a special
behavioural
change
strategy
might also
be adopted
to
implement
these
practices788,
839
(see Part
I, Sections
18 and 20).

An optimal
training
programme
must be
tailored to the
target
audience, its
skills, and
requisite
capacities. It
should focus
on different
objectives
covering the
three learning
domains
known as
19.2
Blooms
Organization of taxonomy842
a training
affective,
programme
psychomotor,
cognitive
An educational
which are
programme is
designed to
intended to raise facilitate
awareness, build learning,
knowledge, and training,
help to remind
and evaluation.
about critical
As part of a
issues and ways promotional
of focusing on
project, training
them. A
should include
promotional
not only
programme
educational
should include a content (Table
specific training I.19.1), but also
programme if the strategies for
aim is the
promoting,
development of teaching,
core
practising, and
competencies (i.e. assessing
a system of
practice
conceptual and performance.
procedural
Teaching and
knowledge
training
allowing the
strategies should
identification and aim at
the efficient
progressive
resolution of a
educational
problem).841
objectives and
Although HCWs preferably
are expected to facilitate different
perform hand
ways of learning;
hygiene,
lessons learnt
theoretically a
should
very simple act, be used to
the contextual
strengthen and
sequence of care sustain
is often complex, awareness and
and hand hygiene practice

improvement. The
training
programme
should reach out
to each individual
in the target
audience and
include refresher
sessions to
update
knowledge. A
variety of
educational
methods should
be used. Among
these, the proven
instructional
effectiveness
of five pedagogic
methods can be
identified: 1)
presentation of
the topic by a
traditional lecture
accompanied by
one or several
other methods
(e.g. interactive
whiteboards,
mind mapping,
video); 2)
demonstration:
the trainer shows
how to perform
a certain
procedure,
assists the
trainee in its
performance,
and asks the
trainee to
explain the
procedure; 3)
interaction:
based on
his/her
expected
background
(knowledge,
acquired
mastery of a given
topic), the trainee
establishes links
and builds
knowledge
starting from a
specific question;
4) discovery: a
problem-solving
approach where
the trainee is
asked to find
the information
needed to solve
the problem,
but without any
previous lecture
on the topic;
and 5)
experiment: the
trainee is
stimulated to
evaluate his/her

personal
experience in
practical
situations and
learn from
these. The
more the
methods

required, which
may preclude the
use of e-learning
are integrated
into the training in resource-poor
843,844
To
programme, the facilities.
conceive
and
more the
programme will construct an elearning module
relate to each
is a very timetrainee, respond
consuming task
to various needs,
requiring specific
and help to build
competences by
the competence
the trainer.845
required.
However, this
form of distance
Although
learning
training
ultimately
sessions
reduces the time
usually require
and energy
the systematic
investment
presence of
by the teacher
both the
and is very
trainer and the
advantageous
trainee, some
for easily
new
monitoring the
perspectives
learning
are offered by
process844.
e-learning, i.e.
Successful elearning where
learning
the medium of
programmes in
instruction is
medical and
computer
care domains
technology. Ehave recently
learning offers
been
considerable
described,845,846
flexibility in
with one used in
time, space,
association with
and selection
traditional
of
training
curricula and
(blendedcontent which
learning). In
may be
building a
particularly
curriculum, it is
useful if a large recommended
HCW population to consider ehas to be
learning as a
trained.843 Basic pedagogic
approach
computer skills
and easy access including
instruction,
to a personal
social
computer and
the Internet are construction,
and cognitive,
emotional and
behavioural
perspectives,
also
encompassing
the contextual
perspective by
facilitating
interaction with
other people. Elearning should
be a strategy
that
complements
the classic
teaching

methods and
remains
associated to
them.

The focus group

technique is well
adapted to the
subject of hand
hygiene. It
considers the
complexity of an
expected
behaviour,
depending on
several multiinfluenced
aspects (such as
perception,
attitude, beliefs)
independent of
the existing
knowledge
before
developing a
training
intervention. The
qualitative
research of
focus groups
may help in
tailoring the
training aimed at
improving hand
hygiene.684,731,847
Visual
demonstration of
the effectiveness
of hand hygiene
with the fingerprint
imprint method72
or the use of a
fluorescent dye814
during practical
sessions seems to
have a strong
impact on
persuading HCWs
of the importance
of hand hygiene.
In many studies,
promoting hand
hygiene through
a multimodal
strategy
including
feedback of local
data on HCAI
and hand
hygiene
practices was an
essential
element of
educational
sessions and
constituted the
basis for
motivating staff
to improve their
performance.60,49
4,657,663,714,716

To facilitate the
process of
starting the
project and its
following
implementation
activities.705,820,8
34
, it is very
important to
ensure that
training
sessions are
accompanied
and supported
by educational
material such as
a guideline
summary,
leaflets,
brochures,
information
sheets, and
flipcharts.

activities. The
WHO
Implementation
Toolkit includes
an extensive
range of tools
for education,
including a slide
presentation; a
brochure
summarizing
why, when, and

how to perform
hand hygiene; a
leaflet containing
the core
recommendation
s of the
guidelines; a
practical pocket
leaflet; and a
training film. All
these
educational tools
are centred on
The present
the concepts of
WHO guidelines
the Five
are
moments for
accompanied by
hand hygiene
educational
and the correct
material to
technique to
convey the key
perform hand
recommendatio
hygiene; they
ns and support
are intended to
training
be used as a

basis for training

the trainers,
observers and
HCWs, following
local adaptation
if required.
Figure I.19.1
shows the
different
educational
methods that
can be used for
each category of
recommendation
s.

19.3 The
infection control
link health-care
worker
Research has
indicated that the
effect of a formal
education
programme for
infection control
would be
significantly
improved when
front-line ward
HCWs have been
recruited to
participate in

91
WHO GUIDELINES ON HAND
HYGIENE IN HEALTH CARE

the education programme

for the guideline.758,848
The infection control link
HCW programme is an
attempt to apply this
principle in practice and
has been widely used to
assist in the
implementation of
guidelines in health-care
facilities.849
In the infection control link
HCW programme, a
senior member of staff is
appointed from each
hospital ward from the
pool
of HCW staff presently
working in that clinical
area. She or he
becomes the ward or
department
representative assisting
the infection control
team in implementing
new policies
in the institution. The
position of the

infection control link

HCW is generally a
voluntary assignment
without monetary

remuneration, and the

HCW is under no
obligation to accept the
appointment. Special
training must be provided
for the infection control
link HCW so that she or
he can be the person on
the spot to enhance
compliance with
guidelines.
The infection control link
HCW could be enlisted to
participate in the
educational programme of
the hand hygiene guideline,
and could help to identify
the reasons for resistance
to the non-established
practice (HCW resistance)
recommendations. An initial
educational session should
be organized for the
infection control link HCWs
before the launch of the
formal programme for the
entire institution. They
could then begin preparing
their wards for better
acceptance of the
guideline. Subsequently, in
the institutionwide, formal

educational programme,
they could also be present
to assist in providing
comments and answering
questions, especially for
HCWs who are from their
clinical areas.
Other innovative methods
should also be explored.
For instance, a recent
paper reported that the
use of an electronic voice
prompt is effective in
enhancing practice.699
Social marketing has also
been proposed as a
possible new approach to
enhance compliance in
infection control, and
perhaps it
may be applicable for the
implementation of the
hand hygiene
programme850 (see Part
I, Section 20.3). Indeed,
adherence to guidelines
is critical for the success
of the entire field

of infection prevention
and control, and not only
for hand hygiene.
Therefore, organizing an
effective formal
educational programme
requires considerable
time and effort, but it
remains essential to
effect changes in staff
behaviour.

Table I.19.1
Contents of
educational
and training
programme
for healthcare workers

Global burden of health

care-associated
infections

Global
Patient
Safety Challenge

Morbidity, mortality,
and costs associated
with HCAIs

Transmission of
pathogens

Routes
transmission

of

Consequences
for the patient and the
HCW (colonization and
infections)

Strategy to prevent the

transmission of
pathogens

Standard
precautions

Hand hygiene

Care-associated
precautions

Indications for hand

hygiene

Concept of healthcare area and patient

zone

My five moments
for hand hygiene

3
Ha
n
d
h
y
gi
e
n
e
a
g
e
n
ts
a
n
d
p
r

o
c
e
d
u
r
e
s
:
C
a
r
e
o
f
h
a
n
d
s
Glove use

Figure I.19.1
Scheme for
effective
education
approaches
and
implementa
tion of a
new
guideline

New guidelines

Non-established
practices

Implementation
methods

Established
practices

Easy
Implementation

Announcement
and
communication
Used education
programme
e.g. lectures and
posters

Difficult
implementation
lack of resources

Provide
resources

Difficult
implementation
HCW resistance

Special
persuasion and
behavioural
change strategy

92

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

20.
Formulating strategies for hand hygiene
promotion
Audits of hand hygiene
practices (see also Part III,
Section 1.1) and
Targets for the promotion of hand hygiene are derived from studies performance feedback
assessing risk factors for non-adherence, reported reasons for the have comprised several
multifaceted promotion
lack of adherence to recommendations, and additional factors
perceived as important to facilitate appropriate HCW behaviour (see campaigns and are valued
as one of
also Part I, Section 16.3). Although some factors cannot be

20.1 Elements of promotion strategies

modified (Table I.20.1), others are definitely amenable to change.

Based on the studies and successful experiences in some
institutions described below, it appears that strategies to improve
adherence to hand hygiene practices should be multimodal and
multidisciplinary.
The last 20 years have shown an increasing interest in the
subject and many intervention studies aimed at identifying
effective strategies to promote hand hygiene have been
connducted.60,217,334,429,485,486,613,648,651,663,666,667,670,680,682,684,686,687,713,
714,803,804,851,852

Recent studies have further enriched the scientific

literature.140,428,493,494,655,657,694,698,699,701,705,707-710,715-718,728,853 In general,

most studies differed greatly in their duration and intervention

approach. Moreover, the outcome measure of hand hygiene
compliance varied in terms of the definition of a hand hygiene
opportunity and assessment of hand hygiene by means of direct
observation60,217,334,485,486,494,572,613,645,651,657,663,666,667,670,680,682,686,687,701,
716

or consumption of hand hygiene products, 60,334,429,486,494,71

making comparison difficult, if not impossible.
Despite different methodologies, most interventions have been
associated with an increase in hand hygiene compliance,
but a sustainable improvement demonstrated by a follow-up
evaluation of two years or more after implementation
3,717,718,803,804,851

has rarely been documented.60,490,494,657,714,715,717,718 Most

studies used multiple strategies, which included: HCWs

education,60,140,334,429,485,486,613,651,663,666,667,670,676,682,684,686,687,698,705,707,708,
713,716,717,813,814,819,834,851 performance feedback,60,334,485,486,651,657,663,666,

the most effective

strategies.60,334,651,657,665,676,684,686,687,715
,716,738,858

Two studies have reported a

very positive impact on hand
hygiene attributable to feedback
performance.666,676 Conversely,
these results should be viewed
with caution. In one study,666

no statistical evaluation is
provided and the very low
number of observed
opportunities during the
three surveys precludes
further conclusions.
Tibballs and colleagues676
showed an extraordinary
improvement after
feedback of hand hygiene
practices. One of the
caveats in this study is that
baseline compliance was
obtained by covert
observation and the
subsequent survey was
overtly performed, which
might have favoured better
results.335

reminders,60,140,334,429,485,494,651,663,666,
use of automated 429,485,486,494,645,651,682,686,
sinks, and/or

The change in system

from the timeintroduction of an alcohol-based handrub.
consuming
Similarly, these elements are the
687,694,698,701,707,717,718,851,854-856
handwashing practice
most frequently represented in the
to handrub with an
national campaigns recently initiated in many countries
alcohol-based
worldwide.857
preparation has
revolutionized hand
Lack of knowledge of guidelines for hand hygiene combined
hygiene practices, and
with an unawareness of hand hygiene indications during
is now considered the
daily patient care and the potential risks of transmission of
standard of care.58
microorganisms to patients constitute barriers to hand hygiene
Several studies show a
compliance. Lack of awareness of the very low average adherence significant increase in
rate to hand hygiene of most HCWs and lack of knowledge about hand hygiene
the appropriateness, efficacy and use of hand hygiene and skin
compliance after the
care protection agents determine poor hand hygiene
introduction of handrub
performance.738 To overcome these barriers, education is one of
60,140,334,428,429,485,486,494,613,645,
solutions.
682,686,687,698,701,707,717,718,855
the cornerstones of improvement in hand hygiene
667,670,676,680,682,684,686,687,713,715,716
667,680,682,686,687,694,698,701,717,847

practices.58,60,140,334,429,485,486,613,648,651,663,666,667,670,676,682,684,686,687,698,705,
707,708,713-717,750,813,814,819,834,851

However, lack of knowledge of

infection control measures has been repeatedly shown after

training.789

Of note, handrub promotion

with an alcohol-based
preparation only started to be
tested in intervention studies
during the
late 1990s. In most of these

studies, baseline hand hygiene

compliance was below 50%,
and the introduction of
handrubs was associated with
a significant improvement in
hand hygiene compliance. In
contrast, in the two studies
with baseline compliance
equal to or higher than
60%,613,682 no significant
increase was observed. These
findings may suggest that high
profile settings may require
more specifically targeted
strategies to achieve further
improvement.

Most studies conducted to

test the effectiveness of hand
hygiene promotion strategies
were multimodal and used a
quasi-experimental design,
and all but one713 used
internal comparison.
Consequently, the relative
efficacy of each of these
components remains to be
evaluated.
HCWs necessarily evolve
within a group, which functions
within an institution. It appears
that possible targets for
improvement in hand hygiene
behaviour not only include
factors linked to the individual,
but also those related to the
group and the institution as a
whole.494,715,724,738,789 Examples
of possible targets for hand
hygiene promotion at the
group level include education
and performance feedback on
hand hygiene adherence,
efforts to prevent high
workloads (i.e. downsizing and
understaffing), and
encouragement and role
modelling from key HCWs in
the unit. At the institutional
level, targets for improvement
are the lack of written
guidelines, available or
suitable hand hygiene agents,
skin care promotion/agents or
hand hygiene facilities, lack of
culture or tradition of
adherence, and the lack of
administrative leadership,
sanctions, rewards or support.
Enhancing individual and
institutional attitudes regarding
the feasibility of making

93

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

when alcoholbased handrub

is not
available.182,185
,656,859
A
change in the
recommended
changes
hand hygiene
(selfagent could be
efficacy),
deleterious,
obtaining
however, if
active
introduced
participation during winter
at both
in the northern
levels, and hemisphere at
promoting a time of
an
higher hand
institutional skin irritability
safety
and, in
climate all particular, if

represent not
major
accompa
challenges nied by
that go well skin care
beyond the promotio
current
n and
perception availabilit
y of
of the
protective
infection
cream or
control
professional lotion.
s usual
More research
role.
is needed on
Table I.20.1 whether
increased
reviews
education,
published
strategies for individual
reinforcement
the
promotion of technique,
hand hygieneappropriate
in hospitals rewarding,
and indicates administrative
sanction,
whether
these require enhanced selfeducation, participation,
motivation or active
involvement of
system
a larger
change.
Some of the number of
organizational
strategies
leaders,
may be
unnecessary enhanced
perception of
in certain
circumstance health threat,
s, but may beself-efficacy,
and perceived
helpful in
social
others. In
pressure,720,724,
particular,
751,789,860
or
changing the
hand hygienecombinations
agent could of these factors
be beneficial would improve
HCWs
in
institutions adherence to
or hospital hand hygiene.
wards with a Ultimately,
adherence to
high
recommended
workload
and a high hand hygiene
demand for practices
hand
should become
hygiene
part of a culture

of patient
safety where a
set

of
interdepen
dent
elements
of quality
interact to
achieve
the shared
objective.8
61,862

It is
important to
note,
however, that
the
strategies
proposed in
Table I.20.1
reflect
studies
conducted
mainly in
developed
countries.
Whether
their results
can be
generalized
to different
backgrounds
for
implementati
on purposes
still needs
further
research.

2
0
.
2
D
e
v
e
l
o
p
i
n
g
a
s
t
r
a
t
e
g
y
f
o
r

864-867

g
u
i
d
e
l
i
n
e
i
m
p
l
e
m
e
n
t
a
t
i
o
n
Most
guidelines,
including
the present
document,
contain a
relatively
large
number of
recommend
ations that
vary in their
degree of
supporting
evidence
and
importance
in
preventing
infection.
Moreover,
some
recommend
ations focus
on
interrupting
the
transmissio
n of
pathogens
from patient
to patient,
while others
focus on
preventing
contaminati
on of
intravenous
catheters
and other
devices with
the patients
own
microbial
flora.
Because of
the

complexity
and scope of
these
recommendati
ons,
prioritization is
critical to
achieve rapid
improvement.
These
strategic
priorities
should guide
education and
guideline
implementatio
n.
The first step
is to choose
the specific
recommend
ations that
are most
likely to
result in
fundamental
change if
practised
reliably (in
other words,
performed
correctly
almost all
the time).
Consideratio
n should be
given to the
specific site
and
complexity of
local healthcare delivery,
as well as
the cultural
norms that
are in play.
These
guidelines
provide
recommenda
tions on a
package (socalled
bundle) of
interventions
that are most
likely to have
the largest
impact on
preventing
infection in a
wide variety
of healthcare delivery

settings.
These
recommendati
ons balance
formal
evidence with
consensus
regarding
each specific
intervention.
The second
step is to
perform an
assessment
(see also Part
III, Section 1)
to determine
whether these
practices are
indeed being
performed.
This
assessment
need not be
exhaustive.
Sampling
strategies
should be
employed. For
example, was
hand hygiene
practised after
the next 10
patient
contacts in the
dispensary or
ward when
monitored one
day a week
over a onemonth period?
What
percentage of
bedsides had
a filled,
operative
alcohol
dispenser
present at
07:00 on one
day, 12:00 on
another day,
and 18:00 on
a third? For
each
recommended
high-priority
intervention,
determine
whether:

the
practice is
being
performed
rarely, or
not at all;

the
practic
e is
being
perfor
med,
but
not
reliabl
y (for
examp
le,
hand
hygien
e is
perfor
med
on
leavin
ga
patient
s
bedsid
e less
than
90%
of the
time);

Simple
continui
ng
educatio
n and
reinforce
ment
together
with
monitori
ng to
ensure
that

performance
has not
deteriorated
should suffice.
For practices
that are not
being
performed at
all, or should
be performed
more reliably,
consider
answers to the
following
questions in
deciding how
3 the
to prioritize
practice and focus
is well education and
establis improvement
hed and work:
is
perform
1 Do we
ed
agree,
reliably
and can
(for
we
exampl
convince
e,
at
others,
least
that the
90% of
practice
the
really is
time).
important
and is
Clearl
supported
y, if a
by
practic
sufficient
e is
evidence
being
or
perfor
consensu
med
s?
reliabl
y, it is
not
neces
sary
to
have
a
major
educa
tion
camp
aign
or
quality
impro
veme
nt
interv
ention
.

Is
impleme
ntation
likely to
be easy
and
timely
(e.g. will
HCWs
resist,
are there
key
opinion
leaders
who will
object,
will a
long
period of
culture

change
be
required)
?

Do we
have the
resource
s to
impleme
nt the
practice
now,
and if
not, are
we likely
to obtain
the
resource
s (e.g. a
reliable
supply
of
alcohol
at a
price we
can
afford)?

Is
chang
e
within
our
own
power
, and
if not,
what
would
be
requir
ed to
be
succe
ssful
(e.g.
will
succe
ss
requir
ea

change
in policy
by
the
governm
ent,
or
the
develop
ment of a
reliable,
highquality
source
for
required
materials
)?
If possible, try
to implement
the high
priority
practices as a
bundle,

emphasizin
g that the
greatest
impact can
be
expected if
all of the
practices
are
performed
reliably.
Experience

has
demonstr
ated that
this
bundled
approach
catalyses
breakthro
ugh
levels of
improvem
ent and
fundame
ntal
change in
attitude
and
practice
in
infection
control
(see, for
example,
the 5

Million
Lives
campaign
at
www.ihi.org
).863
Educational
programme
s are easier
to design
and digest
if they have
a coherent
theme and
emphasize
a limited
number of
critical
points. In
addition,
competenc
y checks
and
compliance
monitoring
are
simplified.
The
Register
ed
Nurses
Associati
on of
Ontario
(RNAO)

has
produced
a series
of
recomme
ndations
for
successf
ul
impleme
ntation
based on
four
publishe
d
systemati
c

reviews; a
summary is
presented in
Table I.20.2.
The
RNAO
goes on to
suggest
that
considerati
on of the
different
needs and
state of
readiness
of each
target
group
should

94

to adoption and
sustainability.

be assessed early in
the planning stages,
citing for example,
that implementation
approaches for
doctors and nurses
may require different
methods.
Acknowledging the
context and culture
into which a
guideline will be
implemented is
important in attaining
stickiness (i.e.
capacity to stick in
the minds of the
target public and
influence its future
behaviour) and
assuring successful
implementation,868,86
9
Curran and
colleagues870
reinforce this, by
suggesting that local
participation and
contextualization of
implementation
interventions is key

The WHO Multimodal

Hand Hygiene
Improvement Strategy
and tools for
implementation are
detailed in Part I,
Section 21.

20.3
Marketing
technolog
y for
hand
hygiene
promotio
n
In the commercial
world, marketing
appears to be an
efficient and essential
technology, judging
by the amount of
expenditure
dedicated to it. Even
if a strange idea at
first, looking at hand
hygiene promotion
through a marketers
eyes could help
to overcome the dead
end of a more
traditional, moralistic

approach. It would be
an error to reduce
marketing to simply
advertising. Marketing
governs all activities
that link the product to
the consumer and
includes components
such as market
research, product
design, packaging,
vendor channels,
product placing and
long-term
relationships with
customers. Marketing
strategies are based
on knowledge from
psychology, sociology,
engineering and
economics. Applying
marketing to the noncommercial field is not
an entirely new
concept. Since Philip
Kotler introduced the
idea of social
marketing871 in the
1970s, the concept
has been applied
successfully in
preventive medicine,
and there are
increasing numbers of
reported examples
within the field of
infection control850
and, more recently, in
hand hygiene
promotion.1,872
When applying
marketing strategies
to infection control,
definitions (Table
I.20.3) have to be
adapted to the
health-care setting.
Here, HCWs take on
the role of
customers.
Marketing is fiercely
consumer
obsessed: it is not
about objective truth,
but all about what
customers believe
and feel. Therefore,
every product launch
starts with market
research to
understand what
customers or
HCWs in this case
want, need or
demand. The
ultimate goal is to
ensure that HCWs
perceive hand
hygiene as an
innovative, intuitiveto-use, and
appealing object that
they associate with

professionalism,
security, and
efficiency. To achieve
this goal might
involve actions
across all levels of
marketing as it is
understood today.
As a tangible product,
a redesigned handrub
bottle would constitute
a promising object to
be used in a marketing
strategy. The bottle
design will be
particularly important.
It should not only be
practical but attractive
to look at and
appealing to touch.
The cap could open
with a discreet but
readily recognizable
click. The click could
then become a
stickiness factor to be
used in promotional
material (Patient
safety just a click
away) and become a
slogan among HCWs.
The handrub solution
should ideally improve
skin condition. Market
research could single
out the best model
among various
prototypes or identify
several different
models that each fits a
particular segment of
the market among all
HCWs.

PART I. REVIEW OF
SCIENTIFIC DATA
RELATED TO HAND
HYGIENE

A marketing
strategy can be
developed by
making use of the
renowned marketing
mix known as the 4
Ps (product, price,
promotion, and
place).873 These are
considered as the
basic building
blocks of the
marketing mix
because they are
deduced from four
generic conditions
for any commercial
exchange to come
about:

existence
of
a
tangible
or
intangible
exchange
goods
(product);

at least two
parties willing
to
exchange
goods
of
reciprocal value
(price);

communic
ation about
the
existence
and quality
of
the
exchange
goods
(promotion
);

an
interaction
in
the
physical
world
to

deliver the
goods
(place).
Along with the
traditional 4 Ps, we
propose a fifth,
persistence, to stress
the need for specific
actions that lead to
sustainability in hand
hygiene promotion.
Explanation of these
5 Ps and examples
of their application in
social marketing with
regard

to hand hygiene
promotion
are
shown in Table
I.20.4. The 5 Ps
constitute a very
powerful
and
actionable
checklist when
engaging in a
promotional
endeavour.
The evolution
of marketing
science goes in
the direction of
societal
marketing,
relationship
marketing, and
viral

marketing to gain
greater effect and
sustainability. The
Internet brought a
new edge to this
movement with
intercustomer
networks and
individualized twoway relationships
between customers
and the industry.
Why should hand
hygiene advocacy
not also profit from
this evolution and
continue to
assimilate new
concepts of
marketing as they
are developed by
the industry?
9
5

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.20.1
Strategies for successful promotion of hand hygiene in health-care settings
Strategy

Action

Selected referencesa

1. System change

Make hand hygiene possible, easy,

convenient

60,429,469,493,648,651,684,705,709,851,852,858

Make alcohol-based handrub available

60,140,429,485,486,494,645,686,687,698,701,707,714,717,718,855,856

Make water and soap continuously available

633,659

Install voice prompts

699,710,852,853

2. Hand hygiene education

60,140,334,429,648,651,666,676,684,686,687,698,705,707,708,714717,813,814,819,851,858

3. Promote/facilitate skin care for

HCWs hands

60,180,608,609

4. Routine observation and feedback

60,334,651,657,665,676,684,686,687,715,716,858

5. Reminders in the workplace

60,140,429,485,489,494,648,651,663,667,680,686,694,698,701,714,717,
740,847

6. Improve institutional safety climate

General

60,429,494,651,713,724

Promote active participation at individual

and institutional level

60,429,494,651,713,715,724,847

Avoid overcrowding, understaffing,

excessive workload

60,185,656,668,708,741

Institute administrative sanction/rewarding

714,720,724

Ensure patient empowerment

486,803-805,874,875

7. Combination of several of the above

strategies
a

60,140,429,651,657,666,676,684,686,687,701,713,716,717,724

Readers should refer to more extensive reviews for exhaustive reference lists.48,204,724,738,749,809

Table I.20.2
Evidence on implementation strategies: data from the Registered Nurses Association of Ontario
Evidence on implementation strategies
Generally effective

Sometimes effective

Little or no effect

Educational materials
Didactic educational meetings

Educational outreach visits

Reminders
Interactive education visits
Multifaceted intervention including two
or more of the following:
Audit and feedback
Reminders
Local consensus process
Marketing

Audit and feedback

Local opinion leaders
Local consensus processes
Patient-mediated interventions

96

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.20.3
Key marketing concepts and their application to the field of hand hygiene
Concept

Marketing

Hand hygiene

Product

The exchange good can be a tangible object or an

intangible service

Hand hygiene: a handrub solution, a moment of its use

Customer

An individual or institution interested in acquiring

a product; can be a party that does not actually
consume the product but delivers it to a further party.

HCW
Health-care institution

Consumer

Customer who actually consumes the product

Could be the patient who profits from hand hygiene use

Need

Basic requirements to live

HCWs have no need for hand hygiene, but they have

a need for recognition and for self-protection that can
be associated with optimal hand hygiene performance

Want

A desire for a product that can or cannot be met by an

exchange value to meet its price

HCWs do not usually want hand hygiene

Demand

A desire for a product that is met by the necessary

exchange value

Ideally, hand hygiene becomes a demand for HCWs;

this would be achieved when they perceive enough
benefit against the costs

Market

Customers who are targeted by a given product

All HCWs: eventually including patients as consumers

Market research

Research to understand customers and their needs,

wants, and demands

Understanding the values and perceptions of HCWs

(and eventually patients) towards hand hygiene

Market
segmentation

Grouping of customers into groups with similar

behaviour vis--vis a product; the market mix

Groups of HCWs and/or patients with unique common

values and interests in hand hygiene

Exchange

Act of exchanging a product against an exchange

value that corresponds to the price between the firm
and their customers

Making HCWs perform hand hygiene in exchange of a

perceived added value (i.e. appreciation by patients)

Branding

To give a firm or a product a unique set of attributes

with a high value of recognition

Giving hand hygiene a positive image optimally linked

to a correct use

Market mix

Building a marketing strategy from basic building

blocks called the 4 Ps (Product, Price, Place,
Promotion), optimized according to the findings of
market research

Optimal design of promotional activity to increase

hand hygiene compliance according to the 4 Ps after
investigation of the HCWs demands, groups with
similar views, and the position of hand hygiene in the
institution

97

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.20.4
The 5 Ps of the market mix and their translation into hand hygiene promotion
5 Ps

Description

Commercial marketing
example

Hand hygiene
marketing example

Product

An object or a service designed to

fulfil the needs, wants or demands of
customers

Soda brand, computer

operating system,
adventure holidays,
counselling

New hand hygiene formula

One hand-operated personal handrub
dispenser
My five moments for hand hygiene
Clear and uniform language in hand
hygiene matters
Building a local hand hygiene brand

Price (cost)

The price is the amount a customer

pays for a product. It is determined by
a number of factors including market
share, competition, material costs,
product identity and the customers
perceived value of the product. The
price relates to what can be gained by
buying the product, its exchange value

Introduction price,
overpricing, sales

Costs to buy the handrub for the

institutions management;
Non-monetary cost for good
compliance for the HCWs such as
negative image with colleagues
Price as time consumption, hand
hygiene going against the rhythm of
work flow
Negative impact on skin condition
Negative perception

Place

Place represents the location where

a product can be bought. It is often
referred to as the distribution channel.
In a second, wider sense, the place
refers to the emotional context in which
the product appears

Web site, convenient

proximity to other
products, motor race
atmosphere, adventure,
admired film star,
success

Use-centred placement of handrub

dispensers
Distribution channels of handrub,
training location
Perceived emotional environment of
hand hygiene

Promotion

Promotion embraces all communication

about a product with the intention
to sell it. Four channels are usually
distinguished:
1) advertising that promotes the product
or service through paid for channels;
2) public relations, free of charge
press releases, sponsorship deals,
exhibitions, conferences, etc.;
3) word of mouth, where customers are
taking over the communication; and
4) point of sale

TV spot for a shower gel,

contest to introduce a
new telephone service,
sponsorship for a solar
car race, non-smokers
are cool TV spot

Promotion of alcohol-based handrub

for hand hygiene on posters
By word of mouth
Through subtle product placing in
scientific meetings or coffee breaks

Persistence

Marketing approach to increase

sustainability, relationship marketing,
investing in long-term relations between
the firm or a brand on one side and
customers on the other; investment in
social consumer networks

VIP customer card with cashback function, investment in

brand value, creation of a
consumer community network

Integr
ation
in the
institut
ional
culture
and
syste
m:
integra
tion in
all
training
course
s and
materi
al on
any
other
topic
frequ
ent

and
natural
integration in
printed
and
spoken
information on
any topic
abundant and
ergonomically
placed handrub
dispensers;
institutional and
by-sector reengineering of
hand hygiene as
a brand with
the participation
of local staff
ongoing
staff
feedback
mechanisms on
usability
and
preferences
98

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

21.
The WHO Multimodal Hand Hygiene
Improvement Strategy
reminders in the workplace;
and the creation of a hand
hygiene safety culture with
The successful implementation of guidelines into practice
the participation of both
continues to elude health improvement efforts globally.876 The
individual HCWs and senior
Replicating Effective Programs (REP) framework is one example of hospital managers.
a successful approach, although largely within the context of HIV Depending on local
prevention interventions.877 Recent work has also focused on
resources and culture,
knowledge transfer, often incorporating learning from the body of
additional actions can be
knowledge on diffusion of innovation.869 The literature confirms that added, in particular patient
there is no magic solution to guarantee uptake and assimilation of involvement (see Part V).

21.1 Key elements for a successful strategy

guidelines into clinical practice.

Against this background, the WHO Guidelines on Hand Hygiene in
Health Care have been developed with the ultimate objective of
changing the behaviour of individual HCWs to optimize compliance
with hand hygiene at the recommended moments and to improve
patient safety. For this objective to be fulfilled,

21.2 Essential steps

for implementation at
heath-care setting
level

a successful dissemination and implementation strategy is

required to ensure that practitioners are aware of the
guidelines and their use.728,878

The Guide to Implementation

details the actions and
resources necessary to ensure
each component of the
Ensuring that guidelines are transformed from a static document
multimodal strategy can
into a living and influential tool that impacts on the target practice become assimilated into
requires a carefully constructed strategy to maximize dissemination existing infection control and
and diffusion.868 Fraser describes implementation as being
safety programmes. The Guide
concerned with the movement of an idea that works across a large is structured around five
number of people (the target population). Based on the best
sequential steps which are
available scientific evidence and underpinned
recommended to reflect an
by both the long-standing expertise of Genevas University
action plan at facility level
Hospitals to promote multimodal hand hygiene promotion
(Figure I.21.1). The target for
campaigns60 and learning from the England & Wales National
this approach is a facility
Patient Safety Agency (NPSA) cleanyourhands campaign, the
where a hand hygiene
WHO Hand Hygiene Implementation Strategy has been
improvement programme has
constructed to provide users with a ready-to-go approach to
to be initiated from scratch.

translate the WHO Guidelines on Hand Hygiene in Health

Care into practice at facility level.

The WHO Multimodal Hand Hygiene Improvement Strategy

consists of a Guide to Implementation and a range of tools
constructed to facilitate implementation of each component. The
Guide to Implementation accompanies the WHO Guidelines on
Hand Hygiene in Health Care and outlines a process for fostering
hand hygiene improvement in a health-care facility. The
implementation strategy has been informed by the literature on
implementation science, behavioural change, spread methodology,
diffusion of innovation, and impact evaluation. At its core is a
multimodal strategy consisting of five components to be
implemented in parallel; the implementation strategy itself is
designed to be adaptable without jeopardizing its fidelity and is
intended therefore for use not only in virgin sites, but also within
facilities with existing action on hand hygiene. The five essential
elements are: system change, including availability
of alcohol-based handrub at the point of patient care and/or access
to a safe, continuous water supply and soap and towels; training
and education of health-care professionals; monitoring of hand
hygiene practices and performance feedback;

Step 1: Facility
preparedness
readiness for
action Step 2:
Baseline
evaluation
establishing the
current situation
Step 3:
Implementation
introducing the
improvement
activities
Step 4:
Follow-up
evaluation

evaluating
the
implement
ation
impact
Step 5: Action
planning and review

cycle developing a
plan for the next 5
years (minimum)
Step 1 is to ensure the
preparedness of the
institution. This includes
getting the necessary
resources in place and the
key leadership to head the
programme, including a
coordinator and his/her
deputy. Proper planning
must be done to map out a
clear strategy for the entire
programme.
Step 2 is to conduct
baseline evaluation of hand
hygiene practice,
perception, knowledge, and
infrastructure available.
Step 3 is to implement the
improvement programme:
availability of an alcohol-based
handrub at the point of care
and staff education and
training are vitally important.
Well-publicized events
involving endorsement and/or
signatures of commitment of
leaders and individual HCWs
will draw great dividends.

Follow-up
evaluation to assess
the effectiveness of
the programme
naturally comes
next as Step 4.
Finally, Step 5 is to develop an
ongoing action plan and
review cycle. The overall aim
is to inculcate hand hygiene as
an integral part of the hospital
culture. A more comprehensive
outline of activity within each
step is presented in Figure
I.21.2.
Each step in the cycle
builds on the activities
and actions that occurred
during the previous step,
and clear roles and
responsibilities are
outlined within the
strategy. The steps are
presented in a userfriendly guidebook,

designed to be
99

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

refined, and
enhanced
over a
minimum 5year period.
A key feature
of an
a working
implementati
resource for on strategy is
implementersevaluation
and leads in and this is a
infection
permanent
control,
feature of the
safety, and WHO
quality.
multimodal
Throughout strategy
the five
during Steps
steps,
2 and 4.
activities are Implementati
clearly
on,
articulated evaluation,
and the
and feedback
accompanyin activities
g tools to aid should be
implementati periodically
on are clearlyrejuvenated
signposted. and repeated
At the end of and become
each step, a part of the
checklist is quality
presented
improvement
and
actions to
implementersensure
are
sustainability.
instructed to Following the
ensure all
full
recommende implementati
d activities on of the
have been strategy for
completed the first time,
prior to
the plan of
moving to theactivities and
next step.
long-term
Central to thesteps should
implementati be based on
on strategy is lessons
an action
learnt about
plan,
key success
recommende factors and
d to be
on areas that
constructed need further
within Step 1, improvement
to guide
. Therefore,
actions
the choice to
throughout privilege
each
some
subsequent specific
step.
activities
and/or steps
Rather
might be
than a
performed.
linear
process,
the five
21.2.1 Basic
steps are
requirements
intended to for
be dealt
implementatio
n
with in a
cyclical
In situations
manner,
where the
with each
complete
cycle
implementatio
repeated,

n strategy is
not considered
feasible,
perhaps
because of
limited
resources and
time,
implementers
can focus on
minimum
implementatio
n criteria to
ensure
essential
achievement
of each
component

of the
multimodal
strategy.
The eight
criteria are
listed in
Table I.21.1.

21.3 WHO
tools for
implementati
on
The Guide to
Implementation
is accompanied
by an
Implementation
Toolkit (called
Pilot
Implementation
Pack during the
testing phase
and illustrated
in Figure
I.21.3)
including
numerous tools
(Table I.21.2) to
translate
promptly into
practice each
of the five
elements of the
WHO
Multimodal
Hand Hygiene
Improvement
Strategy.
These tools
focus on
different
targets:
operation,
advocacy, and
information;
monitoring;
hand hygiene
product
procurement or
local
production;
education; and
impact

evaluation.
The latter is
an essential
activity to
measure the
real impact
21.4 My five
of the
improvement moments for
efforts at the hand
point of care. hygiene
The same
tools used In this
for the
section, a
baseline
new model
evaluation intended to
meet the
should be
used to allow needs for
training,
a
comparison observation,
and
of
standardized performance
reporting
indicators
across all
such as
health-care
hand
settings
hygiene
compliance, worldwide is
1
perception described.
This model is
and
knowledge also
about HCAI integrated in
various tools
and hand
hygiene, and included in
availability of the WHO
equipment Multimodal
Hand
and
Hygiene
infrastructure
Improvement
for hand
Strategy (see
hygiene. The
Part I,
Guide to
Sections
Implementati
21.121.3).
on includes
details on
The concept
each tool
of My five
and
moments for
instructions
hand hygiene
on how and
aims to: 1)
when to use
foster positive
it. The
outcome
practical
evaluation by
toolkit
linking
represents a
specific hand
very helpful
hygiene
and readyactions to
to-go
specific
instrument
infectious
enabling
outcomes in
facilities to
patients and
start
HCWs
immediately
(positive
their hand
outcome
hygiene
beliefs); and
promotion
2) increase
without the
the sense of
need to
self-efficacy
decide upon
by giving
the best
HCWs clear
scientific
advice on
approach to
how to
be selected.
integrate
hand hygiene
in the
complex task
of care

(positive
control
beliefs).
Furthermore,
it reunites
several of the
attributes that
have been
found to be
associated
with an
increased
speed
of diffusion of
an innovation
such as
relative
advantage by
being
practical and
easy to
remember,
compatibility
with the
existing
perception of
microbiologic
al risk,
simplicity as
it is
straightforwar
d, trialability
as it can be
experimented
with on a
limited basis,
and
specifically
tailored to be
observable.87
9
The fact
that the
concept uses
the number 5
like the five
fingers
of the hand
gives it a
stickiness
factor, i.e. the
capacity to
stick in the
minds of the
target public
and influence
its future
behaviour, that
could make it a
carrier of the
hand hygiene
message and
help it to
achieve the
tipping point of
exponential
popularity.880
Since its
development in
the context of
the Swiss
National Hand
Hygiene
Campaign881
and its

integration in hygiene
the WHO
concept.
Multimodal
Hand
The main
Hygiene
specifications
Improvement for the concept
Strategy, the are given in
concept of Table I.21.3.
My five
Importantly, it
moments for aims for
hand
minimal
hygiene has complexity and
been widely a harmonious
adopted in integration into
more than
the natural
400 hospitals workflow
worldwide in without
20062008, deviation from
of which
an
about 70
evidencedhave been
based
closely
preventive
monitored to
effect. The
evaluate
resulting
impact and
concept
lessons
applies
learnt.
across a wide
range of care
settings and
21.4.1
health-care
Concept
features and professions
developmen without losing
the
t
necessary
accuracy to
Require
ment
produce
specific
meaningful
ations
data for risk
for a
analysis and
userfeedback.

centred
hand

Furthermore,
the concept
is congruent
in design and
meaning for
trainers,
observers,
and observed
HCWs. This
sharing of a
unified vision
has a dual
purpose.
First, it
avoids an
expertlay
person gap
and leads to
a stronger
sense of
ownership882
and second,
it reduces
training time
and cost for
observers.
Additionally,
the
robustness of
the concept
reduces inter-

observer
variation and
guarantees
intrahospital,
interhospital, and
international
comparisons
and
exchange.
1
0
0

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

surface exposure,
a bidirectional
exchange of
microorganisms
between hands
and the touched
object occurs and
21.4.1.1
the transient
Health carehand-carried flora
associated
is thus continually
colonization
changing. In this
and infection:
manner,
the prevention
microorganisms
targets
can spread
The
important throughout a
concepts
of health-care
colonization and environment and
between patients
infection
associated with within a few
hours.126,883
health-care

practices
have
been discussed The core
in depth in Part elements of
hand
I.7.

transmission
In summary, four are stripped
down to their
negative
simplest level
outcomes
in Figure I.21.4.
constitute the
Effective hand
prevention
targets for hand cleansing can
prevent
hygiene: 1)
colonization and transmission of
microorganism
exogenous
s from surface
infection of
A to surface
patients; 2)
endogenous and B if applied at
any moment
exogenous
during hand
infection in
transition
patients; 3)
between the two
infection in
surfaces.
HCWs; and 4)
colonization of Typically, surface
the health-care A could be a
door
handle
environment and
colonized
by
HCWs.
MRSA
and
surface B the
skin of a patient.
21.4.1.2 The
core element of Another example
would be surface
hand
A
being
the
transmission
patients
groin and
During daily
practice, HCWs surface B
being an open
hands typically
vascular access
touch a
hub. If
continuous
transmission of
sequence of
microorganisms
surfaces and
between A and
substances
B would result
including
inanimate objects, in one of the four
patients intact or negative
outcomes
non-intact skin,
detailed above,
mucous
membranes, food, the
waste, body
corresponding
fluids, and the
hand transition
HCWs own body. time between
With
the surfaces is
each hand-tousually called

hand hygiene
opportunity. It
follows clearly
that the
necessity for
hand hygiene is
defined by a
core element of
hand
transmission
consisting in a
donor surface, a
receptor surface,
and hand
transition from
the first to the
second.

21.4.1.3
Conceptualiza
tion of the
risk: patient
zone and
critical site
To meet the
objective of
creating a usercentred concept
for hand
hygiene, the
evidence-based
hand
transmission
model (see Part
I.7) was
translated into a
practical
description of
hand hygiene
indications. The
terms zone,
area, and
critical site were
introduced to
allow a
geographical
visualization of
key moments
for hand
hygiene (Figure
I.21.4a).
Focusing on a
single patient,
the health-care
setting is
divided into two
virtual
geographical
areas, the
patient zone
and the healthcare area
(Figures I.21.4a
and I.21.4b).
The patient zone
contains the
patient X and
his/her immediate
surroundings. This
typically includes

the intact skin of

the patient and all
inanimate
surfaces that are
touched by or in
direct physical
contact with the other high
frequency
patient such as
touch
the bed rails,
bedside table, bed surfaces. The
model
linen, infusion
tubing and other assumes that
the patients
medical
flora rapidly
equipment.
It further contains contaminates
the entire
surfaces
patient
frequently
zone, but that the
touched by
patient zone is
HCWs while
being cleaned
caring for the
between patient
patient such as
admissions.
monitors, knobs
Importantly, the
and buttons, and
model is not
limited to a
bedridden patient,
but applies
equally to patients
sitting in a chair or
being received by
physiotherapists
in a common
treatment location.
The model also
assumes that all
objects going in or
out of the patient
zone are cleaned.
If this is not the
case, they might
constitute an
alternative
transmission
route.
The health-care
area contains all
surfaces in the
health-care setting
outside the patient
zone of patient X,
i.e. other patients
and their patient
zones and the
health-care facility
environment.
Conceptually, the
health-care area
is contaminated
with
microorganisms
that might be
foreign and
potentially harmful
to patient X, either
because they are
multiresistant or
because their
transmission
might result in
exogenous
infection.

Within the
patient zone,
critical sites
are
associated
with
infectious
risks (Figure
I.21.4a):
critical sites
can either
correspond
to body sites
or medical
devices that
have to be
protected
against
microorganis
ms
potentially
leading to
HCAI (called
critical sites
with
infectious
risk for the
patient),
or body sites or
medical devices
that potentially
lead to hand
exposure to body
fluids and
bloodborne
pathogens (called
critical sites with
body fluid
exposure risk), or
both precited risks
simultaneously
(called critical
sites with
combined risk).
Drawing blood for
example concerns
a critical site with
combined risk that
is at the same
time associated
with an infectious
risk for the patient
and a body fluid
exposure risk for
the HCW.

Critical sites
either 1) preexist as natural
orifices such as
the mouth and
eyes, etc.; 2)
occur
accidentally
such as
wounds,
pressure
ulcers, etc.; 3)
are careassociated
such as
injection sites,
vascular

catheter
insertion sites,
drainage exit
sites, etc.; or 4)
are deviceassociated
such as
vascular
catheter hubs,
drainage bags,
bloody linen,
etc..
The added
value of
critical
sites lies
in their
potential
use in
visual
material
and
training:
risk-prone
tasks
become
geographi
cally
located
and hence
more
palpable.
On the

behavioural
level,
manipulation

of critical sites
corresponds
to either a
clean/aseptic
procedure or
a body fluid
exposure
procedure,
and in the
case of
simultaneous
risk, to a
clean/ aseptic
and body fluid
exposure
procedure.

21.4.2 The
concept and its
practical
application
My five
moments for
hand hygiene
explained
The
geographical
representation of
the zones and
the critical sites
(Figure I.21.5a)
is useful to
introduce My
five moments for
101

hand hygiene.
The correlation
between these
moments and
the indications
for hand hygiene
according to the
present
guidelines is
given in Table
I.21.4. To further
facilitate ease of
recall and
expand the
ergonomic
dimension, the
five moments for
hand hygiene
are numbered
according to the
habitual care
workflow (Figure
I.21.5b).
Moment 1.
Before touching
a patient
From the twozone concept, a
major moment for
hand hygiene is
naturally
deduced. It
occurs between
the last hand-tosurface

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

the healthcare area

outside the
patient zone,
and the
patients hand
belongs to the
contact
patient zone.
with an
Therefore
object
hand hygiene
belonging
must take
to the
place after
healthtouching the
care area
door handle
and the
and before
first within
shaking the
the patient patients
zone
hand. If any
best
objects are
visualized
touched
by
within the
crossing
patient zone
the virtual
after opening
line
the door
constituted
handle, hand
by the
hygiene might
patient
take place
zone
either before
(Figure
or after
I.21.5a).
touching
Hand
these objects,
hygiene at
because the
this
necessity for
moment
hand hygiene
will mainly
before
prevent
touching
colonizatio
objects within
n of the
the patient
patient
zone is not
with health
supported by
careevidence; in
associated
this case the
microorga
important
nisms,
point is that
resulting
hand hygiene
from the
must take
transfer of
organisms place before
touching the
from the
environment patient.
to the patient
Moment 2.
through
Before a
unclean
clean/aseptic
hands, and
procedure
exogenous
Once within
infections
the patient
in some
zone, very
cases. A
frequently after
clear
a hand
example
exposure to
would be
the patients
the
intact skin,
temporal
clothes or
period
other objects,
between
the HCW may
touching
engage in a
the door
clean/aseptic
handle and procedure on a
shaking the critical site with
patients
infectious risk
hand: the
for the patient,
door handle such as
belongs to opening a

venous access
line, giving an
injection, or
performing
wound care.
Importantly,
hand hygiene
required at this
moment aims
at preventing
HCAI. In line
with the
predominantly
endogenous
origin of these
infections,
hand hygiene
is taking place
between the
last exposure
to a surface,
even within the
patient zone
and
immediately
before access
to a critical site
with infectious
risk for the
patient or a
critical site with
combined
infectious risk.
This is
important
because
HCWs
customarily
touch another
surface within
the patient
zone before
contact with a
critical site

with infectious
risk for the
patient or a
critical site
with combined
infectious risk.
For some
tasks on
clean sites
(lumbar
puncture,
surgical
procedures,
tracheal
suctioning,
etc.), the
use of
gloves is
standard
procedure.
In this case,
hand
hygiene is
required
before
donning
gloves

because
gloves
alone may
not
entirely
prevent
contamina
tion (see
Part I,
Section
23.1).73,884

of HCWs with
infectious
agents that
may occur
even without
visible soiling.
Second, it
reduces the
risk of a
transmission
of
microorganis
ms from a
colonized

Moment 3.
After body
to a clean
fluid
exposure
body site
risk
within the
After a
same
care task
patient.885
associate
This routine
d with a
moment for
risk to
hand hygiene
expose
concerns all
hands to
care actions
body
associated
fluids,
with a risk of
e.g. after
body fluid
accessin
exposure and
ga
is not
identical to
critical
the
site with
hopefully
body
very rare
fluid
case of
exposure
accidental
risk or a
visible soiling
critical
calling for
site with
immediate
combine
handwashing
d
.
infectious
risk
(body
fluid
site),
hand
hygiene
is
required
instantly
and must
take
place
before
any next
hand-tosurface
exposure
, even
within the
same
patient
zone. This
hand
hygiene
action has a
double
objective.
First and
most
importantly,
it reduces
the risk of
colonization
or infection

Disposable
gloves are
meant to be
used as a
second
skin to
prevent
exposure of
hands to
body fluids.
However,
hands are
not
sufficiently
protected by
gloves, and
hand
hygiene is

strongly
recommende
d after glove
removal (see
Part I,
Section 23.1).
Hence, to
comply with
the hand
hygiene
indication

in
Momen
t 3,
gloves
must
be
remove
d and
subseq
uently
cleanse
d.
Moment 4.
After touching
a patient
When
leaving the
patient
zone after
a care
sequence,
before
touching an
object in
the area
outside the
patient
zone
and
before a
subseque
nt hand
exposure
to any
surface in
the
healthcare
area,
hand
hygiene
minimizes
the risk of
dissemina
tion to the
healthcare
environm
ent,
substantia
lly
reduces
contamin
ation of
HCWs

hands
with the
flora
from
patient
X, and
protect
s the
HCWs
themsel
ves.

still required.

Coincidence
of two
moments for
hand hygiene

Two moments
for hand
hygiene may
sometimes fall
together.
Moment 5.
Typically, this
After
occurs when
touching
moving directly
patient
surrounding from one
s
patient to
The fifth
another without
moment
touching any
for hand
surface outside
hygiene is
the
a variant
corresponding
of Moment patient zones.
4: it occurs In this situation,
after hand
a single hand
exposure
hygiene action
to any
will cover the
surface in
two moments
the patient for hand
zone, and
hygiene, as
before a
moments 4 and
subseque
1 coincide.
nt hand
Another
exposure
example of
to any
such a
surface in
simultaneous
the health- moment
care area,
would be the
but without direct access
touching
to a central
the
venous line
patient.
as a first
This
hand-totypically
surface
extends to exposure
objects
after entering
contamina the patient
ted by the
zone. In this
patient
example,
flora
moments 1
that are
and 2
extracted
coincide.
from the
patient
zone to be Two patients
decontami within the
nated or
same patient
discarded. zone
Because
Health-care
hand
settings and
exposure
situations
to patient
have very
objects,
but without different
features
physical
across the
contact
world. It may
with the
patients, is happen that
associated two or more
patients
with hand
contaminat are in such
close
ion, hand
contact that
hygiene is

they occupy
the same
physical
space and
touch each
other
frequently.
For example,
this situation
could be
represented
by a mother
with her
newborn
child, or two
patients
sharing a
single bed or
bedding
space. In
these cases,
the
application
of the patient
zone and the
actual
compliance
with the five
moments is
conceptually
and
practically
difficult.
Nevertheless
, the two
close
patients may
be viewed as
occupying a
single
patient zone.
Hand
hygiene is
certainly still
required
when
entering or
leaving the
common
patient zone
and before
and after
critical sites
according to
their specific
nature, but
the
indication for
hand
hygiene
when

shifting intact
skin contact
between the
two patients is
probably of
little
preventive
value because
they are likely
to share the
same
microbial flora.

A critical
feature to
21.4.2.1
Understandi facilitate the
ng the
understandi
visual
ng and
message

communicat

102

ion of My
five
moments
for hand
hygiene
lies in

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

conceptual
grouping and will
readily
understand
the
risk-based
construct
of
zones and critical
its strong visual sites and the five
message
moments for hand
(Figure I.21.5b). hygiene.
The
The objective is rationale of the
to represent the current concept is
ever-changing
a
strong
situations of
motivator.
care into
With these
pictograms that trainees, it is
could serve a
helpful to
wide array of
insist on the
purposes in
main reason
health-care
for each of the
settings. The
five moments
main visual
for hand
focus depicts a
hygiene.
single patient in Other people
the centre to
respond better
represent the
to
point of care of
circumstantial
any type of
cues. For
patient. The
them, it is
patient zone,
useful to list
health-care
the most
area, critical
frequent
sites and
examples
moments for
occurring in
hand hygiene
their specific
action are
health-care
arranged around settings. The five
and on this
moments model
patient to depict also offers many
the infectious
possibilities for
risks and the
the development
corresponding
of training tools,
moments for hand including on-site
hygiene action in accompanied
time and space. learning kits,
This
visual computerrepresentation is assisted learning,
congruent
with and off-site
the point of care simulators. It is of
importance to
concept.
understand that
HCWs often
Some
execute quite
limitations
sophisticated
can be
medical tasks
envisaged
without conscious
in this
cognitive
model and
attention. Their
are
behaviour is
discussed
triggered
elsewhere
by multiple cues
1
.
in the
environment that
are
21.4.2.2 Training
unconsciously
processed. To
There are
build hand
important
hygiene into their
interpersonal
automatic
differences when
behaviour for
it comes to
these situations,
learning styles.
they may need
Some individuals
training in a given
respond well to

environment with
multiple cues for
action. My five
moments for
hand hygiene
would serve as
solid basic
building blocks for

such training. It
is crucial to
determine the
delimitation of
patient zones
and critical sites
with local staff in
their unique
setting, which
has the added
benefit of
increasing
process
ownership by the
concerned staff.

21.4.2.3
Monitoring
Direct
observation is the
gold standard to
monitor
compliance with
optimal hand
hygiene practice.
The five moments
model can be a
valuable aid to
observation in
several ways.
Many care
activities do not
follow a standard
operating
procedure, so it is
difficult to define
the crucial
moment for hand
hygiene. The five
moments
concept lays a
reference grid
over these
activities and
minimizes the
opportunities for
inter- observer
variation. Once
HCWs are
proficient in the
five moments
concept and its
application, they
are able to
become
observers with
minimal additional
effort, thus
reducing training
costs.1
Furthermore, the
concept solves
the typical

problems of
clearly defining
the denominator
as an opportunity
and the
numerator as a
hand hygiene
hand hygiene
action (see Part practices.58,60
III, Section 1.2). Based on the

21.4.2.4
Reporting
Reporting
results of
hand
hygiene
observation
to HCWs is
an essential
element of
multimodal
strategies to
improve

five moments, it
is possible to
report riskspecific hand
hygiene
performance in
full agreement
with training and
promotional
material. The
impact of
feedback is thus
increased, as
the different
moments can be
individually
discussed and
emphasized.

21.5
Lessons
learnt from
the testing
of
the
WHO
Hand
Hygiene
Improveme
nt Strategy
in pilot and
compleme
ntary sites
Since 2006, the
WHO Hand
Hygiene
Improvement
Strategy (see Part
I, Sections 21.1
21.4) has been
tested in a number
of health-care
settings around
the world to
generate
information on
feasibility, validity,
and reliability of
the interventions,
to provide local
data on the
resources required
to carry out

the
recommenda
tions, and to
obtain useful
information
for the
revision and
adaptation of
the proposed
implementati
on

strategies.62
Before and during
implementation,
the Pilot
Implementation
Pack tools were
translated into the
six official
languages of
WHO (Arabic,
Chinese, English,
French, Russian,
and Spanish) and
also into some
local languages
(e.g. Armenian,
Bengali, and
Urdu). Eight
hospitals were
selected in seven
countries (Table
I.21.5.1) located
in the six WHO
regions (Africa,
the Americas,
South-East Asia,
Europe, Eastern
Mediterranean,
and the Western
Pacific) to
participate in the
pilot test phase
with technical
support and
careful monitoring
from the First
Global Patient
Safety Challenge
team. Field
testing has been
made also
possible through
the support of the
WHO Regional
Patient Safety
Focal Points and
the WHO
representatives at
country level, as
well as
collaboration with
expert technical
and academic
partners and
professional
associations.
Diversity was built
into the selection
of pilot sites to
ensure
comparability of
the results across
the six regions,
and they
represented a
range of facilities
in developed,
transitional, and
developing
countries.
All sites identified

a project and
included the
deputy
detection of hand
coordinator and hygiene
formed a
compliance,
committee
alcohol-based
mandated to give handrub
advice and take consumption,
decisions on the perception of
project plan. The hand hygiene by
instructions
senior managers
included in the
and HCWs,
Guide to
HCWs
Implementation knowledge, and
and the steps
structures related
proposed in the to hand hygiene.
action plan were
carefully followed At the same time,
in all sites, and all a wide range of
implementation different healthtools were used at care settings
worldwide also
the suggested
steps (see Part I, requested to use
the WHO Hand
Sections 21.1
21.3). Therefore, Hygiene
Improvement
hand hygiene
Strategy and
promotion was
tools. For this
conducted
according to the reason, a webbased community
WHO strategy,
and baseline and forum was
established
follow-up
where any healthevaluation
care facility could
103

enrol in order to
access all the
tools included in
the Pilot
Implementation
Pack and to ask
questions related
to
implementation.
In this way, any
health-care
facility has been
able to participate
in field testing as
a complementary
test site (CTS).
For logistic and
economic
reasons, support
offered by the
WHO to a CTS is
limited and mainly
web-based.
Through the web
community,
experiences and
solutions related
to the
implementation
have also been
shared with other
test sites.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

21.5.1 and
21.5.2
briefly
summarize
the
experience
and
This has
lessons
provided a learnt from
discussion the official
forum
pilot sites
exclusivel and a
y for CTSs number of
and an
CTSs. In
opportunit Section
y for
21.5.1, the
mutual
specificities
support
of each
and
pilot site
exchange regarding
during the implement
implement ation and
ation
impact and
process.
sustainabili
ty at
Pilot testing local and
has been
national/region
completed inal levels have
most sites been
and results highlighted in
have been brief
made
paragraphs
available. and the
Similarly, a lessons are
process of summarized in
evaluation Table I.21.5.2.
has been
A detailed and
undertaken exhaustive
in some
report will be
CTSs
published
(Section
separately
21.5.2).
after a careful
Data and
scrutiny of all
lessons
data and
learnt from information
testing have available.
been of
Specific
paramount information
importance about critical
to revise the aspects of the
content of local
the present production of
Guidelines alcohol-based
and to
handrubs is
confirm the detailed in
validity of
Section 12.2.

the final
recommend
ations.
21.5.1
Furthermore Implementatio
, when
n in pilot sites
appropriate,
they
WHO African
enabled
Region (AFR)
modification Mali - Hpital
du Point G
and
improvemen
t of the suite Hpital du Point
G, an acuteof
implementaticare, 456-bed
university
on tools.
Sections

health-care
facility serving

the population
of Bamako and
its surroundings
and being a
referral hospital
for the entire
country, was
selected as the
pilot site
representing
the African
region. No
infection control
expertise was
available before
the enrolment.
A pharmacist
underwent
training in
infection
control and
learnt how to
produce the
WHO
formulation I
at the
University of
Geneva
Hospitals and
became the
project coordinator.
The
preparation
phase was
very
intensive,
in order to
set up the
conditions
for
implement
ation. A
committee
was
established
to advise
on action
plan and
take
decisions;
the
hospital
directorate
showed strong
leadership in
the promotion
and support to
the project kick
off. Nine units
(two surgical,
gynaecology
and obstetrics,
urology,
nephrology,
infectious
diseases,
internal
medicine, and
accident and
emergency)

representing permanently
13 wards
available, only
and 224
a minority of
HCW were patient rooms
selected for was equipped
pilot testing. with sinks
The WHO
(sink:bed ratio
strategy was equal to 1:22)
faithfully
and no soap
implemented and towel
fulfilling all were
steps,
available. This
starting from partly explains
December the very low
2006. The
overall level of
WHOhand hygiene
recommende compliance
d formulation (8.0%) among
based on
ethanol,
produced
locally from
sugar cane
and included
in the
hospital
budget, was
manufacture
d at the
hospital
pharmacy
and bottled
in 100 ml
pocket
bottles; a
cleaning/recy
cling process
was put in
place. At
very low
cost, 3700
bottles were
produced
and quality
control tests
confirmed
accordance
with the
optimal
quality
parameters
in all
samples
(see also
Part I,
Section
12.2).
The
baseline
infrastructur
e survey
identified
severe
deficiencies
in hand
hygiene
facilities
and
products.
Although
clean water
was

1932 observed
opportunities at
baseline.
Compliance
markedly
differed among
professional
categories,
ranging from
an average of
3.2% for
nursing
assistants to
20.3% for
doctors and an
average of
4.4% for
nurses.
Compliance
also varied
among medical
specialities,
with the lowest
level observed
in intensive
care (2.4%).
The level of
HCWs
knowledge was
also very

low, with
limited
understanding
of the
pathogen
transmission
dynamics, of
the concept of
colonization
and of the
infection risk.
Interestingly,
according to
the baseline
perception
surveys, the
level
awareness of
the
epidemiologic
importance of
HCAI and of
its impact was
higher among
senior
managers
than among
HCWs.
Implementatio
n of hand
hygiene
promotion
was launched
on 2
November
2007 in an
official

ceremony
chaired by
the Minister
of Health,
the WHO
representat
ive in Mali
and the
hospital
director,
and
involving all
HCWs.
During the
event,
chairs and
HCWs
were
invited to
sign a giant
bottle of
alcoholbased
handrub as
a symbol of
their
commitmen
t, and
information
leaflets and
T-shirts
with the
project logo
were
distributed.
During the
following
months,
visual
posters
featuring
the

WHO
project,
hand
hygiene
indications
and the
technique
for
handwashin
g and
handrubbin
g were
displayed in
study
wards.
Following
the launch,
five threehour
education
sessions
using WHO
materials
and
including
feedback of
baseline
survey
results
were
organised

for all study

ward HCWs.
All
participants
were given a
100 ml
individual
pocket bottle
of alcoholbased
handrub and
trained to use
it in practice.
From this time
on, alcoholbased
handrub has
been regularly
distributed by
the pharmacy
to the study
ward head
nurses upon
return of the
empty bottles.
Interestingly,
the
improvement
of critical
deficiencies
in
infrastructure
for
handwashing
was not
considered
by the
hospital
directorate
as a top
priority for
improving
practices
because of
resource and
cultural
issues.
Firstly,
improving
sink:bed ratio
is associated
with
economic
constraints at
UHPG.
Secondly,
HCWs
consider that
sinks in
patient
rooms are for
patient use
and are
therefore
usually
reluctant to
use them.
Thirdly, in
patient
rooms, soap
bars would
very likely be

taken by
patients
and/or
visitors and
to install
wallmounted
liquid soap
dispensers
would be too
expensive.
At
follow-up
evaluation (six
months
after
implementation
kick off) hand
hygiene
compliance
increased
to
21.8%
and
handrubbing
became
the
quasi-exclusive
hand hygiene
technique
(93.3%).
Improvement
was observed
among all
professional
categories
and medical
specialties,
especially as
far as
indications
after body
fluid
exposure
risk and
after
touching a
patient are
concerned.
Knowledge
scores the
following
educational
sessions
increased
significantly
(p<.05)
among
professionals.
The HCWs
perception
survey
highlighted
the
importance of
each
component of
the strategy
for successful
promotion.
The project
was strongly
supported by
the hospital
directorate
which

engaged,
and further
together with improvement.
key staff
Hand hygiene
members, in promotion and
an in depth measurement
evaluation of activities have
the results of been
the pilot
included in the
phase in
annual
order to
management
enable
plans for the
sustainability entire hospital.
, expansion Locally adapted
104

posters are in
preparation and
innovative
methods for
hand hygiene
promotion
among most
resistant
professional
categories and
for patient
involvement will
be part

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

of the
forthcoming
boostering
phase of the
campaign.
The study
successful
results about
the feasibility
of the strategy
implementatio
n and practice
improvement
have
motivated the
Mali
government to
expand the
production of
the alcoholbasedhandrub
and the
dissemination
of the strategy
to the national
level.

s by a private
company, which
accepted to
donate the
product and the
dispensers. The
validation of the
local production
of the WHOrecommended
formulation took
much longer than
expected
because of
several initial
failures

at the quality
control test level
(see Part I,
Section 12.2). An
engineer
reviewed the
hospital plan to
place the new
dispensers at the
point of care
according to local
safety criteria.
The system
change was
critical to the
improvement of
hand hygiene
practices,
because alcoholWHO Region of based handrubs
the Americas
were not
(AMR)/Pan
previously widely
American
available and, in
Health
some areas of
Organization
the hospital,
(PAHO)
significant
Costa Rica:
infrastructure
Hospital Nacionaldeficiencies (sink
de Nios (HNN)
to bed ratio
<1:10)
The strategy was
constituted an
implemented
important barrier.
from March 2007
to September
2008 in 12 wards
(290 beds) of
HNN, a
paediatric
hospital

Observers for
hand hygiene
monitoring
underwent two
days of intensive
training and
in San Jos,
were
Costa Rica. All
subsequently
steps of the
validated. An
action plan were
official
completed and
ceremony,
the facility is
chaired by the
now developing
minister of
a review cycle
health, was
and a five-year organized to
plan to ensure launch the hand
sustainability.
hygiene
promotion
The alcoholcampaign (Step
based handrub
3). Giant dolls in
was produced
the shape of a
according to the
handrub bottle
WHO
were prepared
recommendation
and used to

market the
improvement for
promotional
purposes. HNN
committed also
to patient
involvement and
families were

informed of the
pilot project and
encouraged to
use the alcoholbased handrub
when caring for
their children.
Educational
activities with
feedback of data
collected during
the baseline
period (Step 2)
were organized
with the
participation of all
HCWs from the
test units. Overall,
1421 and 1640
hand hygiene
opportunities
were detected at
baseline and
followup (after 5 months
of
implementation),
respectively.
Overall
compliance
increased from
25.2% to 52.2%.
The key success
factors of
implementation in
this site were the
high-level,
medical
leadership and the
pragmatic,
continuous action
by head nurses.
Strong support
from the
government not
only facilitated the
excellent pilot
implementation of
the WHO strategy,
but also led to its
national scale-up
with a National
Call to Action
made by the
minister of health
to all hospitals in
the country.
The Costa Rica
experience has
had a catalytic
influence on
other countries
in AMR. The

expertise of the
pilot project
team has been
successfully
exploited by the
WHO Regional
Office for the
Americas
(AMRO) in
collaboration
with PAHO,
which has
coordinated
training
initiatives
involving other
countries.
Argentina,
Brazil,
Colombia,
Ecuador, Peru,
and Trinidad
and Tobago are
now preparing
to adopt the
WHO strategy.

WHO South-East
Asia Region
(SEAR)
Bangladesh,
Chittagong
Medical College
Hospital (CMCH)
CMCH has
been
implementing
the WHO Hand
Hygiene
Improvement
Strategy since
September
2007 in five
wards
(neonatal care,
surgery,
orthopaedics,
and paediatric
and adult
ICUs). Given
the critical
conditions of
the hospital
(162% bed
occupancy, no
infection control
professional, no
data on HCAI
and
antimicrobial
resistance,
significant
infrastructural
deficiencies),
there was much
scepticism at the
time of the pilot
enrolment about
the feasibility of
the project and its
worthiness in the
presence of other
major priorities.
To overcome
these obstacles,
the hospital
directorate took
the decision to
make
a major
investment
in the
project.
From the
CMCH staff,
one doctor
and one
nurse were
selected as
pilot project
coordinators
and trained
in Lahore
and then in

Chittagong
with the support of
the WHO country
office. A
multidisciplinary
infection control
committee
including the
departmental
heads of all
relevant units was
established. The
alcohol-based
handrub, based
on the WHO
recommended
formulation II
(isopropyl alcohol)
was manufactured
locally by the
national Essential
Drug Company
Ltd. A survey was
undertaken to
establish the best
position for the
alcohol-based
handrub
dispensers to
meet the point of
care concept.
Sinks (1 for every
15 beds) were
installed in all of
the pilot wards, as
only the nursing
station and
doctors rooms
had a sink. In
order to improve
inadequate water
supply, two deep
tube wells were
sunk and major
water supply lines
were improved.
Following a
preliminary
assessment,
which clearly
highlighted that
no hand hygiene
action was
regularly
performed by
HCWs because
of absence of
sinks, running
water and soap
in the wards,
outside the
doctors rooms
and the nurses
stations, the
decision was
taken not to
undertake
baseline hand
hygiene
observations and
to consider
compliance

equal to 0% at
baseline.
Specific
challenges to the
observation of
compliance were
the high bed
occupancy (two
patients per bed
in some wards)
and
overcrowding
that made it
difficult to apply
the patient zone
concept, the
complexity of the
WHO method,
and cultural
sensitivities to be
observed.
However,
baseline HCW
perception
surveys yielded
some interesting
findings. Bearing
in mind the
infrastructural
deficiencies with
respect to sink
availability, it is
significant that
during the prepilot phase 83.5%
and 44.5% of
respondents,
respectively,
stated that their
hand hygiene
compliance

exceeded 50%
(most
respondents
estimated it to be
between 80% and
100%) and that
they had received
formal training in
hand hygiene. In
addition, 87.8%
considered that
the performance
of hand hygiene
required a major
effort, and 54.7%
stated that the
availability of
alcohol-based
handrub at the
point of care
would have no or
little effect on the
improvement of
hand hygiene
practices.
To launch
the
implement
ation
phase, a
high
profile
event was
held at the
hospital
with the
attendanc
e of the
WHO
representative,
105

the minister of
health, senior
ministerial
officials, and
public and
private hospital
representatives.
Five hundred
persons
attended the
event. In the
wards, alcoholbased handrub
was made
available through
wall dispensers
and pocket
bottles
distributed to all
HCWs. Posters
translated into
Bengali were
displayed
throughout the
wards at the
locations of
alcohol-based
handrub
dispensers,
above
washbasins, and
between each bed
space, and largesize versions of
the posters were
positioned at the
ward entrance. All
ward-based staff,
both

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

and plans to
expand the
WHO strategy
to the entire
hospital. It is
in the process
of developing
doctors and an antibiotic
nurses,
utilization
were trained policy, to
to follow the conduct a
Guidelines prevalence
with
study, and
refresher
has already
courses
pilot infection
every
registers on
fortnight.
wards. An
Some
audit on
perception surgical
difficulties procedures is
emerged in planned to
the use of investigate
the WHO
the
educational
appropriatene
concepts
ss of surgical
and tools
instruments
(see Table
reprocessing
I.21.5.2) and
and of
a simplified
surgical hand
two
preparation.

moments
approach
The Joint
was
Secretary
adopted.
Hospital of the
Evaluation
Ministry of
of the
Health and
implementati
Family Welfare
on impact
(MOHFW)
with the use
visited CMCH
of the WHO
during
surveys has
implementation
been
of the pilot and
undertaken
has called for a
(Step 4) and
national roll-out
data are
of the pilot
under
project without
analysis.
The project
has led to
very
beneficial
actions
beyond
hand
hygiene
improvemen
t both at
CMCH and
at national
level. The
CMCH
infection
control
committee
is well
established
and meets
regularly
every month
or more
often if
necessary

delay. The
MOHFW thus
expressed its
strong
commitment to
strengthen
infection control
across the
country, in
particular by
ensuring that
each hospital
has a
functioning
infection control
team and
propoer access
to handwashing
facilities by
installing one
washbasin per
10 beds in all
hospitals.
Alcohol-based
handrub will be
procured on a

national scale
and its use
promoted as
the gold
standard for
hand hygiene
of non-soiled
hands. The
proposed
timeframe is for
roll-out during
the financial
year 2008
2009 with
consolidation
during 2009
2010, and a
specific budget
has already
been allocated
that includes
the
strengthening
of human
resources. The
WHO country
office will
support the
MOHFW in the
adaptation and
updating of
guidelines and
norms required
for the success
of the initiative.

WHO
European
Region (EUR)
Italy: network
of 41 ICUs
In November
2006, the
Italian ministry
of health
decided to join
the Clean
Care is Safer
Care initiative
by launching a
national
campaign
organized by a
national
coordinating
centre for
HCAIs
(Agenzia
Sanitaria e
Sociale
Regionale
EmiliaRomagna) and
funded by the
National Centre
for Disease
Control (Centro
Nazionale per
la Prevenzione
e il Controllo
delle Malattie,

CCM).
Participation
in the
campaign
was
proposed to
all of the 21
Italian
regions and
public
hospitals.
Overall, 190
hospitals
from 16
regions
joined the
campaign,
accounting
for 315
hospital
wards,
mostly ICUs
and surgical
and medical
units. The
entire range
of tools
included in
the WHO
Pilot
Implementati
on Package
was
translated
into Italian
and the
printed
material
distributed.
One national
and four
regional
training
courses for
coordinators
and
observers
were
organized;
the WHO
strategy and
action plan
were entirely
adopted (see
Part I,
Section
21).886 A web
platform was
created on
the CCM
web site for
tool
downloading,
technical
questions,
and
interactive
discussion
among the
sites. One
hundred
sixty one
hospitals

reported their
findings and
experience to
the national
coordination
centre and sent
the databases
of all surveys
included in the
WHO strategy.
Preliminary
analysis of
hand hygiene
observations
related to 66
953
opportunities
detected at
baseline in 172
hospitals
indicate

that
overall
complian
ce was
43% and
that, in
71% of
hand
hygiene
actions,
handwas
hing was
the
techniqu
e used.
Given the
high level of
data
collection
accuracy and
adherence to
the WHO
strategy in the
Italian
campaign, a
network of
participating
ICUs was
selected to
become the
pilot site
for EUR
accordin
g to preestablish
ed
criteria
(Table
I.21.1).
Fortyone ICUs
from
eight
regions
were
eligible,
and most
of them
impleme
nted
hand
hygiene
promotio
n
between

October
2007 and
January
2008 and
conducted
baseline and
follow-up
evaluations
during 36
months
before and

of alcoholbased
handrubs
improved
from 70% to
100% and
that pocket
bottles were
available to
each HCW in
92% of cases
at follow-up
(vs 52% at
baseline).
Improvement
Observation was more
s related to striking
9 828 and 9 among
nurses and
302
opportunities nursing
were carried students
(compliance
out at
baseline and increased
from 58% to
follow-up,
respectively, 73% and from
52% to 69%,
with an
respectively);
equal
distribution compliance
increased
of
professional from 48% to
categories 59% among
and types of medical
doctors and
indication.
from 56% to
Overall, a
69% among
significant
improvemen auxiliary
nurses. A
t in hand
comparison
hygiene
compliance of the
(from 55% to knowledge
questionnaire
69%) was
results at
detected
baseline and
following
implementati follow-up
(1238 vs 802
on of the
respondents,
hand
respectively)
hygiene
identified
strategy.
Comparing areas that
need further
baseline
with follow- improvement,
e.g. the
up, use of
understandin
handrubs
to perform g of the
dynamics of
hand
microrganism
hygiene
transmission
increased
from 36.9% and the role
to 60.4% of of different
sources of
hand
infection. In
hygiene
contrast,
actions.
there was an
This is
reflected in interesting,
positive
the
correlation
structure
between
surveys
the increase of
results
hand hygiene
from 30
ICUs which compliance
before patient
indicate
contact (from
that
permanent 49% to 65%)
availability and before an

after the
implement
ation.
Thirty
ICUs sent
the
complete
set of
baseline
and
follow-up
data of all
WHO
surveys.

aseptic/clean
task (53% to
70%) and the
improvement
of knowledge
at follow-up
when
answering
questions
related to
these two
indications.

According to
the perception
questionnaire
(1116 vs 902
respondents at
baseline and
follow-up,
respectively),
the percentage
of HCWs who
underwent
training on
hand hygiene
increased from
39.7% to
86.6%,
respectively.
Most
respondents
attributed the
highest scores
(6 and 7 of a
7-point Likert
scale) to every
component of
the WHO
strategy when
asked about
the importance
of the strategy
components in
determining
their hand
hygiene
performance
improvement.
Working
group
discussions
with 24 pilot
ICU
coordinators
using the
CTS
evaluation
interview
template
(see Part I,
Section
21.5.2)
provided
very
interesting
information
on the
implementati
on strategy
feasibility
and

invaluable
suggestio
ns for
improvem
ent (Table
I.21.5.2).
The
discussion
was very
instructive
,
particularl
y to
identify
actions for
securing
the

sustainability
of the hand
hygiene
promotion
programme.
In most pilot
hospitals,
staff working
on the wards
not involved
in the pilot
testing
requested
hand
hygiene
promotion to
be
106

extended to
their settings.
The
campaign is
becoming
hospital-wide
in many
institutions
and
additional
health-care
facilities have
spontaneousl
y joined the
national
campaign.

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

WHO Eastern
Mediterranean
Region (EMR)
For several
reasons,
more than
one pilot
site was
selected in
EMR.
Although all
sites have
committed
to
undertake
all

activities
included in
the action
plan for the
implementatio
n of the WHO
Hand
Hygiene
Improvement
Strategy, they
are at
different
stages of
implementatio
n.

Kingdom of
Saudi Arabia
Two different
health-care
settings
agreed to
participate in
the pilot
testing in
Riyadh, Saudi
Arabia. In both
sites, a hand
hygiene
campaign was
undertaken in
2005,
following the
ministerial
pledge to the
First Global
Patient Safety
Challenge and
the launch of a
national
campaign. In
connection
with the latter,
all hospitals
affiliated to the
Ministry of
Health were

provided with
alcohol-based
handrubs as
the gold
standard for
hand hygiene
according to
the WHO
strategies.
Since

2007,
hand
hygiene
promotion has
been
further
reinforced with
participation in
the testing of
the
WHO
strategy. In both
cases,
the
hospital
bore
the entire cost
of
implementation.

King
Abdulaziz
Medical City
(KAMC),
Riyadh, is a
960-bed
teaching
hospital
delivering
high-quality
primary,
secondary
and tertiary
health-care
services for
the Saudi
Arabia
National
Guard. The
infection
control
committee
appointed the
coordinator
and his
deputy and
also
identified
infection
control
practitioners
and infection
control
champions
(focal points)
to implement
the activities.
The KAMC
ICUs (seven
units: adult,
paediatric,
neonatal,
burn, adult
and
paediatric

cardiovascul
ar, and
medical
cardiac) and
two surgical
units were
selected to
be the pilot
wards based
on the acuity
of care
provided, the
high risk of
microorganis
m
transmission,
and the high
number of
hand hygiene
opportunities.
Alcoholbased
handrub was
already
available at
KAMC, but
during the
campaign
preparation
phase a new
product was
selected
among
several
proposed
according to
WHO criteria,
and the
number of
fixed
dispensers
located at the
point of care
was
increased.
The goal of
the campaign
was to reach
at least 90%
or above
compliance
with hand
hygiene
practices.

Through the
use of a
specific
form,
evaluation of
the quality of
the hand
hygiene
technique
was added
to the range
of other
WHO
surveys at
baseline and
follow-up.
Each unit

had a
champion in
charge of
carrying out
the surveys,
coordinating
staff training
on hand
hygiene, and
liaising with
the
campaign
coordinator
and his
deputy.
Champions
had also to
be prepared
to meet
specific,
challenging
situations in
their
interaction
with HCWs
and others,
such as
surprise,
apprehensio
n of the
unknown,
scepticism,
cynicism,
and strong
resistance.
Feedback
was given to
HCWs,
leaders, and
key players
during the
launch day
when the
promotion
campaign
was
inaugurated.
Formal
reports on
local
compliance
data were
distributed to
the
respective
area
directors.
The
campaign
was
launched on
13 April 2008
with an
official
ceremony by
the hospital
director and
other highlevel
authorities

and
an
advertiseme
nt on the

KAMC web
site. A leaflet

was prepared
to inform the
patients and
invite them to
participate in
the campaign
by asking
HCWs to
perform hand
hygiene. An
original
aspect of
implementatio
n at KAMC
was the
organization
of mobile
stands inside
and around
the hospital,
which moved
to a different
location every
two to three
hours in order
to reach all
HCWs and
patients.
These stands,
managed by
the infection
control
practitioners,
displayed
WHO and
non-WHO
posters and
documents on
hand hygiene.
Stand visitors
could watch
the WHO
training film
and were
taught the
correct
technique

to perform
hand
hygiene
antisepsis.
Throughout
a two-month
period, 23
training
sessions
were
organized
with the
participation
of 530 staff
members
from the
pilot units.
Several
promotional
tools and
posters

were
adapted
from the
WHO
versions or
newly
produced in
English and
Arabic
(Table
I.21.5.1).
Overall,
1840 and
1822 hand
hygiene
opportuniti
es were
detected at
baseline
and followup (after
three
months
since
implementa
tion),
respectivel
y. Overall
compliance
increased
from 45.1%
to 59.4%
with
improveme
nt greatest
among
nurses
(43.9 vs
62.8%).
Complianc
e rates with
Moment 3
(after body
fluid
exposure
risk) and
Moment 4
(after
touching a
patient)
were high
during both

observation
periods
(82.9% vs
85.0% and
67.7% vs
76.2%,
respectively)
.
Compliance
with Moment
2 (before
clean/
aseptic
procedure)
achieved the
greatest
increase
(45.8% vs
84%);
improvemen

t was also
detected
with Moment
1 (before
touching a
patient)
(29.4% vs
58.1%,
respectively)
and Moment
5 (after
touching
patient
surrounding
s) (13.2% vs
30.0%,
respectively)
.

King Saud
Medical
Complex
(KSMC),
Riyadh, is a
1446-bed
teaching
hospital
delivering
primary,
secondary,
and tertiary
care, under
the
government
of the Saudi
Arabia
Ministry of
Health. It
consists of
four
hospitals: a
general
hospital,
maternity
hospital,
childrens
hospital, and
a dental
centre.
In
September
2007, a
hand
hygiene
committee
was created
to plan and
carry out the
activities
related to
the project.
Together
with four
infection
control
professional
s, three
infection
control
nurses were
identified to

play the role

of trainers
for the
education
sessions
and
observers.
Sessions
train the
trainers
were
organized
and led by
the
coordinator
and deputy
coordinator.
The WHO
strategy
was
implemente
d
hospitalwid
e, but the
observation
of hand
hygiene
practices
was carried
out only in
selected
areas.
Alcoholbased
handrub
dispensers
were
already
installed in
all wards
and
department
s, but the
decision
was taken
to introduce
the WHO
formulation.
A local
company
was
appointed
by the
ministry of
health to
produce
different
samples of
alcoholbased
handrub
according to
the WHO
Guide to
Local
Production.
Four types
of solutions
were
produced:
one
correspond
ed

modificati
ons such
as a
different
fragrance
or
emollient.
All four
formulatio
ns were
made in
the form
of a
solution,
and all

to the
WHO
formulatio
n1
(based on
ethanol),
while the
other
three
were the
same
formulatio
n but with
some
107

four
products
were
quality
controltested at
the
University
of Geneva
Hospitals
in
Switzerlan
d and
found

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

to be
consiste
nt with
WHO
require
ments
for the
final
concent
rations
of the
ingredie
nts.
Followin
g the
receptio
n of
these
results,
the test
of
accepta
bility
and
tolerabil
ity of
these
product
s
among
HCWs
was
carried
out
accordi
ng to
the
WHO
method.
The
best
tolerate
d and
most
appreci
ated
product
was
selecte
d and
distribut
ed in
wall
dispens
ers at
the
point of
care.
Hand
hygiene
observa
tions
were
conduct
ed

monthly
and during
the
baseline
period.
KSMC
overall
hand
hygiene
complianc
e was
56%.
Feedback
of results
of the
surveys
conducted
during the
baseline
period, in
particular
hand
hygiene
complianc
e, was
given to all
decisionmakers on
19 May
2008.
Great
emphasis
was
placed on
education
at this pilot
site. From
Septembe
r 2007 to
October
2008, the
members
of the
hand
hygiene
committee
managed
to lead 56
sessions
during
which 998
HCWs
were
trained in
the
concepts
promoted
by the
First
Global
Patient
Safety
Challenge,
in
particular,
My five
moments
for hand
hygiene.
In
addition, a

weekly
training
session
was
scheduled
every
Sunday
and
attendanc
e was a
contract
requireme
nt for new
staff and
for staff
renewing
their
contracts.
In 2008,
1297
HCWs
participate
d in these
sessions.
Much
effort was
dedicated
to
producing
a large
range of
new
posters on
hand
hygiene
with more
visual
impact
and
adapted to
the local
culture.
These
were
distributed
in large
quantities
across all
wards.
Monthl
y
observ
ations
during
the
implem
entatio
n
period
(from
May to
Septem
ber
2008)
docum
ented
an
increas
e of the
averag
e

com
plian
ce
rate
to
75%,
with
speci
fic
depa
rtme
nts
reac
hing
rates
as
high
as
88.8
%.

the alcoholbased handrub

previously
purchased from
a commercial
source at a
much higher
price (US$ 3.00
per 500 ml vs
US$ 1.85 per
500 ml).

Baseline
structure
evaluation
pointed out no
relevant
deficiency
related to
handwashing:
sink-to-patient
ratio was about
1:3, and clean,
Pakistan,
Institute of running water
was regularly
Medical
available. In
Sciences
(PIMS)
contrast,
alcohol-based
Three ICUs handrubs were
medical (9 available
beds),
(intermittently)
surgical (14 in only one of
beds), and the three ICUs.
neonatal (17 A high level of
beds)
awareness of
were
the impact of
selected for HCAI and of
pilot testing the importance
the WHO
of hand
Hand
hygiene was
Hygiene
demonstrated
Improvemen by the 123
t Strategy at HCWs
PIMS, a
responding to
tertiary
the perception
referral
survey. It is
hospital with widely reported
1055 beds. that most
AlcoholHCWs believe
based
that compliance
handrubs
in their hospital
have been is higher than
in use at
50%. At PIMS,
PIMS since among 755
the
observed
emergency opportunities,
the overall
situation
following the hand hygiene
compliance at
2005
earthquake. baseline was
In keeping 34.7% with no
significant
with the
differences
WHO
project, the between the
major
WHOrecommende professional
d formulation categories.
Compliance
based on
isopropanol was highest
with Moment 1,
was
produced at before touching
PIMS where a patient
it replaced (60.0% by
nurses and

55.5%

by doctors),
and there was
a remarkable
difference in
the

complianc
e with
Moment
4, after
touching
a patient,
between
nurses
(48.8%)
and
doctors
(22.9%).
On 11
August
2008, a
training
workshop
on hand
hygiene
was held at
PIMS to
train the
trainers and
key
individuals
involved in
the project,
and the
implementa
tion phase
was
launched.
All staff
members of
the pilot
ICUs were
subsequentl
y trained
and the
WHO hand
hygiene
posters
were made
available in
Urdu to
overcome
language
barriers. An
interesting
specificity
of the
promotion
campaign
at PIMS
was that
training was
not limited
only to
regular
staff, but
was
simplified
also and
offered to
the socalled

janitors,
illiterate
support
employees
who are in
charge of
clinical and
human waste
disposal and
the emptying
of urinary
bags. The
adaptation of
educational
messages to
their level of
knowledge
was a very
challenging
task.
The WHO
project
implementation
in ICUs had an
overall, positive
impact at PIMS
because an
infection
control doctor
and three fulltime infection
control nurses
were
appointed, and
an infection
control
committee was
established.
For the first
time, proper
surveillance of
HCAI was also
established in
the Neonatal
ICU using
WHO tools. As
a result of this
project, HCAI
has now
become a high
priority as a
part of quality
and patient
safety agenda
of the hospital.
In addition,
given the
substantial cost
savings and
the potential
availability of
additional
funds, it is
planned that
the production
of the WHO
formulation will
be expanded
for distribution
to other wards
and
departments.

In addition, the
previous health
secretary at
the federal
ministry of
health has
expressed an
interest to train
100 000 health
visitors
throughout
Pakistan and
distribute
alcohol-based
handrub
to them. It is
also
anticipated
that by the end
of the project,
the WHO
representative
and the
federal
ministry of
health will
explore the
feasibility of
the production
of the WHO
formulation on
a national
scale using
public/private
partnership.

WHO Western
Pacific Region
(WPR)
China,
Hong Kong
Special
Administrat
ive Region
(SAR): four
pilot
hospitals
The
implementation
of the WHO
Hand Hygiene
Improvement
Strategy
started in Hong
Kong SAR in
2006, a few
months after
the pledge
signature in
October 2005.
Four pilot
hospitals with
20 study wards
in total have
progressively
enrolled since
April 2006.
Enrolled wards
were surgery,
internal
medicine, adult

ICUs,
the conduct
orthopaedics of a long, and
term followgeriatrics.
up of hand
Each
hygiene
hospital
compliance
selected a measureme
coordinator nt.
and a team
of infection During the
control
preparation
professional phase, much
s to carry out energy was
the project. devoted to
Aspects
setting up the
specific to
local production
the study
of the WHO
design for
formulations in
Hong Kong the perspective
SAR pilot
of ensuring
hospitals
cost
included that effectiveness
each test
and large-scale
ward
production.
be
Production was
associate put out to
d with a
tender, and the
company
control
proposing the
ward of
lowest price
the same
(including the
type, and
108

purchase of
plastic fixed
dispensers and
pocket bottles)
was selected.
The quality of
the final
products was
ascertained at
Genevas
University
Hospitals (see
Part I, Section
12.2). The
WHO
tolerability
and
acceptabilit
y survey
(doubleblind,
randomize
d, crossover
design)
was carried
out, and
65% of
HCWs
indicated a

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

solutions and
explanations were
given. All possible
efforts were made
to enhance
HCWs access to
alcohol-based
preference for one handrubs by
of the two WHO increasing the
alcohol-based
number of
handrub
dispensers at the
formulations in
point of care in
use, although
test wards,
some considered distributing the
it to have an
new products in
unpleasant odour. pocket bottles as
All 41 Hong Kong well with special
SAR public
belts and clip
hospitals are
holders, and
currently
making powderpurchasing the
free gloves
WHO formulations available in test
from the selected wards. A question
local company at and answer
the price of US$ (Q&A) leaflet was
0.50 for the 100 prepared,
ml bottle and US$ responding to all
1.60 for the 500 HCWs concerns
ml dispenser.
about the use of
Compliance at
alcohol-based
baseline (April handrubs (e.g.
October 2006)
skin damage, fire
was 20.7% and safety, bottle
contamination),
22.2% in study
and control wards, and topics were
respectively. Such discussed with
HCWs according
low rates are
surprising in Hong to the needs.
Kong SAR, when Feedback about
considering the hand hygiene
performance was
major
achievements with given to HCWs
individually and
hand hygiene
compliance only a immediately after
observation. A
few years
previously at the competition was
time of the severe announced to
acute respiratory identify the best
syndrome (SARS) slogan to promote
Clean Care is
outbreak.
Safer Care in
Implementation in Chinese. To boost
the test wards of implementation,
emphasis was
the Hong Kong
placed on role
SAR pilot
hospitals involved modelling after
original aspects of the first and the
adaptation of the second follow-up
periods.
WHO strategy
and tools.
Three periods of
Education was
follow-up
carried out by
observations
presentations
were carried out
targeted to the
every 3-4
different
months. In the
professional
first period
categories.
(October 2006
Different
March 2007),
scenarios
overall
simulating real
compliance rates
care situations
were presented to were 56.6% and
18.3% in the test
staff, and

and control
wards,
respectively. In
test wards,
compliance
improved in all
professional
categories apart
from doctors
(15.5%
compliance at
baseline) who
showed no
improvement and
a significantly
lower compliance
at all follow-up
measurements
(mean 23.4%).
Between July
2007 and
January 2008,
the hand hygiene
campaign was
announced
hospitalwide in all
pilot hospitals,
with an official
launch ceremony.
All the abovementioned
actions were
extended to all
wards and no
longer limited to
test wards only.
After the
hospitalwide rollout, compliance
rates in test
wards remained
52.4%, whereas it
increased to
43.8% in the
control wards. On
21 January 2008,
following the
success of the
WHO strategy
implementation in
the pilot
hospitals, the
Hospital
Authority, Hong
Kong SAR,
launched a
national
campaign aiming
to create an
institutional safety
climate and
improving hand
hygiene in 38
public hospitals.
At that time a big
banner (15 m
wide and 9 m
hight) was posted
up outside the
Hospital Authority
Head Office for

increasing public
awareness of the

importance of
hand hygiene.
Most of these
hospitals are
currently
displaying a giant
banner on hand 21.5.2 Lessons
hygiene at their learnt from
entrance to show complementary
test sites
their participation
and using the
Since the start
WHO
of the testing
Implementation
phase of the
Strategy, toolkit,
WHO
and
Multimodal
methodology. It is
Hand Hygiene
also of note that
Implementatio
the strategy was
n Strategy,
adapted and
complementar
successfully
y test sites
implemented in
(CTS) were
seven home-care
able to access
facilities in Hong
the entire
Kong SAR.

range of tools
included in the
Pilot
Implementation
Pack following
registration
through an
interactive web
platform created
for this purpose.
Although CTS did
not receive direct
monitoring by the
First Global
Patient Safety
Challenge team, a
process of
evaluation has
been undertaken
when the
implementation
phase reached an
advanced stage.
A structured
framework was
developed
including three
levels: level I, the
mapping exercise;
level II,
quantitative
evaluation; and
level III,
qualitative
evaluation. The
mapping exercise
was conducted
with the use of an
online form and
allowed to collect
general
information about
the health-care
settings, their
progress in the
implementation of
the WHO Strategy
and which tools
had been adopted
or adapted. Sites

at advanced/semiadvanced stages
of implementation
and which had
used most of the
WHO tools
underwent
evaluation levels
II and III through a
semi-structured
telephone
interview with the
coordinators. The
interview included
both open and
ranking questions
(7-point Likert
scale) on different
components of
the WHO Strategy
and the Pilot
Implementation
Pack. The
objective was to
receive feedback
on the drawbacks
and advantages
of the
implementation of
the strategy,
feasibility of
alcohol-based
handrub local
production, and
the validity and
obstacles
encountered in
the use of the
tools. For the
purpose of
quantitative
evaluation, the
coordinators were
requested to send
the available data
on key indicators
e.g. hand hygiene
compliance,
alcohol-based
handrub and soap
consumption,
as well as the
results of the
knowledge/pe
rception/struct
ure surveys.
Level II
evaluation is
ongoing.
A total of 114
complete
responses were
received for the
level I survey and
concerned both
single sites and
networks of
health-care
settings. Fortyseven
coordinators from
the advanced and

semi-advanced
sites,
representing 230
health-care
settings from
Egypt, France,
Italy, Malta,
Malaysia,
Mongolia, Spain,
and Viet Nam,
participated in the
level II and III
evaluation.

21.5.2.1
Comments
on the WHO
Multimodal
Hand
Hygiene
Improvement
Strategy and
the Guide to
Implementati
on
General
comments by
most
coordinators on
the WHO
Multimodal
Hand Hygiene
Improvement
Strategy
indicate that it is

comprehensive
and detailed,
and its action
plan very
helpful to guide
practically the
local
implementation.
For these
reasons, it was
considered to be
a successful
model suitable to
be used also for
other infection
control
interventions.
However, there is
a strong need for
a
summarized/simpl
ified version.
Some
coordinators
raised concerns
about the
complexity of the
strategy and the
Pilot
Implementation
Pack, especially
in contexts with
limited human
resources, while
others requested
more details on
implementation in
109

poorly-resourced
countries. As the
main focus of the
strategy is on
hospitals,
adaptation to
other types of
health-care
settings was
strongly
suggested. The
overall median
score attributed to
the usefulness of
the Guide to
Implementation to
help understand
the rationale
behind

the strategy,
the step-wise
approach to
implementatio
n, the
objectives and
application of
the tools was
6 (range 4-7).
The section on
sustainability
was
considered
worthy of
expansion with
more detail by
some
individuals.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Some
examples of
the local
adaptation
of the
strategy are
the local
production
of posters,
brochures,
training
films,
badges and
gadgets,
organizatio
n of focus
groups on
glove use,
use of the
fingerprint
method for
educational
purposes,
and the
involvement
of patients
and visitors
in hand
hygiene
promotion.

21.5.2.2
Comments
on specific
elements of
the WHO
Strategy

paper towels),
these could
not be
completely
overcome,
mainly due to
lack of
resources.
Forty-six CTS
adopted
locallyproduced
WHOrecommende
d handrub
formulations
produced
either at the
hospital
pharmacy or
in a
centralized
facility. In the
sites where
handrub was
already in
use, the
system was
strengthened
through the
increase in
the number of
dispensers
and the use
of different
types of
dispensers.
Reported
long-term
obstacles to
system
change
included staff
subconsciou
sly resistant
to using
handrub
(mainly for
selfprotection
reasons),
leakage
problem with
liquid
solutions,
rumours
about
handrubs
causing skin
cancer, and
allergic
reactions.

System
change.
System
change was
considered
a very
important
component
of the WHO
Strategy
(median
score 7,
range 4-7).
As far as
handwashin
g was
concerned,
in some
cases
where major
Education. This
infrastructur
component was
e
considered of
deficiencies
major
were
importance for
present
the success of
(e.g. lack of
sinks and the campaign
and the WHO

tools were
widely used
with the
addition of local
data in most
cases. HCWs
who had
previously
received less
education
expressed the
most interest.
In many cases,
traditional
educational
sessions with
slide-shows
were used, but
other methods
such as
interactive
sessions and
practical
sessions on
hand hygiene
technique were
also adopted.
The My five
moments for
hand hygiene
concept was
perceived as
the key winning
message of the
Strategy and
the visual
impact of the
educational
tools and the
training film
were highly
appreciated.

Major
obstacles
were the
limited time
availability of
HCWs
beyond the
work shifts
and the
reluctance of
doctors to
attend
training
sessions.
The median
score
attributed to
the
importance
of education
was 7 (range
5-7). Scores
given to the
usefulness of
the different
WHO
educational
tools were as

when limited
follows:
manpower
training
was available.
film, 7
(range 57); slide
presentatio
n, 6 (range
5-7); hand
hygiene
brochure,
7 (range 57); pocket
leaflet, 7
(range 57); and the
9
recommen
dations
leaflet, 7
(range 57).
Observation
and
feedback.
All sites
adopted the
WHO
observation
method and
found it
relatively
easy to
apply due to
the precise
instructions
included in
the Manual
for
Observers.
The median
score
attributed to
both the
importance
of
observation
and
feedback
and the
usefulness
of the
Manual for
Observers
was 7
(ranges 4-7
and 1-7,
respectively
). Observers
were mainly
infection
control
nurses.
Nevertheles
s, difficulties
were
experienced
for their
validation
and the time
availability
for this task,
particularly

Feedback
was noted as
being very
important to
raise
awareness
and to
acknowledge
the results
achieved.
The method
used most
frequently
was a slide
presentation
during
educational
sessions; in
some cases,
immediate
compliance
feedback and
a written
report were
given to staff
and the
hospital
directorate. In
some
facilities, the
reaction of
HCWs to
reported low
rates of
compliance
was not
positive; in
others, when
data were
disseminated
to other units,
they
generated
much interest
to take part in
the
implementati
on.
The other
WHO tools for
evaluation
(structure,
perception
and
knowledge
surveys) were
used in some
sites. Although
their
usefulness to
gather a more
comprehensiv
e
understanding
of hand
hygiene

practices
was
acknowledg
ed, it was
also pointed
out that it
was too
timeconsuming
to perform
the surveys,
some
questionnair
es are too
long, and
some
questions
are difficult
to
understand.
In some
sites, a
combined
knowledge/
perception
questionnair
e was
developed
locally.
Remind
ers in
the
workpla
ce.
WHO
posters
were
used in
all sites
and
adapte
d
locally
in some
cases.
They

were also
useful for
patients and
visitors and led
to spontaneous
patient
participation.
Perishability
was one
concern and, in
some sites,
posters were
plasticized to
overcome this
problem. The
median score
attributed to the
importance of
reminders was
6 (range 3-7;)
median scores
attributed to the
WHO posters
were as
follows: 5
Moments, 7
(range 6-7);
How to
Handrub, 6
(range 5-7);
and How to
Handwash, 6
(range 5-7).
Patient safety
climate. Some
coordinators
pointed out
that the
implementatio
n of the hand
hygiene
campaign
acted as a
trigger to
introduce

other patient
safety topics.
Support from
top managers
and the
directorate
varied from
strong
practical
support to
more moral
and verbal
support
among the
different sites.
No active
patient
participation
was reported.
The median
score
attributed to
the
importance of
the promotion
of a safety
culture was 6
(range 2-7);
scores
attributed to
the
usefulness of
the tools to
secure
managerial
support were:
information

sheets, 5
(range 3-7);
advocacy
sheet, 4
(range 2-6);
and senior
managers
letter
template, 5
(range 2-7).
110

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.21.1
Basic requirements for implementation
Multimodal strategy

Minimum criteria for implementation

1A. System change: alcohol-based

handrub

Bottles of alcohol-based handrub positioned at the point of care in each ward, or given
to staff

1B. System change: access to safe

continuous water supply and towels

One sink to at least every 10 beds

Soap and fresh towels available at every sink

2.

Training and education

All staff involved in the test phase receive training during Step 3
A programme to update training over the short-, medium- and long-term is established

3.

Observation and feedback

Two periods of observational monitoring are undertaken during Steps 2 and 4

4.

Reminders in the workplace

How to and 5 Moments posters are displayed in all test wards (e.g. patients rooms;
staff areas; out-patient/ambulatory departments)

5.

Institutional safety climate

The chief executive, chief medical officer/medical superintendent and chief nurse all
make a visible commitment to support hand hygiene improvement during Step 3 (e.g.
announcements and/or formal letters to staff)

Table I.21.2
Type of tools* available to implement the WHO Multimodal Hand Hygiene Improvement Strategy
Type of tool

Tool

Informational/technical

WHO Guidelines on Hand Hygiene in Health Care

A summary of the Guidelines
The Global Patient Safety Challenge document
Information sheets
WHO-recommended hand antisepsis formulation guide to local production
Alcohol-based handrub production planning and costing tool

Educational

Slide presentation on HCAI and hand hygiene for HCWs and observers
Training films
Pocket leaflet
Hand hygiene brochure
Manual for observers

Promotional (marketing/reminder tools)

How to handrub poster

How to handwash poster
My Five Moments poster
Clean hands poster
Clean environment poster
Clean practices poster
Clean products poster
Clean equipment poster
Sample letter to chief nurses/senior medical staff

Evaluation and monitoring

Facility situation analysis

Country situation analysis
Senior executive manager perception survey
HCW perception survey
Ward structure survey
Soap and handrub consumption survey
Hand hygiene observation survey
HCW knowledge survey
How to use Epi-Info
Baseline and follow-up data summary report framework
Alcohol-based handrub tolerability and acceptability survey

* Most tools are freely available at: http://www.who.int/gpsc/en/

111

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.21.3
Requirement specifications for a user-centred hand hygiene application concept
Consistent with evidence-based risk assessment of HCAI and spread of multi-resistant microorganisms
Integrated into a natural care workflow
Easy-to-learn
Logical clarity of the concept
Applicable in a wide range of health-care settings
Minimising the density of the need for hand hygiene
Maximal know-how congruence between trainers, observers, and HCWs

Table I.21.4
My five moments for hand hygiene: explanations and link to evidence-based recommendations
Moment

Endpoints of hand transmission

Prevented negative outcome

1. Before touching aDonor surface: any surface in the health-care area

patient
Receptor surface: any surface in the patient zone

2.

Before clean/ aseptic procedure

Patient colonization with health-care microorganisms;

exceptionally, exogenous infection
Donor
surfac
e: any
other
surfac
e
Patient

3. After body fluid

exposure risk

Donor surface: critical site with body fluid exposure

risk or critical site with combined infectious risk
4. After touching
5. After
a touching
patient
patient

endogenous infection; exceptionally

exoge
nous
infecti
on
Receptor surface: critical site with infectious risk for
the patient or critical site with combined infectious
risk
surroundings
Receptor surface: any
Receptor surface: any surface in the
surface in the healthDonor surface: any surface in the care area
touching the patient

1
1
2

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.21.4
My five moments for hand hygiene: explanations and link to evidence-based recommendations (Cont.)
Moment

Examples of care situations

when the moment occurs

WHO recommendation (ranking

for scientific evidencea )

Comments: changes since

Advanced Draft of these
guidelines

The two
occurrence in
moments
routine care,
before and
unequal negative
after touching a
outcome in case
patient were
of failure to
separated
adhere, and
because of
usual adherence
their specific
level
sequential
Before handling
a
n
This concept was
determi
retained
2. Before clean/
Oral/dental care, secretion
enlarged to cover
ne
as a
an invasive device
cont
body
aseptic
aspiration, skin lesion care,
all transfer of
these
separate
for patient care,
ami
site
procedure
wound dressing, subcutaneous
microorganisms to
body
item, but
regardless of
nate
during
injection; catheter insertion,
vulnerable body
sites
covered
whether or not
d
patien
opening a vascular access
system;
sites potentially
objectiv
by within
gloves
are used
bod
t care
preparation of food, medication,
resulting in
ely, this
patient
(IB)
y
(IB)
dressing sets
infection
indicati
zone
site
on was
moments
to a
Since it is not
If moving from
not
clea
possible to
n any fluidurines,
After
faces,
x of body fluid
text for further wound
comments
See
dressin exposure
sample, vomit;removi
handling
3.
After body fluid
all
comment 2 in
ng
After
contact
was Moment
resolved2by including
opening waste (bandages,
Oral/dental care, secretion
gs
tasks
gloves with body
the
draining napkin,
exposure risk aspiration; skin
that
in hand
body
site to a
fluids or
notion
of exposure
system, incontinence
(IB)
can
exposu
lesion care, wound
clean
body siterisk
instead of
endotrache
pads);
cleaning
of
After
potent
re
to
dressing,
(before
actual exposure.
al tube contaminated
andrisk was
body This
ially
body
subcutaneo
clean/aseptic
fluid
generalized
to
result
fluids.
insertion
visibly
soiled
us injection;
procedure)
If moving
exposu
include
non
and
material
or areas
drawing
(IA)
from
a
during patient
re risk medical
excretions,
intact
removal; (lavatories,
and
A
contaminated
care (IB)
covers
mucous
this
recommendation;
skin,
clearing up
instruments)
manipulatio
parado
see
membranes,
or
getting
pulse, taking
abdominal
Before
bloodand
pati
See
1(before
4. After touching a Shaking
washed,
pressure, chest
palpation
after
ents
comment
touching a
hands, helping a patient
taking auscultation,
touching
(IB)
in Moment
patient)
patient to move around,
After
(in
edic the
(IB
R ed
ations
iat
n
y am
t
5. After touching
contact
cl
al immedia
)
e to
where
e
t
ina
o
patient
with
ud
equ te
t
cov
the
an
i
c ted
surroundings
inanimat
in
ipm vicinity
a er
patient
d
a
o environ
e
g
ent) of the
i
all
s
po
l
n ment is
objects
m
in patient
n situ
immed
te
l
t
eviden
c
e (see
P
art II):
category IA,
s
tro ngly
r
a
Ranking system for
e
1. Before touching a Shaking hands, helping a patient patient to move
around, getting washed,
taking pulse, blood pressure, chest auscultation,
abdominal palpation

Before and after touching

patients (IB)

13
1

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.21.5.1
Pilot sites for the testing of the WHO Guidelines on Hand Hygiene in Health Care and its strategy and tools
WHO
region

Country

City

Hospital

Hospital wards

Status of the
testing at
finalization
of guidelines
(October
2008)

Local tool preparation and/or

adaptation

AFR

Mali

Bamako

Hpital du
Point G

Pilot testing complete

in nine units
including medicine,
surgery, emergency,
anaesthesia and
intensive care,
gynaecology and
obstetrics

Concluded

Leaflet for hand hygiene

campaign launch
WHO-recommended
formulation
Promotional tee-shirts

AMR

Costa Rica

San Jose

Hospital
Nacional de
Nios

Targeted on subset
of wards, including
infectious disease

Step 5

SEAR

Bangladesh

Chittagong

Chittagong
Medical
College
Hospital

Five wards representing

450 beds

Step 4

Translation into Bengali of most

WHO tools
Simplified 2-moments
observation tool including the
case of 2 patients per bed
WHO- recommended
formulation

EUR

Italy

National
network

Network of
41 ICUs

ICUs selected
according to the
following criteria:

Concluded

Guide to Implementation
summary
Posters
Use of the fingertip method to
educate HCWs
Gadgets

- Having a reliable
system for HCAI
surveillance (HELICS
protocol; surveillance
system for MRSA
bacteraemia)

Training film
Hand hygiene song
Posters
WHO-recommended
formulation

- Explicit consent to
provide requested
data (results from all
WHO surveys and
HCAI rates)
- No other major
prevention project
concurrently
to the strategy
implementation
- Compliance with the
time line agreed with
WHO

114

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.21.5.1
Pilot sites for the testing of the WHO Guidelines on Hand Hygiene in Health Care and its strategy and tools (Cont.)
WHO
region

Country

City

Hospital

Hospital wards

Status of the
testing at
finalization
of guidelines
(October
2008)

Local tool preparation and/or

adaptation

EMR

Saudi
Arabia

Riyadh

King Saud
Medical
Complex

Hospitalwide

Step 5

Campaign original logo

Posters and banners displayed
outside the hospital
Pens, mugs, t-shirts, round big
buttons with campaign logo
Screen saver
DVD, educational brochures
and pocket leaflets for HCWs,
patients (adults and children)
and visitors translated into 4
different languages (arabic,
english, tagalog, urdu)
Demonstrations of the hand
hygiene technique
Use of finger tip printculture to
educate HCWs and patients
Drawing book for children
with cartoons related to the
campaign
WHO-recommended
formulation with alternative
fragrances and emollients
National hand hygiene
guidelines
Hand hygiene guideline
summary for the HCWs during
pilgrimage season

Saudi
Arabia

Riyadh

King
Abdulaziz
Medical
City

Nine pilot areas

including 7 ICUs and 2
surgical wards

Concluded

Pakistan

Islamabad

Pakistan
Institute
of Medical
Sciences
(PIMS)

Medical, surgical and

neonatal ICUs

Step 4

Translation of posters into Urdu

WHO-recommended
formulation

China

Hong Kong
SAR

Four pilot
hospitals:
Queen Mary
Hospital,
Caritas
Medical
Centre,
Tuen Mun
Hospital,
Yan Chai
Hospital

Selection of tests and

control wards in the
four hospitals

Concluded

Giant banners for the outside

wall of the hospital
Cartoons and other posters
Q&A leaflet responding to
HCWs concerns about the use
of alcohol-based handrubs
WHO-recommended
formulation

WPR

Banners and posters

Brochures for HCWs
Brochures for patients
Pocket leaflets for HCWs
Badges, pens and mugs

115

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.21.5.2
Lessons learnt from testing in pilot sites
Country

Site

Lessons learnt and suggestions for improving the WHO strategy

Mali

Hpital du
Point G

Strong support from the WHO country office was critical to overall pilot success, particularly for
ministerial engagement and proposed scale-up activities

1
2

Active support from the hospital directorate was critical to the project endorsement and development

Difficulties were experienced with some questions comprehension and the collection of the
perception questionnaires. These should be shortened and simplified

Procurement of some ingredients and dispensers for the WHO-recommended formulation was
not possible within the country.

Finding an effective method for the distribution of handrub pocket bottles has been a challenging
issue, especially because of the risk of being taken along outside the hospital

Successful implementation at this pilot site has been critical to demonstrate the feasibility of the
WHO Multimodal Hand Hygiene Improvement Strategy in a setting with limited resources in the African
region

Costa Rica

Hospital
Nacional de
Nios

The national pledge was a strong driver for action

Strong support from WHO regional and country offices has been critical to overall pilot success,
particularly for proposed scale-up activity

1
2

Strong medical and nurse leadership at the facility level was also a key factor of success

Translation and adaptation of tools and the sourcing of alcohol-based handrub were significantly
more time-consuming than originally planned and resulted in delays

Strengthening local capacity to verify quality of the WHO formulation would significantly speed up
the process for regional scale-up

Strengthening local capacity for monitoring and evaluation, particularly data analysis, would
yield significant regional and country benefits

Advocacy could be strengthened and assist in securing donor funding, particularly having a
strong case for the intervention and associated advocacy materials

There were initially numerous aesthetic concerns relating to the alcohol-based hanrubs, particularly
the perception of dead microbes remaining on hands as a disincentive to use the handrub

There were recycling and environmental concerns related to alcohol- based handrub dispensers.
Bottle reprocessing offered a solution

116

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.21.5.2
Lessons learnt from testing in pilot sites (Cont.)
Country

Site

Lessons learnt and suggestions for improving the WHO strategy

Bangladesh

Chittagong
Medical
College
Hospital

The national pledge was a strong driver for action

Strong support form WHO regional and country offices has been critical to overall pilot success,
particularly in relation to proposed scale-up activity
Facility preparation, especially installation of handwash basins, took more time than expected. Local
procurement of heavy duty sanitary equipments such as lever operated pillar taps was not possible.

The close collaboration of a doctor and a nurse as project coordinators was essential to
effectively develop and maintain hand hygiene behavioural change among all HCW and patient
attendants

At the facility level, commitment by the director, strong support by the head of the newly
formed infection control committee, and strong medical and nurse leadership were significant
drivers for improvement

Production of a handrub at the para-statal Essential Drug Company Ltd (EDCL) was effective and
facilitates the process to add alcohol-based handrubs to the government approved essential medical
and surgical requisition list, aspect which is important for budget implication of the national scale-up

The handrub quality control, performed by the EDCL, in future should be complemented through
a WHO quality control mechanism

The Guide to Implementation was a very useful basis for all discussions between WHO
headquarters and the country and facility leads

The five-step approach was adhered to but adaptations were made based on real-life application,
in particular usability was considered an area requiring improvement (need for a simpler guide)

Strengthening local capacity for monitoring and evaluation, particularly data analysis, would
yield significant regional and country benefits

In many cases, relatives provide routine physical care to their patient and are being encouraged to
use the sinks and handrubs. Need to provide patients and relatives with information on HCAI or hand
hygiene.

Comment boxes are present in hospitals and subject to regular review, demonstrating highlevel commitment and a culture supportive of patient perspectives

10

The Five moments-2 concept was considered complicated, especially as far as observation
is concerned

11
12

Initial cultural sensitivities have emerged as regards observation staff did not like being observed

Perception, knowledge, and structure questionnaires raised questions in relation to their

cultural suitability

13

The training film was not used due to lack of easy access to equipment and and re-shooting the film
in a Bangladesh hospital is planned to aid scale-up

14

It was not possible to procure locally durable, economic and purpose-designed wall mounted
handrub dispensers and procurement abroad would have delayed the project by at least 6 months.
Instead liquid soap dispenser were procured

15

With the installation of sinks in the wards, soap use (and with it some theft) increased. Due to a
normative annual budgeting and procurement cycle of the hospital consumables, difficulties to supply
increased amounts of soap to the wards were experienced

16

Local production of heavy duty flip-top dispenser head or spray head for pocket-carry bottle was
not possible. Instead large numbers of spare flip-top heads were procured

17
18

Paper towels and paper towel holder were procured from local markets

Staff feedback on the WHO formulation was positive, though an unpleasant smell after application
was reported

Italy

Network of
ICUs

Strong support from the national coordination centre and the regional coordinators has been critical to
the overall success of the national campaign and the testing in the ICU network

The fact that the campaign was in partnership with a WHO campaign generated a lot of stimulation
and motivation to participate and achieve the intended objectives

The strategy approach was particularly appreciated as a very suitable model for practical
implementation of recommendations. Recommendation was made to use the same model for other
interventions

The Guide to Implementation is complex and the burden of activities to be carried out is arduous.
A summary of the guide was produced by the national coordination centre and considered very helpful

Feedback was considered very important to raise HCWs awareness and to maintain a high level
of support and attention by senior managers throughout the programme roll-out

The five moments approach, the visual impact of WHO educational tools, and the training film
were considered to be the key determinants of the success of educational sessions

6
7

Difficulties were experienced to attract the medical audience

The knowledge questionnaire is difficult to understand; an Improvement in the formulation of

questions 16 and 21 and the removal of question 26 were suggested.

Difficulties were experienced in the use of the Epi Info databases provided by WHO and
therefore it was necessary to make corrections and adaptations
117

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.21.5.2
Lessons learnt from testing in pilot sites (Cont.)
Country

Site

Lessons learnt and suggestions for improving the WHO strategy

Saudi
Arabia

King Saud
Medical
Complex

Strong infection control team and support from the hospital directorate were keys to the success
In general, the WHO strategy requires considerable investment, particularly in human resources. This is
not very clear in the Guide to Implementation

1
2

WHO should offer training on using Epi Info for data entry and especially data analysis

When the WHO formulation (liquid) was introduced, some HCWs expressed their preference for
gel products

The knowledge questionnaire is difficult to understand in many places, especially questions 23, 24,
and 25

Saudi
Arabia

King
Abdul Aziz
Medical
City

Leadership is an important success factor.

Assessing shared beliefs and values regarding the issue of patient safety is highly important in order to
create a safety culture
A patient-centred/customer-focused approach would be beneficial.

1
2

It is important to build on system thinking and not individual thinking

3
4

A post description is needed to facilitate co-ordinator selection.

More training is needed for co-ordinators on: behavioural theories; change management; and
project management principles
Some questions regarding the perceptions and knowledge questionnaires are redundant and
others are difficult to understand and need re-wording

A facilitators guide together with the PowerPoint presentation can be very helpful. The
presentation should include slides that assess the feelings (emotions) of the HCWs, i.e. photos of
infections, experiences of people who were infected, etc.

The Let us do it Together form to assess the how to perform hand hygiene (psychomotor) should
be added to the other WHO tools

7
8
9

A standardized sample reporting format is needed where metrics are shown in a consistent manner

10
11

A small guide is needed on how to overcome resistance to change

An Excel sheet could be helpful for the calculation of product consumption

Communication is the key component of success: to provide ideas on the topic in a very helpful
and informative manner (communications management plans)
Coordinators and project facilitators should be trained on how to address HCWs resistance, i.e.
surprise, apprehension of the unknown, scepticism, cynicism, complacency, strong resistance, etc.

Pakistan

Pakistan
Institute
of Medical
Sciences
(PIMS)

The success of this project was possible due to strong commitment of PIMS senior management.
The project is very demanding in terms of time to be dedicated to education, because of shortage of
permament members of staff and high turnover of medical and nursing students
Language barriers exist (especially among non-medical staff), and there is a need for translation of the
WHO material into the local language (currently been undertaken)

There are difficulties to identify some tasks as aseptic, e.g. dental/oral care; therefore, the wording
of Moment 2 is not adequate

Availability and production of good quality 100 ml flip-top bottles to dispense alcohol-based hand
rub was challenging

Providing a dedicated room with adequate temperature control and storage facilities for the
production and storage of alcohol was a difficult task

4
5

The Guide to Implementation was complex and difficult to understand

Delay to obtain quality control information of locally produced WHO formulation from Geneva
because of restriction of sending liquid sample by postal and couriers services

Staff were delighted at the introduction of the WHO formulation as the commercial product
previously in use had a very high incidence of dermatitis

7
Hong Kong
SAR

Four pilot
hospitals

No religious issues were raised on the use of the alcohol-based handrub product

Barriers to implement system change: HCWs concerns about the use of alcohol-based handrubs
(potential skin damage, fire safety, and pocket bottle contamination) and the perception that hands are
clean only after handwashing.
Difficulties to allocate time to attend the education sessions
No hand hygiene compliance improvement was observed among doctors. The WHO strategy should
include suggestions and ideas how to induce behavioural change in different professional categories

118

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Figure I.21.1
Visual representation of the 5-Step Implementation Strategy

Step 1

Step 5

WHO Guide to
Implementation
Step 4

Step 1

Step 5

Step 2

WHO Guide to
Implementation
Step 4

Step 3

Step 2

Step 3

Year 1

Year 2

Repeat minimum 5 years

Table I.21.2
Action plan step-by-step
Step 1:
Facility Preparedness

Step 2:
Baseline Evaluation

Step 3:
Implementation

Step 4:
Follow-up Evaluation

Step 5:
Developing Ongoing
Action Plan and Review
Cycle

Activities

Activities

Activities

Activities

Activities

Identify coordinator

Baseline Assessments:
undertake

Launch the strategy

Follow-up assessments:
undertake

Study all results carefully

Identify key individuals/

groups

Senior managers
perception survey

Feedback baseline data

Health-care worker
knowledge survey

Feedback of follow-up
data

Undertake Facility
Situation Analysis

Health-care worker
perception survey

Distribute posters

Senior executive
managers perception
survey

Develop a five year

action plan

Complete alcohol-based Ward structure survey

handrub production,
planning and costing
tool

Distribute alcohol-based
handrub

Health-care workers
perception and
campaign evaluation
survey

Consider scale-up of the

strategy

Train observers/trainers

Distribute other WHO

materials from the Pilot
Implementation Pack

Facility Situation
Analysis

Procure raw materials for Data entry and analysis

alcohol-based handrub
(if necessary)

Educate facility staff

Data entry and analysis

Collect data on costbenefit

Hand hygiene
observations

Undertake practical
training of facility staff

Hand hygiene
observations

Evaluate computer
equipment

Health-care worker
knowledge survey

Undertake handrub
tolerance tests

Monthly monitoring of
use of products

Undertake training on
data entry and analysis

Monitor use of soap and

alcohol

Complete monthly
monitoring of usage of
products

Local production or
market procurement of
handrubs

119

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Figure I.21.3
The Pilot Implementation Pack (now named Implementation Toolkit) comprising tools corresponding to each component of the
WHO Multimodal Hand Hygiene Improvement Strategy
120

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Figure I.21.4
Core elements of hand transmission

1
b

b
b

2
b

a
a

3
b

1)
2)

b
a

Donor surface A contains microorganisms a; receptor surface B contains microorganisms b.

A hand picks up a microorganism a from donor surface A and carries it over to receptor surface B, no hand hygiene action
performed.

3)

Receptor surface B is now cross-contaminated with microorganism a in addition to original flora b. The arrow marks the
opportunity for hand hygiene, e.g. the time period and geographical dislocation within which hand hygiene will prevent crosstransmission; the indications for hand hygiene are determined by the need to protect surface B against colonisation with a the

preventable negative outcome in this example.

Reprinted from Sax, 20071 with permission from Elsevier.
121

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Figure I.21.5a
Unified visuals for My five moments for hand hygiene

PATIENT ZONE
CRITICAL SITE WITH
INFECTIOUS RISK
FOR THE PATIENT

CRITICAL SITE
WITH BODY FLUID
EXPOSURE RISK

HEALTH-CARE AREA
The patient zone is defined as the patients intact skin and his/her immediate surroundings colonized by the patient flora and the health-care
area as containing all other surfaces.
Symbols for critical sites with infectious risk for the patient and critical sites with body fluid exposure risk, two critical sites for hand hygiene
within the patient zone (Figure I.21.5a).
Reprinted from Sax, 20071 with permission from Elsevier.

122

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Figure I.21.5b
Unified visuals for My five moments for hand hygiene

E
O

/ASE P

ED

A
O

2
BEFORE
TOUCHING

AFTER
TOUCHING

A PATIENT

A TER
F

F
L
U

I
S
K

The patient zone, health-care area, and critical sites

with inserted time-space representation of My five
moments for hand hygiene (Figure I.21.5b).
Reprinted from Sax, 20071 with permission from
Elsevier.

DEX

T
O
U
C
H
I
N
G

A PATIENT

5
P
A
T

IE
N
T
S
U
R
R
O
U
N
DI
N
G
S

123

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

22.
Impact of improved hand hygiene
Evaluation of the effectiveness of hand hygiene guidelines or recommendations on the ultimate outcome, i.e. the
HCAI rate, is certainly the most accurate way to measure the impact of improved hand hygiene, but it represents a
very challenging activity. Indeed, guideline implementation should not be evaluated per se but in relation to the
availability of clear instructions on how to translate it into practice and, ideally, the existence of related tools and
impact of their implementation. As an illustration, in a sample of 40 hospitals in the USA, Larson and colleagues
found that although most HCWs were aware of the hand hygiene guidelines with alcohol-based handrub available
in all facilities, a multidisciplinary implementation programme was conducted in only 44.2% of the hospitals. 728 The
impact was quite disappointing: mean hand hygiene compliance rates were no higher than 56.6%, and the
correlation of lower infection rates with higher compliance was demonstrated only for bloodstream infections. The
authors concluded that a real change following guideline dissemination is not achievable unless fostered by factual
multidisciplinary efforts and explicit administrative support.
practices. The intervention
Difficulties to deal with this challengig issue depend firstly on
lasted eight months, and a
the diversity of methodologies used in available studies, and
follow-up survey six months
this is well reflected in the very different conclusions that can be after the end of the
intervention showed a
drawn from systematic reviews on the topic.887,888
sustained improvement in
hand hygiene practices.
The lack of scientific information on the definitive impact of
More recently, several
improved hand hygiene compliance on HCAI rates has been
studies demonstrated a clear
reported as a possible barrier to appropriate adherence with
impact of improved hand
hand hygiene recommendations. However, there is convincing
hygiene on MRSA
evidence that improved hand hygiene through multimodal
rates.489,494,718 In a district
implementation strategies can reduce infection
hospital in the United
rates. In addition, although not reporting infection rates,
several studies showed a sustained decrease of the incidence Kingdom, the incidence of
hospitalof multidrug-resistant bacterial isolates and patient
acquired MRSA cases
colonization following the implementation of hand hygiene
significantly decreased after a
improvement strategies.428,655,687,701 Failure to perform
successful hand hygiene
appropriate hand hygiene is considered the leading cause of
489
HCAI and spread of multi-resistant organisms, and has been promotion programme.
Similarly, in Australia,
recognized as a significant contributor to outbreaks.
a hospitalwide, multifaceted
At least 20 hospital-based studies of the impact of hand hygiene on programme to change hand
hygiene culture and practices
the risk of HCAI have been published between 1977 and
led to a 57% reduction of
June 2008 (Table I.22.1).60,61,121,181,182,195,196,489,494,645,657,659,663,667,713718,852
Despite study limitations, most reports showed a MRSA bacteraemia episodes
temporal relation between improved hand hygiene practices as well as a significant
reduction of the overall number
and reduced infection and cross-transmission rates.
of clinical isolates of MRSA
and ESBL-producing E. coli
195
Maki found that HCAI rates were lower when antiseptic
and Klebsiella spp.494 The
659
handwash was used by HCWs. Doebbeling and colleagues
programme was subsequently
compared hand antisepsis using a chlorhexidine-containing
expanded to another six
detergent to a combination regimen that permitted either
health-care institutions and
handwashing with plain soap or use of an alcohol-based handrub.
then to
HCAI rates were lower when the chlorhexidine-containing product
the entire state of Victoria.
was in use. However, because relatively little of the alcohol rub
After 24 months and 12
was used during periods when the combination regimen was in
months of follow-up,
operation and because adherence to policies was higher when
respectively, MRSA
chlorhexidine was available, it
bacteraemia and the number
was difficult to determine whether the lower infection rates
of MRSA clinical isolates
were attributable to the hand hygiene regimen used or to
significantly decreased both in
the differences in HCW compliance with policies.
the 6 pilot hospital and
statewide (see Table I.22.1).719
713
A study by Larson and colleagues found that the frequency of
In another study, the
VRE infections, but not MRSA, decreased as adherence of
intervention consisted of the
HCWs to recommended handwashing measures improved.
hospitalwide introduction of an
This strategy yielded sustained improvements in hand hygiene
alcohol-based gel and MRSA
surveillance feedback through
charts.718 Significant
reductions of MRSA

bacteraemia and MRSA

central line-associated
bacteraemia were observed
hospitalwide and in the ICU,
respectively, with a follow-up
of 36 months. In this study,
however, it is difficult to define
the actual role of hand hygiene
to reduce MRSA bacteraemia,
because charts were a strong
component of the intervention
and, at the same time general
infection control measures
were intensified and the use of
antibiotic-coated central
venous catheters was initiated
in the ICU.
In 2000, a landmark study by
Pittet and colleagues60
demonstrated that
implementing a
multidisciplinary programme to
promote increased use of an
alcohol-based handrub led
to increased compliance of
HCWs with recommended
hand hygiene practices and a
reduced prevalence of HCAI.
Individual bottles of handrub
solution were distributed in
large numbers to all wards,
and custom-made holders
were mounted on all beds to
facilitate access to hand
antisepsis. HCWs were also
encouraged to carry a bottle in
their pocket. The promotional
strategy was multimodal and
involved a multidisciplinary
team of HCWs, the use of wall
posters, the promotion of
bedside handrubs throughout
the institution, and regular
performance
feedback to all HCWs (see
http://www.hopisafe.ch for
further details on
methodology). HCAI rates,

attack rates of MRSA

124

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

reduction in
MRSA
transmission may
well have been
affected by both
improved hand
hygiene
crossadherence
transmission, and and the
consumption of simultaneou
handrub were
s
measured in
implementati
parallel.
on of active
Adherence to
surveillance
recommended
cultures for
hand hygiene
detecting
practices
and isolating
patients
improved
progressively from colonized
with
48% in 1994 to
66%
MRSA.889
Follow-up
in 1997 (P
evaluation 8
<0.001). While
years after
recourse to
the
handwashing
beginning of
with soap and
water remained the
programme
stable, the
revealed
frequency of
continuous
handrubbing
improvement
markedly
with
increased over
the study period hand hygiene
(P <0.001), and practices,
the consumption increased
of alcohol-based recourse to
alcohol-based
handrub solution
handrub, and
increased from
stable HCAI rates;
3.5 litres to 15.4
it also highlights
litres per 1000
the cost
patient-days
effectiveness of
between 1993
the strategy.61 The
and 1998 (P
experience from
<0.001).
Genevas
Importantly,
University
increased
Hospitals
recourse to
constitutes the
handrubbing was
first report of a
associated with a hand hygiene
significant
campaign
improvement in demonstrating a
compliance in
sustained
critical care,334
improvement over
suggesting that several years;
time constraint
some recent
bypassing was
further studies
critical. The
reported a positive
increased
impact of hand
hygiene promotion
frequency of
hand antisepsis with a prolonged
was unchanged follow-up
after adjustment
(up to 3
for known risk
years).494,714,717,718
factors of poor
More recently, a
adherence.
During the same number of
studies assessed
period, both
overall HCAI and the effectiveness
of hand hygiene
MRSA
improvement to
transmission
prevent HCAI in
rates decreased
neonatal care.
(both P <0.05).
Following the
The observed
implementation

of hand hygiene
multimodal
strategies, Lam
and
colleagues648
and Won and
colleagues714
demonstrated a
significant
decrease of
overall HCAI
rates
in neonatal ICUs,
whereas PessoaSilva and
colleagues657
observed only a
decrease in very
low-birth-weight
neonates (Table
I.22.1). A
significant
reduction of HCAI
was also
observed in adult
ICU patients in a
hospital in
Argentina.716
Other
investigations
showed an
impact of
improved hand
hygiene
on specific
types of HCAI
such as
rotavirus715
and surgical
site infections
in
neurosurgery7
17
(Table
I.22.1).
Furthermore,
a recent
review of the
literature
related to the
effectiveness
of

handwashing
against SARS
transmission
concluded that
nine of 10
epidemiologic
al studies
showed a
protective
effect of hand
hygiene, but
this result was
only significant
in three in a
multivariate
analysis.890
In several other
studies in which
hand hygiene
compliance was
not monitored,
multidisciplinary
programmes that

involved the
introduction of an
alcohol-based
handrub were
associated with a
decrease in
HCAI and crosstransmission
rates.429,489,645,735
The beneficial
effects of hand
hygiene
promotion on the
risk
of crosstransmission
have also been
reported in
surveys
conducted in
schools or daycare
centres,454,891-896
as well as in
community
248,249,449,754,815,
settings.
830,897-900

While none of
the studies
conducted in
the health-care
setting
represented
randomized
controlled trials,
they provide
substantial
evidence that
increased hand
hygiene
compliance is
associated with
reduced HCAI
rates. Indeed,
only very few
studies
concluded that
hand hygiene
promotion had
no impact on
HCAI. A very
early study from
Simmons and
colleagues

showed that
interventions
aimed at
improving
handwashing
practices in ICUs
failed to improve
them substantially
and therefore to
reduce HCAI.667 A
very recently
published twoyear, prospective,
controlled crossover trial by Rupp
and colleagues
has attracted
much attention,
including from the
lay press. The
authors observed
that a significant
and sustained
improvement in
hand hygiene
adherence
following the
introduction of an
alcohol-based
handrub did not
lead to a
substantial
change
in deviceassociated
infection rates
and infections
due to multidrugresistant
pathogens.707
Nevertheless, it is
crucial to note
that although the
study was, in
general, welldesigned and
conducted, it
presents key
limitations that
have led to harsh
criticism following
its publication,901903
including lack
of screening for
crosstransmission, lack
of statistical
power, and use of
an alcohol-based
handrub that fails
to meet the EN
1500 standards
for antimicrobial
efficacy.
Methodological
and ethical
concerns make it

difficult to set up
randomized
controlled trials
with appropriate
sample sizes
that could
establish the
relative
importance of
hand hygiene in
the prevention of
HCAI. The
studies so far
conducted,
although semiexperimental
and of good
quality in most
cases, could not
determine a
definitive causal
relationship
owing to the

lack of statistical
significance, the
presence of
confounding
factors, or the
absence of
randomization.
Given that
multimodal
strategies are
the most
preferred
methods to
obtain hand
hygiene
improvement,60,7
13,719,728

additional
research on the
relative
effectiveness of
the different
components of
these strategies
would be very
helpful to
successful
achievement of a
sustainable
impact.809,904
The unique
large,
randomized
controlled trial to
test the impact of
hand hygiene
promotion clearly
demonstrated
reduction
of upper
respiratory
pulmonary
infection,
diarrhoea, and
impetigo among
children in a
Pakistani
community, with
positive effect on
child health.249,449

Although it
infection rates in
remains important health-care
to generate
settings, these
additional
results strongly
scientific and
suggest
causal evidence that
for the impact of improved
enhanced
hand
adherence with hygiene
hand hygiene on practices
125

reduce
the risk
of
transmiss
ion of
pathogen
ic
microorg
anisms.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.22.1
Association between improved adherence with hand hygiene practice and health care-associated infection rates
(1975 June 2008)
Year

Authors

Hospital
setting

Major results

Duration of
follow-up

1977

Casewell &

Adult ICU

Significant reduction in the percentage of patients colonized or

2 years

Phillips121

infected by Klebsiella spp.

1989

Conly et al.663

Adult ICU

Significant reduction in HCAI rates immediately after hand hygiene

promotion (from 33% to 12% and from 33% to 10%, after two
intervention periods 4 years apart, respectively)

6 years

1990

Simmons et

Adult ICU

No impact on HCAI rates (no statistically significant improvement of

11 months

al.667
1992

Doebbeling et

al.

hand hygiene adherence)

Adult ICUs

Significant difference between rates of HCAI using two different

8 months

hand hygiene agents

659

1994

Webster et al.181

NICU

Elimination of MRSA, when combined with multiple other infection

control measures.
Reduction of vancomycin use. Significant reduction of nosocomial
bacteremia (from 2.6% to 1.1%) using triclosan compared to
chlorhexidine for handwashing

9 months

1995

Zafar et al.182

Newborn
nursery

Control of a MRSA outbreak using a triclosan preparation for

handwashing, in addition to other infection control measures

3.5 years

2000

Larson et al.713

MICU/NICU

Significant (85%) relative reduction of VRE rate in the intervention

hospital; statistically insignificant (44%) relative reduction in control
hospital; no significant change in MRSA

8 months

2000

Pittet et al.60,61

Hospitalwide

Significant reduction in the annual overall prevalence of health careassociated infections (42%) and MRSA cross-transmission rates
(87%). Active surveillance cultures and contact precautions were
implemented during same time period. A follow-up study showed
continuous increase in handrub use, stable HCAI rates and cost
savings derived from the strategy.

8 years

2003

Hilburn et al.645

Orthopaedic
surgical unit

36% decrease of urinary tract infection and SSI rates (from 8.2% to
5.3%)

10 months

2004

MacDonald et

Hospitalwide

Significant reduction in hospital-acquired MRSA cases (from 1.9%

1 year

489

al.
2004

Swoboda et
al.852

to 0.9%)
Adult
intermediate
care unit

Reduction in HCAI rates (not statistically significant)

2.5 months

126

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.22.1
Association between improved adherence with hand hygiene practice and health care-associated infection rates
(1975 June 2008) (Cont.)
Year

Authors

Hospital
setting

Major results

Duration of
follow-up

2004

Lam et al.648

NICU

Reduction (not statistically significant) in HCAI rates (from 11.3/1000

patient-days to 6.2/1000 patient-days)

6 months

2004

Won et al.714

NICU

Significant reduction in HCAI rates (from 15.1/1000 patient-days to

10.7/1000 patient-days), in particular of respiratory infections

2 years

2005

Zerr et al.715

Hospitalwide

Significant reduction in hospital-associated rotavirus infections

4 years

2005

Rosenthal et

Adult ICUs

Significant reduction in HCAI rates (from 47.5/1000 patient-days to

21 months

al.

27.9/1000 patient-days)

716

494

2005

Johnson et al.

Hospitalwide

Significant reduction (57%) in MRSA bacteraemia

36 months

2007

Thi Anh Thu et

al.717

Neurosurgery

Reduction (54%, NS) of overall incidence of SSI. Significant

reduction (100%) of superficial SSI; significantly lower SSI incidence
in intervention ward compared with control ward

2 years

2007

Pessoa-Silva et

Neonatal unit

Reduction of overall HCAI rates (from 11 to 8.2 infections per 1000

patient-days) and 60% decrease of risk of HCAI in very low birth
weight neonates (from 15.5 to 8.8 episodes/1000 patient-days)

27 months

al.657

2008

Rupp et al.707

ICU

No impact on device-associated infection and infections due to

multidrug-resistant pathogens

2 years

2008

Grayson et al.719

1) 6 pilot
hospitals

1) Significant reduction of MRSA bacteraemia (from 0.05/100 patientdischarges to 0.02/100 patient-discharges per month) and of clinical
MRSA isolates
2) Significant reduction of MRSA bacteraemia (from 0.03/100
patient-discharges to 0.01/100 patient-discharges per month) and of
clinical MRSA isolates

1) 2 years
2) 1 year

2) all public
hospitals
in Victoria
(Australia)

ICU: intensive care unit; NICU: neonatal ICU; MRSA: methicillin-resistant S aureus; VRE: vancomycin-resistant Enterococcus spp; MICU:
medical ICU; HCAI: health care-associated infection; SSI: surgical site infection;
NS: not significant.
Source: adapted from Pittet, 2006885 with permission from Elsevier.

127

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

23.
Practical issues and potential barriers to optimal
hand hygiene practices
23.1 Glove policies
23.1.1 Reasons for glove use
Prior to the emergence of HIV and the acquired immunodeficiency
syndrome (AIDS) epidemic, gloves were essentially worn
primarily by HCWs either caring for patients colonized or infected
with certain pathogens or exposed to patients with a high risk of
hepatitis B. Since 1987, a dramatic increase in glove use has
occurred in an effort to prevent the transmission of HIV and other
bloodborne pathogens from patients to HCWs.905 The National
Institute for Occupational Safety and Health Administration in the
USA (NIOSHA) mandates that gloves be worn during all patientcare activities involving exposure to blood or body fluids that may
be contaminated with blood,906 including contact with mucous
membranes and non-intact skin. In addition, gloves should be
worn during outbreak situations, as recommended by specific
requirements for Personal Protective Equipment (PPE).58,423,906
The broad scope of these recommendations for glove use
potentially leads to inevitable, undesirable consequences, such as
the misuse and the overuse of gloves; therefore, there is a need
to define glove use indications with greater precision.

thickness, elasticity and

strength that are different
from other medical gloves
(either sterile or nonsterile).
Medical
gloves
are
designed to serve for care
purposes only and are not
appropriate
for
housekeeping activities in
health-care facilities. Other
specific types of gloves
are intended for these
types
of
non-care
activities.

In published studies, the

barrier integrity of gloves has
varied considerably based on
the type and quality of glove
material, intensity of use,
length of time used,
manufacturer, whether gloves
were tested before or after
use, and the method used to
Medical glove use by HCWs is recommended for two main
913-920
In
reasons: 1) to reduce the risk of contaminating HCWs hands with detect glove leaks.
some published studies, vinyl
blood and other body fluids; 2) to reduce the risk of germ
gloves more frequently had
dissemination to the environment and of transmission from the
defects than did latex gloves,
HCWs to the patient and vice versa, as well as from one patient
the difference being greatest
to another.701,884,907,908
after use.913,914,917,921 Intact
Single-use (also called disposable) examination gloves, either non- vinyl gloves, however, provide
protection comparable to that
sterile or sterile, are usually made of natural rubber latex or
provided by latex gloves.913
synthetic non-latex materials such as vinyl, nitrile and neoprene
Limited studies suggest that
(polymers and copolymers of chloroprene). Because of the
nitrile gloves have leakage
increasing prevalence of latex sensitivity among HCWs and
patients, the FDA has approved a variety of powdered and powder- rates close to those of latex
gloves.922-925 Although recent
free latex gloves with reduced protein contents, as well as
studies suggest that
synthetic gloves that can be made available by health-care
institutions for use by latex-sensitive HCWs and for patients with improvements have been
latex hypersensitivity.909 Several new technologies are emerging made
919

in the quality of gloves, the

(e.g. impregnated glove materials that release chlorine dioxide
when activated by light or moisture to produce a disinfecting micro- laboratory and clinical studies
cited above provide strong
atmosphere),910 but none of them has so far led to changes in
evidence that hands should still
49
glove use recommendations. The correct and consistent use of
be decontaminated or washed
existing technologies with documented effectiveness is
after glove
encouraged before new technologies are introduced. The main
removal.73,123,139,204,520,914
feature of examination gloves to bear
in mind is that they are meant to be single-use and to be

discarded.907,911,912 In most cases, they are non-sterile.

Sterile surgical gloves are required for surgical interventions.
Some non-surgical care procedures, such as central vascular
catheter insertion, also require surgical glove use. In addition to
their sterile properties, these gloves have characteristics of

23.1.2 Glove efficacy

The efficacy of gloves in
preventing contamination of
HCWs hands has been
confirmed in several clinical
studies.72,110,139 One study found
128

that HCWs who wore gloves

during patient contact
contaminated their hands with
an average of only 3 CFUs per
minute of patient care, compared
with 16 CFUs per minute for
those not wearing gloves.72 Two
other studies of HCWs caring for
patients with C. difficile or VRE
found that wearing gloves
prevented hand contamination
among a majority of those
having direct contact with
patients.110,139 Wearing gloves
also prevented HCWs from
acquiring VRE on their hands
when touching contaminated
environmental surfaces.139
Preventing gross contamination
of the hands is considered
important because handwashing
or hand antisepsis may not
remove all potential pathogens
when hands are heavily
contaminated.88,278 Furthermore,
several studies provide evidence
that wearing gloves can help
reduce transmission of
pathogens in health-care
settings.701,884 In a prospective
controlled trial that required
HCWs routinely to wear vinyl
gloves when handling any body
substances, the incidence of C.
difficile diarrhoea among
patients decreased from 7.7
cases/1000 patient discharges
before the intervention to 1.5
cases/1000 discharges during
the intervention.422 The
prevalence of asymptomatic C.
difficile carriage also decreased
significantly on glove wards,
but

not on control wards. In ICUs

with VRE or MRSA
epidemics, requiring all
HCWs to wear gloves to care
for all patients in the unit
(universal glove use)
appeared to contribute to the
control of outbreaks.926-928
These data must be
interpreted in the light of the
actual direct impact on patient
care, however, and some
additional considerations
need to be discussed.49,929
Glove use is not sufficient to
prevent germ transmission
and infection if

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

not rigorously
accompanied by
previous and
successive
further preventive
measures.930 The
benefit of gloves
is strictly related
to the conditions
of usage; the
appropriateness
of the latter
strongly
influences the
actual reduction
of germ
dissemination
and infection
crosstransmission.
Hand
hygiene is
the most
important
measure to
protect
patients,
HCWs and
the
environme
nt from
microbial
contaminat
ion. Hand
hygiene
indications
exist
regardless
of glove
use, even
if they
influence
glove
wearing. A
study
highlighted
the risk
related to
universal
gloving as
regards
multidrugresistant
organism
transmission:
universal gloving
can lead to a
significant
increase of
device-related
infections.884.
Furthermore,
wearing gloves
does not provide
complete
protection against

the acquisition of
infections caused
by HBV and
HSV.913,931,932
These studies
provide definitive
evidence
that gloves
must be
removed after
care of a single
patient and
during the care
of a patient,
when moving
from any body
site to another
such as non
intact skin,
mucous
membrane or
invasive
medical device
within the
same patient,
and that hand
cleansing must
be performed
after glove
removal.
Bacterial flora
colonizing
patients may
be recovered
from the hands
of up to 30% of
HCWs who
wear gloves
during patient
contact.123,139
Doebbeling
and
colleagues520
conducted an
experimental
study in which the
artificial
contamination of
gloves was
undertaken with
conditions close to
clinical practice.
The authors
cultured the
organisms used
for artificial
contamination
from 4100% of
the gloves and
observed counts
between 0 and 4.7
log on hands after
glove removal. In
a recent study
identifying
neonatal-care
activities at higher
risk for hand
contamination, the
use of gloves
during routine
neonatal care did
not fully protect

HCWs hands
from bacterial
contamination
with organisms
such as
Enterobacteriacae
, S. aureus, and
fungi.73 In such
instances,
pathogens
presumably gain
access to the
caregivers hands
via small defects
in gloves or by
contamination of
hands during
glove
removal.123,520,913,9
14

23.1.3 Glove use

and hand
hygiene
The impact of
wearing gloves on
compliance with
hand hygiene
policies has not
been definitively
established, as
published studies
have yielded
contradictory
results.49,216,661,672,
739

Several studies
found that HCWs
who wore gloves
were less likely to
cleanse their
hands upon
leaving a patients
room,661,688,739,908,9
30

and two
established an
association
between
inappropriate
glove use and low
compliance with
hand
hygiene.908,930 In
contrast, three
other studies
found that HCWs
who wore gloves
were significantly
more likely to
cleanse their
hands following
patient
care.216,672,802,933
Most of these
studies were
focused

on hand
hygiene
performance
after glove
removal only
and did not
consider other

indications.
One study
found that the
introduction of
gloves
increased
overall
compliance
with hand
hygiene, but
the introduction
of isolation
precautions did
not result in
improved
compliance.934
For example,
compliance

misuse is not only

associated with
shortage of
supply, but also
with a poor
knowledge and
perception of the
risk of pathogen
transmission.695,93
7-940
Other studies
pointed out the
practical difficulty
to combine hand
with glove
hygiene and
changing when
689,759
In
moving between glove use.
one
study,
glove
different body
sites in the same use compliance
rates were 75%
patient was
unsatisfactory, as or higher across
all HCW groups
well as
except doctors,
compliance with
whose
optimal hand
hygiene practices. compliance was
only 27%.128
Furthermore,
HCWs should be
although some
reminded that
studies
failure to remove
demonstrated a
gloves between
high compliance
patients or when
with glove use,
moving between
they did not
different body
investigate its

of the
patient
may contribute
6
Surveys
to
the
conducted at
transmission of
facilities with
73,927,
limited resources organisms.
930,932,941
In two
showed that
low compliance reports, failure
to
remove
with
and
recommendation gloves
s for glove use gowns and to
and its
wash
hands
when
moving
between
patients
was
associated with
an increase in
MRSA
transmission
during
the
SARS
outbreak.942,943
possible

sites

misuse.683,689,935,93 same

Whether hand
hygiene should
be performed
before donning
non-sterile
gloves is an
unresolved
issue and
therefore this
moment should
not be
recommended
as an indication
for hand
hygiene. In this

connection, a
study found that
volunteers did
not contaminate
the outside of
their gloves
significantly
more often when
they did not
wash their
hands before
donning gloves,
compared with
the level of
glove
contamination
that occurred
when they
washed their
hands first.944
The study did
not determine
whether or not
HCWs
transmitted
pathogens to
patients more
frequently when
they did not
wash their
hands before
donning gloves.

23.1.4
Appropriate and
safe use of
gloves
The use of
gloves in
situations when
their use is not
indicated
represents a
waste of
resources
without
necessarily
leading to a
reduction of
crosstransmission.88
4,930
The wideranging
recommendatio
ns for glove
use have led to
very frequent
and
inappropriate
use in general,
far exceeding
the frame of
real
indications and
conditions for
appropriate glove
use that remain
poorly understood
among HCWs.
Careful attention
should be paid to
the use of

medical gloves
according to
indications907

identify clinical
situations when
gloves are not
for donning, but indicated; 2)
differentiate
also for their
these from
removal.
situations where
Moreover,
gloves should
numerous
conditions
be worn; and 3)

regulate glove
use and are
aimed at
preventing glove
contamination
and further
consequences.
General
indications for
gloving and for
glove removal
are listed in
Table I.23.1 and
practical
examples of
care situations
with indication
for glove use
are included in
the pyramid
(Figure I.23.1).
It is important
that HCWs are
able to: 1)

correctly select
the most
appropriate type
of gloves to be
worn.
Indications
including indirect
health-care
activities, such
as preparing
parenteral
nutrition or
handling soiled
waste, are also
shown in the
figure. In
general, the
moment for
glove removal
meets the
recommendation
s for single use,
i.e. related to a
single patient
and to a single

care situation
within the same
patient.
Conditions for
glove use also
imply the
existence of a
glove use
procedure. Proper
glove use requires
continuous
reasoning and a
behavioural
adjustment
according to the
care situation
(Table I.23.2).
These conditions
are associated
with equipment
procurement and
management
(supply,
availability,
storage, and
disposal) and with
rigorous
sequences and
techniques for
glove donning and
removal (Figures
I.23.2 and I.23.3).
Conditions
129

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

glove
contamination
and possible
crosstransmission
in case of
glove damage
for glove
or improper
use in
use/efficacy. 2)
health
Gloves must
care are
be removed to
as crucial
perform
as the
handwashing
identificati
or
on of
handrubbing
indication
to protect a
s.
body site from
Indication
the flora from
s
another body
represent
site or skin
a frame
area
to limit
previously
the start
touched within
and end
the same
of glove
patient. 3)
Hand hygiene
use.
must be
Importantl
performed
y, gloves
immediately
must be
after glove
donned
removal to
immediat
prevent HCW
ely before
contamination
the
and further
contact or
transmission
the
and
activity
dissemination
that
of
defines
microorganisms
the
indication . It should be
noted that
and
handwashing
removed
immediately with soap and
water is
after this
contact or necessary
when gloves
activity is
are removed
945
over.
because of a
tear or a
Glove use
puncture and
does not
obviate the the HCW has
had contact
need to
comply with with blood or
another body
hand
hygiene.884 fluid; this
1) When the situation is
considered to
hand
be equivalent to
hygiene
a direct
indication
exposure to
occurs
blood or
before a
contact
another body
requiring
fluid.
glove use,
handwashin Further crucial
g or
conditions for
handrubbin appropriate
g must be
glove use are
performed their
before
mechanical
donning
and
gloves to
microbiological
prevent
integrity.

Medical gloves
should be kept
in their original
package or box
until they are
donned;945 this
requires that
gloves are
available at the
point of care as
well as alcoholbased
handrubs.
Moreover, it is
appropriate to
have more
than one type
of gloves
available, thus
allowing HCWs
to select the
type that best
suits their
patient-care
activities as
well as their
hand size.
When
removed,
gloves should
be discarded
and disposed
of; ideally,
gloves should
not be washed,
decontaminate
d, or
reprocessed
for any reuse
purpose.
These
conditions
are essential
to prevent
germ
transmission
through
contaminated
gloves to the
patient and
the HCW,
and their
further
dissemination
in the
environment.
When gloving
is required
continously
because
contact
precautions
are in place,
all these
conditions
are difficult to
integrate as
part of

usual care
activities.
Indeed, while
the general

indication to
don gloves
should
remain until
the contact
with the
patient and
his/ her
immediate
surrounding
s is
completed,
indications
for glove
removal,
hand
hygiene
and, again,
further
indications
for gloving
may occur.

23.1.5
Factors
potentially
interfering
with glove
use
The use of
petroleumbased
hand
lotions or
creams
may
adversely
affect the
integrity of
latex
gloves.946
Following
the use of
powdered
gloves,
some
alcoholbased
hand rubs
may
interact
with
residual
powder on
HCWs
hands,
resulting in
a gritty
feeling on
hands. In
facilities
where
powdered
gloves are

commonly
used, a
variety of
alcoholbased hand
rubs should
be tested
following

removal of
powdered
gloves in order
to avoid
selecting a
product that
causes this
undesirable
reaction.520,914
As a general
policy, healthcare settings
should
preferably
select nonpowdered
gloves for both
examination
and surgical
purposes.

23.1.6
Caveats
regarding
washing,
decontami
nating and
reprocessi
ng gloves
Manufactur
ers are not
responsible
for glove
integrity
when the
principle of
single
usage is
not
respected.
Any
practice of
glove
washing,
decontami
nation or
reprocessi
ng is not
recommen
ded as it
may
damage
the
material
integrity
and
jeopardize
the gloves
protective
function.
Although
these
practices are
common in
many healthcare settings,
essentially in
developing
countries,
where glove
supply is
limited,947 no
recommendati
on exists
concerning
the washing
and reuse of
gloves, nor
the washing or
decontaminati
on of gloved
hands
followed by
reuse on
another
patient.
In one study,

washing
arriving at
consistent
gloved
recommendati
hands
ons. To this
between
end, we call
patient
treatments upon the
manufacturers
using 4%
chlorhexidin of gloves for
e and 7.5% medical
application to
povidoneiodine liquid concentrate on
soaps for 30 this issue and
to conduct
seconds
eradicated research to
develop
all
organisms recyclable
inoculated gloves for both
examination
from
both glove and surgical
surfaces.948 use, and to
provide also
Another
information
study
describes a about safe
reprocessing
significant
reduction of methods for
the reuse of
bacterial
gloves in
count on
perforated resourcelimited
gloves to
permit their settings.
reuse for
non-sterile Cleansing
procedures gloved hands
to allow for
after
cleansing of prolonged
the gloved use on the
hand using same patient
an alcohol- may result in
considerable
based
preparation savings of
disposable
with
chlorhexidin examination
gloves. Some
e.949
Although the evidence
exists that
microbial
cleansing
efficacy of
latex-gloved
glove
washing and hands using
decontamina an alcoholbased
tion is
demonstrate handrub
solution is
d, the
consequenc effective in
es of such removing
processes microon material organisms
integrity still and shows
increasing
remain
contamination
unknown.
rates of
More
research on hands only
after 910
glove
cycles of
integrity
cleansing.950,951
after
However,
washing,
decontamina cleansing
plastic-gloved
ting, and
reprocessing hands with an
is necessary alcohol-based
formulation
to answer
leads to early
numerous
dissolving of the
unsolved
plastic material.
issues
If there is an
before

intention
to
proceed with the
process

of glove
decontaminat
ion, this
should be
started only
after
performing a
local study
using the
type of gloves
and products
provided at
the facility. It
should be
noted that
this process
may be
applied only
in the
framework of
contact
precautions
implementati
on907 and as
long as
gloves are
not soiled
with blood
and other
body fluids.
As a
consequence
, this limited
context for
glove
decontaminat
ion probably
does not
represent an
effective
response to
the serious
problem of
glove
shortage in
developing
countries.
In
conclusion,
no
evidencebased
recommend
ation
currently
exists
regarding
glove
reprocessin
g. While this
may be an
interesting
option at
facilities
where
supply is
insufficient,
all
consequenc
es of the

reproces
sing
should be
anticipate
d and
measure
d before
putting it
into
practice.
A
reproces
sing
method
has been
suggeste
d by the

Johns
Hopkins
Program for
Internationa
l Education
in
Reproductiv
e
Gynaecolog
y and
Obstetrics
(JHPIEGO).
952
This
process is
not
standardize
130

d nor
validated,
and no
recommend
ation of this
or any other
reprocessing
process can be
expressed in
the absence of
good quality
research. This
protocol firstly
includes a
situation
analysis

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

HCWs should
be educated to
appropriate use
of gloves (see
Figure I.23.1).
In institutions with
assessment and limited resources,
some criteria for some authors
opting for
suggest that if the
reprocessing
necessity for the
gloves in order to reprocessing of
minimize the risks single-use gloves
and to optimize persists after a
the results. Before thorough
planning or
evaluation, the
continuing the
reprocessing of
reprocessing of previously
used gloves,
decontaminated
every health-care and thoroughly
facility should first cleaned surgical
undertake an
gloves using
assessment of
sterilization
factors leading to (autoclaving) or
the shortage of
high-level
single-use gloves, disinfection
such as budget (steaming) can
constraints or
produce an
interrupted supply acceptable
chains. Efforts
product; when
should focus on combined with
reducing the need double gloving,
for gloves by
this may
avoiding wastage constitute a
caused by
temporary
unnecessary use tolerable
and by providing a practice.952,953
secure stock
However, the
of good quality
practice could be
single-use
retained only if
surgical and
basic criteria,
examination
such as glove
gloves,
quality, are
satisfied and the
together with a
selected
budget for
processes and
regular
technologies for
restocking.
Opting for glove reprocessing are
reliable and under
reprocessing
control. A
without having
universal problem
made these
is the introduction
assessments
of equipment,
would amount
technology, and
to contributing
method with no
to the
maintenance of evaluation of
associated needs.
inappropriate
In this case, their
glove use.
reliability and
Health
safety are not
administrators
929
are encouraged guaranteed.
If reprocessing
to purchase
does take place,
good quality
the institution
disposable
should develop
gloves and
clear policies to
replenish
define clinical
stocks in time.
situations where
In addition,
clinic managers gloves are
and supervisors needed, when
the use of
should check
reprocessed
that gloves are
not wasted, and gloves can be

tolerated, and
when gloves
should be
discarded and
not reprocessed
(e.g. when holes
are detected).
Only surgical
latex gloves may
be reused either
as surgical
gloves using
double gloving
or as gloves for
examination
purposes. Some
authors
recommend that
latex rubber
surgical gloves
should be
discarded after
three
reprocessing
cycles because
gloves tear more
easily with
additional
reprocessing.954,
955
Examination
gloves should
never be
reprocessed
because of their
particular
composition
properties,
thinness, and
inelasticity.

Systematic
research is
urgently needed
to evaluate
reprocessing
methods and to
develop and
validate a
process that
leads to a
product of
acceptable
quality.
Furthermore,
well-conducted
costbenefit
studies are
required to
evaluate the
potential benefits
of reprocessing
gloves and the
general need for
investing in
preventive
measures.
Through an
analysis of the
financing
structures of
health-care
delivery systems
in developing

countries,
incentives for
investment in the
prevention of
HCAIs from the
individual,
prevent
institutional, and to
material
sticking
societal
perspectives can together and to
facilitate reuse.
be identified.
The practice of
autoclaving used
plastic gloves in
case of shortage
and of
autoclaving new
plastic gloves
meant for
examination for
use as surgical
gloves has been
described.956 The
reprocessing at
125 C leads to
gloves sticking
together, and
separation
causes tears and
holes. The
authors found
41% of recycled
gloves with
impaired
integrity.956
Another potential
hazard is often
witnessed in
developing
countries: many
reprocessing
units use powder
inside
reprocessed
latex gloves

The
consequences
of
use
of
powdered latex
gloves in terms
of
the
development of
latex
allergies
and
impaired
working
conditions
leading
to
sickness
in
HCWs are well
documented.957

In general, one
of the major risks
of reprocessing
gloves is that
they could show
a higher rate of
non-apparent
holes and tears
after the
reprocessing
cycle than new
ones. A study by
Tokars et al.
showed that
surgeons
wearing a single
layer of new
surgical gloves
had blood
contact in 14% of
the procedures,
and blood
contact was 72%
lower among
surgeons who
double gloved.958
Therefore,
double gloving in
countries with a
high prevalence
of HBV, HCV and
HIV for long
surgical
procedures (>30
minutes), for
procedures with
contact with
large amounts of
blood or body
fluids, for some
high-risk
orthopaedic
procedures, or
when using
reprocessed
gloves is
considered an

appropriate
practice.
The illegal
recovery and
recycling of
discarded gloves
from hospital
waste dumping
sites, often using
dubious and
uncontrolled
reprocessing
methods, can
constitute an
additional health
hazard and is of
growing concern
in countries with
limited
resources.
Hospitals are
therefore
encouraged to
destroy each
glove before
discarding.
In brief, the
opinion of
international
experts
consulted by
WHO is that
glove
reprocessing
must be strongly
discouraged and
avoided, mainly
because at
present no
standardized,
validated, and
affordable
procedure for
safe glove
reprocessing
exists. Every
possible effort
should be made
to prevent glove
reuse
in health-care
settings, and
financial
constraints in
developing
countries leading
to such practices
should be
assessed and
tackled.
Institutions and
health-care
settings should
firmly avoid the
reuse of gloves.
In circumstances
where the
reprocessing of
gloves has been
carefully
evaluated but

cannot be
avoided, a clear
policy should be
in place to limit
reprocessing and
reuse
of gloves until a
budget is
allocated to
ensure a secure
supply of singleuse gloves.
Policies for
exceptional
reprocessing
should ensure a
process that
follows strict
procedures for
collection,
selection and
reprocessing,
including
instructions for
quality/ integrity
control and
discarding of
unusable gloves.

23.1.7
Conclusions
Medical glove
use is an
evidencebased

measure to
protect
patients,
HCWs, and the
environment.
The
recommendati
ons for glove
use must be
implemented
regardless of
the type
of setting and the
resources
available.
Nevertheless,
glove misuse is
observed
regularly
worldwide,
irrespective of
the underlying
reasons. Even in
institutions where
gloves are widely
available, HCWs
often fail to
remove gloves
between patients
or between
contact with
various sites on
a single patient,
thus facilitating
the spread of
microorganisms.1
54,744,952,959,960

131
WHO GUIDELINES ON HAND
HYGIENE IN HEALTH CARE

intended to complement
hand hygiene and are
effective as long as they
are used according to the
proper indications. Hand
hygiene still remains the
basic and most effective
measure to prevent
pathogen transmission
and infection.
In no way does glove
use modify hand
hygiene indications or
replace hand hygiene
by washing with soap
and water or
handrubbing with an
alcohol-based
handrub.

Gloves represent a risk

for pathogen
transmission and
infection if used
inappropriately.

Knowledge
dissemination
and practical
training on the
appropriate use
of gloves are the
foremost
interventions
leading not only
to best practices,
but also to
resource saving.
Deficient glove
procurement in
terms of quantity
and quality
causes
inappropriate and
unsafe practices
such as glove
misuse
and overuse and
may lead to
uncontrolled
reprocessing.929,
947
No evidencebased
recommendation
s for glove reuse
or reprocessing
exist other than
those described
above. Medical
gloves are
meant to be
disposable and
for single use.
They are

23.2 Importance of
hand hygiene for safe
blood and blood
products
Providing a safe unit of
blood to a patient who
requires blood
transfusion is a multistep
process. It includes
identifying safe blood
donors for blood
donation, safe blood
collection without
harming the blood donor
and the donated blood,
screening

of donated blood for HIV,

hepatitis B and C, and
syphilis, processing the
blood into blood products,
and issue of blood or
blood product to the
patient, when prescribed.
Appropriate hand
hygiene practice is
crucial to the safety of
blood and blood
products at all stages
in the transfusion
chain during which the
donated blood units are
handled. The microbial

contamination of blood or
blood products may occur
at the time of blood
collection or during the
processing into blood
products, labelling, storage
and transportation, or
during administration of
blood at the patient
bedside. This can have
fatal consequences for the
recipients of the
transfusion. Serious
consequenses of microbial
contamination can be
avoided by giving particular
attention to the hand
hygiene of the donor care
staff at the time of blood
collection and by thorough
cleansing of the
venepuncture site on the
donor arm.

Furthermore, blood
collection staff frequently
needs to collect blood in
environments that are
especially challenging.
Special care must be
exercised in hand hygiene
while collecting blood in
outdoor situations where
access to running water is
limited.
It is essential that all those
who work in areas where
blood is handled pay strict
attention to hand hygiene.
Standard operating
procedures should be
available to staff, detailing
exactly how hands should
be decontaminated in order
to protect blood donors,
patients, and the staff
themselves, as well as the
blood and blood products.
Figure l.23.4 depicts the
crucial steps during blood
collection, processing, and
transfusion with an
associated risk for the
contamination of blood or
blood products attributable
to poor hand hygiene of the
staff involved in these
processes. At each step,
there are several critical
procedures, including
meticulous hand hygiene,
which ultimately lead to the
safety of blood and blood
products.

23.3 Jewellery
Several studies have
shown that skin
underneath rings is more
heavily colonized than

comparable areas of skin

on fingers without rings.961963
A study by Hoffman and
colleagues962 found that
40% of nurses harboured
Gram-negative bacilli such
as E. cloacae, Klebsiella
spp., and Acinetobacter
spp. on skin under

rings and that some nurses

carried the same organism
under their rings for
months. In one study
involving more than 60 ICU
nurses, multivariable
analysis revealed that rings
were the only significant
risk factor for carriage of
Gram-negative bacilli and
S. aureus and that the
organism bioburden
recovered correlated with
the number of rings
worn.964 Another study
showed a stepwise
increased risk of
contamination with S.
aureus, Gram-negative
bacilli, or Candida spp. as
the number of rings worn
increased.153 In a
Norwegian study
comparing hand flora of
121 HCWs wearing a
single plain ring and 113
wearing no rings, there
was no significant
differences in the total
bacterial load
or rates of carriage of S.
aureus or non-fermentative
Gram-negative rods on
hands, but personnel
wearing rings were more
likely to carry
Enterobacteriaceae
(P=0.006).965 Among 60
volunteers from
perioperative personnel
and medical students,
Wongworawat & Jones966
found no significant
difference in bacterial
counts on hands with or
without rings when an
alcohol product was used,
but there were significantly
more bacteria on ringed
hands when povidoneiodine was used for
handwashing (P<0.05).
Furthermore, Rupp and
colleagues707 reported that
having longer fingernails
and wearing rings were
associated with increased
numbers and species of
organisms on hands.

In addition, at least one

case of irritant dermatitis
under the ring has been
reported as a result of
wearing rings.967
A survey of knowledge
and beliefs regarding
nosocomial infections

and jewellery showed

that neonatal ICU
HCWs were not aware
of the relationship
between bacterial hand
counts and rings, and
did not believe that
rings increased the risk
of nosocomial
infections; 61%
regularly wore at least
one ring to work.960
Whether the wearing of
rings results in greater
cross-transmission of
pathogens remains
unknown. Two studies
found that mean bacterial
colony counts on hands
after handwashing were
similar among individuals
wearing rings and those not
wearing rings.963,968 One
study compared the impact
of wearing rings on the
efficacy of several different
products in 20 subjects who
wore a ring on one hand
and no ring on the other: an
alcohol-based formulation;
a waterless, alcoholchlorhexidine lotion; and a
povidone-iodine scrub.
There were no significant
differences in bacterial
counts when the two
alcohol-based formulations
were used, but there were
higher counts on the ringed
hands (p<0.05) after
povidone-iodine scrub966.
Further studies are needed
to establish if wearing
rings results in a greater
transmission of pathogens
in health-care settings.
Nevertheless, it is likely
that poorly maintained
(dirty) rings and jewellery
might harbour
microorganisms that could
contaminate a body site
with potential pathogens.
Rings with sharp surfaces
may puncture gloves.
Hand hygiene practices
are likely to be performed
in a suboptimal way if
voluminous rings or rings
with sharp edges or
surfaces are worn.
Jewellery may also be a
physical danger to either
patients or the HCW
during direct patient
care, e.g. a necklace
may be caught in
equipment or bracelets
may cause injury during
patient handling.

The consensus
recommendation is to
strongly discourage the
wearing of rings or other
jewellery during health
care. If religious or cultural
influences strongly
condition the HCWs

attitude, the wearing of a

simple wedding ring (band)
during routine care may be
acceptable, but in high-risk
settings, such as the
operating theatre, all rings
or other jewellery should be
removed.969 A
132

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

the presence
of fingernail
disease may
reduce the
efficacy of
hand
hygiene and
simple and
result in the
practical solution transmission
allowing
of
effective hand
pathogens. A
hygiene is for
cluster of P.
HCWs to wear aeruginosa
their ring(s)
SSIs
around their
resulted from
neck on a chain colonization
as a pendant.
of a cardiac
surgeons
onychomycot
23.4
ic nail.523

Fingernails and
artificial nails A growing body
of evidence
suggests that
Numerous
wearing artificial
studies have
nails may
documented
contribute to the
that subungual
transmission of
areas of the
certain health
hand harbour
care-associated
high
pathogens.
concentrations
HCWs who wear
of bacteria,
artificial nails are
most
more likely to
frequently
harbour Gramcoagulasenegative
negative
pathogens on
staphylococci,
their fingertips
Gram-negative
than those who
rods (including
have natural
Pseudomonas
nails, both
spp.),
before and after
Corynebacteri
handwashing154,
a, and
534,974,975
63,534,970
or
yeasts.
handrub with an
Freshly
alcohol-based
applied nail
gel.154 It is not
polish does
clear if the
not increase
length of natural
the number of
or artificial nails
bacteria
is an important
recovered
risk factor, since
from
most bacterial
periungual
growth occurs
skin, but
chipped nail polishalong the
may support the proximal 1 mm
growth of larger of the nail,
adjacent to
numbers of
subungal
organisms on
fingernails.971,972 skin.154,972,974 An
Even after careful outbreak of P.
handwashing or aeruginosa in a
surgical scrubs, neonatal ICU
HCWs often
was attributed to
harbour
two nurses (one
substantial
with long natural
numbers
nails and one
of potential
with long
pathogens in
artificial nails)
who carried the
the
implicated
subungual
strains of
spaces.154,973
,974
Pseudomonas
In
spp. on their
particular,

hands.976 Case
patients were
significantly
more likely than
controls to have
been cared for
by the two
nurses during
the exposure
period,
suggesting that
colonization of
long or artificial
nails with
Pseudomonas
spp.
may have played
a role in causing
the outbreak.
HCWs wearing
artificial nails have
also been
epidemiologically
implicated in
several other
outbreaks of
infection caused
by Gram-negative
bacilli or
yeast.159,167,977 In a
recent study,
multiple logistic
regression
analysis showed
the association of
an outbreak of
extendedspectrum betalactamaseproducing K.
pneumoniae in a
neonatal ICU
resulting from
exposure to an
HCW wearing
artificial
fingernails.155 A
cluster of five
cases of S.
marcescens
bacteraemia in
haemodialysis
was associated
with a nurse who
used an artificial
fingernail to open
a vial of heparin
that was mixed to
make a flush
solution. The
strains isolated
from the five
patients and the
nurse were
indistinguishable.8
56
Allergic contact
dermatitis
resulting in
months of sick
leave has been
reported in an
office worker with
artificial nails.978

Long, sharp
fingernails,
either natural or
artificial, can
puncture gloves
easily.123 They
may also limit
HCWs
performance in
hand hygiene
practices. In a
recent survey
among neonatal
ICU HCWs, 8%
wore artificial
fingernails at
work, and
knowledge
among them
about the
relationship
between Gramnegative
bacterial hand
contamination
and long or
artificial
fingernails was
limited.960
Jeanes &
Green979
reviewed
other
forms of
nail art
and
technolog
y in the
context of
hand
hygiene in
health
care,

including:
applying
artificial
material to the
nails for
extensions; nail
sculpturing;
protecting nails
by covering
them with a
protective layer
of artificial
material; and
nail jewellery,
where
decorations
such as stones
may be applied
to the nails or

the nails are

pierced. In
addition to
possible
limitations of
care
practice,
there may be
many
potential
health
problems,
including
local
infection for
individuals
who have
undergone
some form of
nail
technology.97
9

Each health-care
facility should
develop policies
on the wearing of
jewellery, artificial
fingernails or nail
polish by HCWs.
These policies
should take into
account the risks
of transmission of
infection to
patients and
HCWs, rather
than cultural
preferences.

Consensus
recommendation
s are that HCWs
do not wear
artificial
fingernails or
extenders when
having direct

contact with
patients and
natural nails
should be kept
short ( 0.5 cm
long or
approximately
inch long).

23.5
Infrastructure
required for
optimal hand
hygiene
Compliance with
hand hygiene is
only possible if
the health-care
setting ensures
the adequate
infrastructure and
a reliable supply
of hand hygiene
products at the
right time and at
the right location
in alignment with
the concept of
My five moments
for hand hygiene
(Part I, Section
21.4).1 An
important cause
of poor
compliance
may be the
lack of userfriendliness
of hand
hygiene
equipment,
as well as
poor logistics
leading to
limited
procurement
and
replenishme
nt of
consumables
. The latter is
one of the
most
commonly
cited
obstacles to
hand
hygiene
improvement
in developing
countries
(reports
of workshops
hosted by the
WHO Regional
Offices for
Africa (AFRO)
and SouthEast Asia
(SEARO) in
2007, see
http://

www.who.int/g
psc/in/). As an
example, very
low overall
hand hygiene
compliance
(8%) was
shown in a
university
hospital in Mali
where, at the
same time, a
survey on
infrastructure
for hand
hygiene
demonstrated
that no
alcohol-based
handrub was
available. Only
14.3% of
patient rooms
were equipped
with sinks, and
soap and towels
were available at
only 47.4% of
sinks.980 In
developed
countries,
Suresh &
Cahill981
described
several
deficiencies in
the structural
layout of hand

hygiene
resources that
hinder their
usage: poor
visibility, difficulty
of access,
placement at
undesirable
height, and wide
spatial
separation of
resources that
are used
sequentially.

describing the
overall
infrastructure
necessary, this
section is
particularly
focused on
soap and
handrub
dispensers.

Other parts of
these
Guidelines
have already
described the
need for clean
water for
handwashing
and have
elaborated on
the
advantages of
handrubs over
handwashing,
namely, the
freedom from
the
requirement of
sinks and the
possibility to
clean hands at
the point of
care. While

All health-care
settings should
have written
guidelines
describing the
appropriate
placement of
sinks and soap
and handrub
dispensers.
Furthermore, the
delegated
responsibility with
regards to supply
of hand hygiene
products,
replenishment of
consumables,
and maintenance
of the dispensers
should be clearly
described and
communicated.

133

23.5.1 General
guidelines

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

reliability is
paramount
since its failure
completely
prevents any
access to
handwashing
23.5.2 Sinks facilities. In
summary,
While not
manual or
all settings elbow-or foothave a
activated taps
continuous could be
water
considered the
supply, tap optimal
water
standard within
(ideally
health-care
drinkable, is settings. Their
preferable
availability is
for
not considered
handwashin among the
g (see Part
highest
I, Section
priorities,
11.1). In
however,
settings
particularly in
where this
settings with
is not
limited
possible,
resources. Of
water
note,
flowing
recommendatio
from a prens for their use
filled
are not based
container
on evidence.
with a tap is
preferable
To avoid
to stillwater
standing
splashes, the
water in a
water stream
basin.
should not be
Where
directed
running
straight into
water is
the drain,
available,
and taps
the
should be
possibility
fitted with an
of
accessing it aerator
without the screen. The
mesh of the
need to
aerator
touch the
screen
tap with
soiled hands should be
is preferable. sufficiently
This may be wide to
achieved by ensure that
taps that are no water
opened by remains on
top of the
using an
aerator
elbow or
screen, as
foot. In
this may lead
settings
to bacterial
without
contaminatio
budget
restrictions, n and
consequent
sensorspread of
activated
982
taps may be microbes.
used for
handwashin
g, although it 23.5.3
Dispensers
must be
noted that
the system In most health-

care facilities,
alcohol-based
handrub
dispensers
have
historically
been located
close to the
sink, often
adjacent to the
wall-mounted
liquid soap.
Part of their
function was to
dispense preset amounts of
handrub
(mostly 1. 5 ml,
half of what
was needed
according to
older
guidelines).
Frequently,
these
dispensers
were designed
to allow the
user to apply
handrub
without using
their
contaminated
hands to touch
the dispenser
(elbowactivated).
While wallmounted
dispensers
at the sink
seemed a
logical place to
start promoting
hand antisepsis
with rubs over
handwashing,
the main
advantage of
handrubs is the
fact that they
can (and
should) be used
at the point of
care, for
example at the
end of the bed.
Placement of
handrubs
exclusively at
the sink
therefore
disregards one
of their unique
features and is
not aligned with
promoting hand
hygiene at the
five moments
when it is
required in
health care.

The
advantag
es and
disadvant
ages of
the
different
dispenser
systems
are
discussed
below and
summariz
ed in
Table
I.23.3.
Although
the same
wallmounted
dispenser
s are
used
frequently
for
handrubs
and liquid
soaps, this
section will
focus on
handrub
dispersion.
It is obvious
that
economic
constraints
as well as
local
logistics
have a
major
influence on
the choice
of
dispensing
system.
Furthermore
, in many
settings, the
different
forms of
dispensers,
such as
wallmounted
and those
for use at
the point of
care, should
be used in
combination
to achieve
maximum
compliance.
Some of the
prerequisite
s for all
dispensers
and their
placement
are given in
Table I.23.4.
Some

examples of

dispensers for
use at the
point of care
are shown in
Figure I.23.5.
23.5.3.1 Wallmounted
systems
Wallmounted
soap
dispensing
systems are
recommend
ed to be
located at
every sink in
patient and
examination
rooms,
when
affordable.
Wall-mounted
handrub
dispensers
should be
positioned in
locations that
facilitate hand
hygiene at the
point of care, in
accordance
with the
concept of the
My five
moments for
hand hygiene.
Careful
consideration
should be given
to the
placement of
these
dispensers in
areas with
patients who
are likely to
ingest the
product, such
as disoriented
elderly patients,
psychiatric
patients, young
children, or
patients with
alcohol
dependence. In
patient areas
where beds are
geographically
in very close
proximity,
common in
developing
countries, wallmounted,
alcohol-based
handrubs can
be placed in the
space between
beds to

facilitate
). They
hand hygieneshould be
at the point used
preferably
of care.
with
Some
institutions disposable,
transparent
have
customized containers of
dispensers to a
fit on carts or standardized
intravenous- size, thus
allowing the
pools to
ensure use use of
during care products
from different
delivery.
suppliers
(e.g. EuroSplashes
dispenser for
on the
standardized
floor from
500 ml and
wall1000 ml
mounted
bottles). The
dispenser
product
s have
should be
been
placed in the
reported
dispenser in
as a
such a way
potential
that the label
problem,
and content is
as this
visible to
may lead
ensure timely
to the
discolouratio replacement of
n of certain empty
containers by
floor
surfaces or housekeeping
even result or maintenance
in the floor staff.
Dispersion of
surface
the handrub
becoming
should be
slippery.
possible in a
Some
manufacture nontouch fashion
rs in
developed to avoid any
touching of the
countries
dispenser with
offer
contaminated
dispensers
hands, e.g.
with a
elbowsplash-guard
dispensers or
intended to
pumps that
catch
can be used
splashes
with the
and droplets
wrist.58 Despite
to avoid
the fact that
these
ease of access
problems.
may lead to
increased use,
Dispenser
as shown by
s should
Larson and
be
colleagues654
mounted
when
on the wall
comparing the
in a
frequency of
manner
handrub use of
that allows
manually
unrestricte
operated and
d, easy
touch-free
access
dispensers in a
(i.e. not in
paediatric ICU,
corners or
robust
under
mechanical
hanging
systems are
cupboards
preferable over

electronic
non-touch
systems that
are more
susceptible to
malfunction,
more costly,
and frequently
only usable
with the
suppliers own
hand hygiene
formulation. In
general, the
design and
function of the
dispensers
that will
ultimately be
installed in a
health-care
setting should
be evaluated,
because some
systems were
shown to
malfunction
continuously,
despite efforts
to rectify the
problem.983

23.5.3.2
Table-top
dispensers
(pumps)
A variation of
wall-mounted
dispensers
are holders
and frames
that allow
placement of
a container
that is
equipped with
a pump. The
pump is
screwed onto
the container
in place of the
lid. It is likely
that this
dispensing
system is
associated
with
the lowest
cost.
Containers
with a pump
can also be
placed
easily on
any
horizontal
surface,
e.g.
cart/trolley
or night
stand/bedsi
de table.

Several
manufact
urers
have
produced
dispenser
holders
that allow

positioning
of the
handrub
onto a bed
frame, thus
enabling
access to
the handrub
134

at the point
of care. A
disadvantag
e of these
loose
systems is
the

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

used for back-up,

as many of the
pocket bottles or
clip-ons are
frequently not
transparent and
may be found to
fact that the
be empty when
bottles can be
required. In some
moved around of these systems,
easily and
the amount of
may be
handrub may be
misplaced,
so small (1020
resulting in
ml) that several
decreased
containers per
reliability.
HCW are needed
Where
each day. Costs
possible, the
and dependency
combination of on a single
fixed (wallmanufacturer and
mounted) and
its products may
loose
be a problem
dispensers
especially with the
should be
clip-on system.
used.
Because many of
these systems are
used as
23.5.3.3 Pocket disposables,
or clip-on
environmental
dispensers
considerations
should also be
Studies that
taken into
compared the use account. In some
of personal
situations,
alcohol-based
concern has been
handrub
expressed about
dispensing
the potential
systems with the contamination of
traditional wallthe external
mounted
surface of the
dispenser and
bottle. However,
sinks were unable this is considered
to show a
to be almost
sustained effect theoretical and
on hand hygiene negligible
compliance,709
because of the
possibly because excess spillage of
the increased
the disinfectant
availability of
and the overall
hand hygiene
short time until
products is only a replacement.
single intervention
within a broad
multimodal
23.5.3.4
approach.
Automated wallIndividual,
mounted
portable
dispensers
dispensers are
ideal if combined These types of
with wall-mounted systems have
emerged from
dispensing
the non-medical
systems, to
increase point-of- setting, are
care access and aesthetically
appealing, and
enable use in
units where wall- are presently
being marketed
mounted
dispensers should in many healthcare settings.
be avoided or
Such systems
cannot be
are truly noninstalled. Also,
touch and easy
wall-mounted
systems can be to use. Barrau

and
colleagues984
compared a
wall-mounted,
hand-activated
sprayer system
with bottles on
a table,
suggesting a
possible benefit
of the sprayer
system. The
study had
several flaws,
among them
the low volume
of product
dispensed,
which may be
associated
with lower
efficacy.985 On
average, less than
0.8 ml was
supplied for a
one-time handrub,
an amount less
than three times
than that currently
recommended. In
addition to the
costs of the
dispensers and
the problem of
their
maintenance,
many of these
systems have to
be filled with the
manufacturers
own handrub,
which is generally
more expensive
than other
products
distributed in 500
ml and 1000 ml
standardized
containers. In
general, the
maintenance is
more complicated
and the chance of
malfunction is
higher in
automated
systems.

23.5.3.5
Indicators/surveil
lance
With
in
the
healt
hcare
setti
ng,
simp
le

struc
ture
and
perf
orm
ance
indic
ator
s
may
be
used
to
eval
uate
:

the
number
of
dispens
ers filled
compar
ed with
the total
number
of
dispens
ers in a
unit;

the number
of
dispensers
in working
order
compared
with
the
total
number of
dispensers
in a unit ;

the
prop
ortio
n of
pati
ent
and
treat
men
t
roo
ms
with
disp
ens
ers
pres
ent
at
the
poin
t of
care
;
the
number
of sinks
in patient
and
treatment
rooms
and
sink/bed
ratio;
the
proportion
of
sinks
equipped
with soap
and singleuse towels.

Recently,
special
dispensers with
electronic
surveillance
systems have
been made
commercially
available. While
measures of use
are not validated
in observational
studies and do
not allow
conclusions
about individual
HCW adherence

to hand
hygiene
indications,
particularly the
five moments,
these
electronic
devices, in

combination
with other
measures,
may help to
collect
information
about soap
and handrub
use, including
the effect of
quality
improvement
and
educational
initiatives.986

23.6
Safet
y
issue
s
relate
d to
alcoh
olbase
d
prepa
ration
s
23.6.1 Fire
hazard issues
Alcohols are
flammable.
Flashpoints of
alcohol-based
handrubs
range from
17.5C to
24.5C,
depending on
the type and
concentration
of alcohol
present.484,540
Therefore, risk
assessment
and
minimization is
crucial and
alcohol-based
handrubs
should be
stored away
from high
temperatures
or flames in
accordance
with National
Fire Protection
Agency
recommendatio
ns in the USA.
Although
alcohol-based
hand rubs are
flammable, the
risk of fires
associated with

such products is
very low. For
example, none
of 798 healthcare facilities
surveyed in the
USA reported a
fire related to an
alcohol-based
handrub
dispenser. A
total

of 766 facilities
had accrued
an estimated
1430 hospitalyears of
alcohol-based
handrub use
without a fire
attributed to a
handrub
dispenser.987
In Europe,
where alcoholbased
handrubs have
been used
extensively for
many years,
the incidence of
fires related to
such products
has been
extremely
low.484 A recent
study988
conducted in
German

hospitals found
that handrub
usage
represented an
estimated total
of 25 038
hospital-years.
The median
volume usage
was between
31 litres/month
(smallest
hospitals) and
450
litres/month
(largest
hospitals),
resulting in an
overall usage of
35 million litres
for all hospitals.
A total of seven
non-severe fire
incidents was
reported (0.9%
of hospitals).
This is equal to
an annual
incidence per
hospital of
0.0000475%.
No reports of
fire caused by
static electricity
or other factors
were received,
nor any related
to storage
areas.
Indeed, most
135

reported incidents
were associated
with deliberate
exposure to a
naked flame, e.g.
lighting a
cigarette.
One recent report
from the USA
described a flash
fire that occurred
as a result of an
unusual series of
events, which
consisted of an
HCW applying an
alcohol gel to her
hands then
immediately
removing a
polyester isolation
gown and
touching a metal
door before the
alcohol had
evaporated.989
Removing the
polyester gown
created a large
amount of static
electricity that
generated an
audible static
spark when she
touched the metal
door, igniting the
unevaporated
alcohol on her
hands.989 This

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

accept alcoholbased
handrubs in
corridors. In
addition, the
CMS 3145-IFC
(Fire Safety
incident
Requirement
underscores for Certain
the fact that, Health Care
following the Facilities,
application Alcohol-Based
of alcohol- Hand Sanitizer
based
and Smoke
handrubs, Detector
hands
Amendment)
should be was published
rubbed
in March 2005,
together
addressing this
until all the issue.990

alcohol has
evaporated.

In the USA, 23.6.2 Other

shortly after safety-related
publication issues
of the 2002
CDC/HICPA Accidental
C hand
and
hygiene
intentional
ingestion and
guideline,
fire marshals dermal
in a number absorption of
alcoholof states
based
prohibited
preparations
the
placement of used for hand
hygiene have
alcoholbeen
based
reported.599,77
handrub
8-780
Acute,
dispensers
severe
in egress
alcohol
corridors
because of a intoxication
concern that resulting from
accidental
they may
represent a ingestion of
fire hazard. an unknown
On 25 March quantity of
alcohol2005, the
based
Center for
handrub was
Medicare
recently
and
reported in
Medicaid
the United
Services
Kingdom,
adopted a
resulting in
revised
the
version of
unconsciousn
the USA
ess of an
National Fire
adult male
Protection
patient
Agencys
(Glasgow
Life Safety Coma Scale
Code that
3).778,781 This
allows such
unusual
dispensers
complication
to be placed of hand
in egress
hygiene may
corridors.
become more
The
common in
International the future,
Fire Code
and security
recently
measures are
agreed to

needed.
These may
involve:
placing the
preparation in
secure wall
dispensers;
labelling
dispensers to
make the
alcohol
content less
clear at a
casual glance
and

adding a
warning
against
consumption;
and the
inclusion of
an additive in
the product
formula to
reduce its
palatability. In
the
meantime,
medical and
nursing staff
should be
aware of this
potential risk.
Alcohol toxicity
usually occurs
after ingestion.
It is primarily
metabolized by
an alcohol
dehydrogenas
e in the liver to
acetone.
Symptoms and
signs of
alcohol
intoxication
include
headache,
dizziness, lack
of coordination,
hypoglycaemia
, abdominal
pain, nausea,
vomiting, and
haematemesis.
Signs of
severe toxicity
include
respiratory
depression,
hypotension,
and coma.
Among
alcohols,
isopropyl
alcohol
appears to be
more toxic than
ethanol, but
less so than
methanol.
Blood

isopropyl
alcohol
levels of 50
mg/dl are
associated
with mild
intoxication
and 150
mg/dl with
deep coma.
Apparently,
isopropyl
alcohol has
no adverse
effects on
reproduction
and is not
genotoxic,
teratogenic,
or
carcinogenic
.991
In
addition
to
accidental
ingestion,
alcohols
can be
absorbed
by
inhalation
and
through
intact
skin,
although
the latter
route
(dermal
uptake) is
very low.
Any
absorptio
n
exceeding
certain
levels
may
result in
toxicity
and
chronic
disease in
animals99
2
and
humans.7
80

Recently,
the Health
Council of
the
Netherlan
ds993
suggeste
d to
classify
ethanol
as
carcinoge
nic and to
include it
in skin
notation

because of
the fear of
an
increased risk
of breast and
colorectal
cancer in
persons with
an
occupational
exposure to
ethanol. While
the Dutch
Social and
Economic
Council
advised the
Ministry of
Social Affairs
and
Employment to
consider an
exception for
the use of
alcohol-based
handrubs in
health-care
settings, the
Ministry of
Social Affairs
and
Employment
rejected such
an exception
and set

the maximum
amount of
occupational
absorbed
ethanol at

such a low
level that the
decision
could
possibly lead
to a ban of
ethanolcontaining
handrubs in
the
Netherlands
if upheld.
Obviously,
such a
decision
would be
disastrous for
health-care
settings and
could induce
other
countries to
consider
similar
measures.
Indeed, while
there are no
data to show
that the use
of alcoholbased
handrub may
be harmful
and studies
evaluating
the
absorption
into blood
show that it
is not
reduced
compliance
with hand
hygiene will
lead to
preventable
HCAIs.
Data used by
the Dutch
Heath
Council
estimated the
absorption
level after
spraying of
the total body
under
occlusive
circumstance
s and after
exposure
times of up to
24 hours,
although this
is obviously
not relevant

for the
application
of
handrubs.
Furthermor
e, they
estimated a
worst case
dermal
uptake of
30 mg
ethanol
after a
single
application
to hands
and
forearms,
and a daily
uptake of
600 mg/day
after 20
application
s per day,
an estimate
that has
been
proven
wrong by
several
new
studies.782,7

alcoholcontaining

handrub
(52.6% (w/w)
isopropyl
alcohol) were
applied to
HCWs hands
every 10
minutes over a
4-hour period.
A blood
sample was
taken 5
minutes after
the final
application of
handrub and
blood
isopropyl
alcohol levels
were
measured. In
9 out of 10
participants, a
rise in the
blood
isopropyl
alcohol level
was noted at
very low levels
(the highest
observed level
84,994,995
was 0.18
mg/dl), much
In practice, less than the
absorption of levels
ethanol from achieved with
a handrub
mild
would be by
intoxication
a
(50 mg/dl).
combination
of dermal
More
absorption
recently,
and
Miller and
inhalation. In
colleagues
a study
conducted
using a
two studies
solution of
in which
44% ethanol
large
sprayed on
the skin and amounts of
an ethanolleft for 15
based
minutes,
there was no handrub
were used
positive
identification very
of ethanol in frequently
over periods
any of the
of several
blood
hours; they
samples
taken (limit found that
of detection blood
alcohol
was 9
994
levels at the
mg/litre).
Turner and end of the
colleagues trial periods
were below
evaluated
the dermal the level of
782,
absorption detection.
995
through
Brown
HCWs intact and
skin599:3 ml colleagues
of an
exposed
isopropyl
HCWs to

intensive use
(30
times/hour)
of ethanoland
isopropanolbased
handrub
solutions and
found only
extremely
low
concentratio
ns of ethanol
in the blood
(far too
low to cause
symptoms) and
that blood
isopropanol
levels were
undetectable.78
3
Similarly,
insignificant
levels of
ethanol were
detected in the
breath of a few
study
participants and
no trace of
isopropanol.
Kramer and
colleagues
studied the
intensive use of
handrub
solutions
containing 55
95% ethanol
and found that
blood ethanol
concentrations
were far below
levels that
would result in
any noticeable
symptoms. For
example, the
highest median
blood ethanol
concentration
after intensive
use of a 95%
ethanol hand
rub was 20.95
mg/litre,
whereas levels
of 200 500
mg/litre are
needed to
impair fine
motor
coordination,
and levels of
5001000
mg/litre are
needed to
impair
judgement.784
The
presence of
ethanol in the

blood of
human
beings can
also have
other
origins.
Ethanol
can be
found in
ripe fruit
with
concentrati
ons of
0.6% or

higher as a
product of
fermentation
by natural
yeasts.996 A
very small
amount of
ethanol is
present as
an
endogenous
substance in
the blood,
136

probably
resulting
from
microbial
production in
the
gastrointestin
al tract.
Studies have
shown
concentration
s ranging
from 0
mg/litre to1.6

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

mg/litre.997,998 In rare instances, much higher endogenous

concentrations have been reported (> 800 mg/litre) in
Japanese subjects with serious yeast infections;
endogenous ethanol appears to have been produced after
they had eaten carbohydrate-rich foods.997
Studies to measure both alcohol and acetone levels in
subjects chronically exposed to topical alcohols are required
to investigate further this issue. Based on work emerging
from the United Kingdom,Table I.23.5 lists the risks and
recommended mitigation measures.999,1000
Table I.23.1
Indications for gloving and for glove removal

Indication
Glove use

Glove removal

1)

before a sterile condition

2)

anticipation of a contact with blood or another body fluid, regardless of the existence of sterile conditions and
including contact with non-intact skin and mucous membrane

3)

contact with a patient (and his/her immediate surroundings) during contact precautions

1)

as soon as gloves are damaged (or non-integrity suspected)

2)

when contact with blood, another body fluid, non-intact skin and mucous membrane has occurred and has
ended

3)

when contact with a single patient and his/her surroundings, or a contaminated body site on a patient has
ended

4)

when there is an indication for hand hygiene

Table I.23.2
A question-frame to capture practical conditions for appropriate and safe glove use
Before donning gloves

When to wear gloves

When to remove gloves

Does the indication for use of gloves still

remain?
Does any indication for glove removal
occur?

When does the exact moment for

removing glove apply?
Has the technique to remove gloves been
respected?
Have gloves been properly disposed?
Has hand hygiene been performed
immediately after glove removal?
Have hands been washed if soiled with
blood or another body fluid after glove
removal?

Is there any indication for glove use?

What is this indication?
What type of gloves is required?
Are gloves still in their original
packaging?
When does the exact moment to put
on gloves apply?
How do they protect the patient, the
HCW, the environment?
Is any hand hygiene action indicated
before donning gloves?
If any indication for hand hygiene,
was handwashing or handrubbing
performed?
Was it performed immediately
before donning gloves?
Have both hands to be gloved?
Has the gloving technique been
respected?

137

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.23.3
Advantages and disadvantages of different dispensing methods
Dispenser type

Advantages

Disadvantages

1
Not always placed in
HCWs know where they are can allow
convenient locations; in some units
attainment of hand hygiene in alignment
they will not align with the
with the Five moments concept
requirements of the Five moments
Can be operated by a no-touch system (if
concept
elbow-operated)
2
Dependent
on (freedom
good
Standardized
with regard to refill
to choose
other
suppliers)
service
(refilling
and maintenance)
Visible
patientsand
and visitors
visitors
3 for staff,
Patients

Wall- and bed-mounted

dispensers

Table-top dispensers (pumps)

1
Pocket- and clip-on
dispensers

Can
run-out at point
of care, thus
require backup and
facilitated
access in

Automated-wall mounted

Table I.23.4
Characteristics
to be considered
as a prerequisite
for all dispensers
and their
placement

can access and ingest (e.g.

areas where patients are
1
Use at point
1
N c
o
fixed a
of care allowing
n
location
attainment of hand
a
hygiene in alignment
2
P cc
with the Five
atients
e
moments concept
and
ss
visitors
2
Low costs
a
ward
Dep
s for e
refill n
d
2
e
Costs n
t
3
o

n
s
u
p
p
l
i

er
(clipon)

4
Enviro
nm
ent

confused
and
paediatric
wards)

Splas
hes on floor
that
stain
certain floor
surfaces

nd
inge
st
(e.g.
elde
rly
and
pae
al concerns
and disposal
if containers
are
not
reused

diatric
wards)

3
o-touch
difficult

Prerequisite

Comment

Easy and unobstructed access

Allow enough space around the dispenser; e.g. do not place under cupboards or next to
other objects that hinder/obscure free access

Logical placement

HCWs should know intuitively where dispensers are placed. They should be as close as
possible, (e.g. within arms reach) to where patient contact is taking place, to avoid to have to
leave the care/treatment zone

Wide availability

Available in all patient rooms (possibly at the bedside) and in all examination rooms and other
points of care

Standardized (with regard to fillings/

containers)

Standardization should ensure that dispensers can be used with products of multiple brands,
instead of only fitting the product of a single manufacturer
A Euro-dispenser has been developed that holds European standard 500 ml and 1000 ml
containers

No-touch system

To allow use by contact with clean body part (e.g. elbow dispenser, pump on a bottle
operated by a clean wrist). This is with the exception of pocket bottles or systems worn on
HCWs uniforms

Disposable reservoir

Dispensers should generally have a disposable reservoir (container/bottle) that should not
be refilled. If reusable reservoirs have to be used, they should be cleaned and disinfected
according to the instructions in Section 12

Avoid contamination

Dispensers should be constructed in such a way that contaminated hands do not come into
contact with parts of the delivery system of the dispenser and/or those parts unable to be
cleaned
138

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.23.5
Summary of risks and mitigation measures concerning the use of alcohol-based hand hygiene preparations
Risk

Mitigation

Fire

Involve fire officers, fire safety advisers, risk managers, and health and safety and infection control professionals in
risk assessments prior to embarking on system change
Risk assessment should take into account:
the location of dispensers
the storage of stock
the disposal of used containers/dispensers and expired stock
Storage: store away from high temperatures or flames
Drying: following application of alcohol-based handrubs, hands should be rubbed together until all the alcohol has
evaporated (when dry, hands are safe)

Storage

Local and central (bulk) storage must comply with fire regulations regarding the type of cabinet and store,
respectively

1
2
3

Production and storage facilities should ideally be air-conditioned or cool rooms

No naked flames or smoking should be permitted in these areas

National safety guidelines and local legal requirements must be adhered to for the storage of ingredients
and the final product

Care should be taken when carrying personal containers/dispensers, to avoid spillage onto clothing,
bedding or curtains and in pockets, bags or vehicles

Containers/dispensers should be stored in a cool place and care should be taken regarding the securing of
tops/lids

The quantity of handrub kept in a ward or department should be as small as is reasonably practicable for
day-to-day purposes

A designated highly flammables store will be required for situations where it is necessary to store more
than 50 litres (e.g. central bulk storage)

Containers and dispenser cartridges containing handrub should be stored in a cool place away from
sources of ignition. This applies also to used containers that have not been rinsed with water

Disposal

Used containers and dispensers will contain gel residues and flammable vapours
Rinsing out used containers with copious amounts of cold water will reduce the risk of fire and the containers may
then be recycled or disposed of in general waste

Location of dispensers

Han
d
r
u
b
di
s
p
e

WHO
Formulation

1
The
W
H
O
r
e
c

nsers should not be placed above or close to potential

sources of ignition, such as light switches and electrical
outlets, or next to oxygen or other medical gas outlets,
because of the increased risk of vapours igniting

The siting of handrub dispensers above

carpets is not recommended, because of the risk of
damage and lifting/ warping of carpets.

Consideration should be given to the

risks associated with spillage onto floor
coverings, including the risk of pedestrian slips
ommended formulation handrubp
n facilities should directly dilute it
should not be produced inr
to the concentrations outlined in
quantities exceeding 50 litres locallyo
the Guide to Local Production
or in central pharmacies lackingd
(http://www.who.int/gpsc/
specialized air conditioning andu
tools/InfSheet5.pdf)
ventilation
c
2
The flashpoints of ethanol
1
Since undiluted ethanol is t
80% (v/v) and isopropyl alcohol
i
75% (v/v) are 17.5 C and 19 C,
highly flammable and may ignite
o
respectively
at temperatures as low as 10 C,

Spillage

Significant spillages should be dealt with immediately by removing all sources of ignition, ventilating the area, and
diluting the spillage with water (to at least 10 times the volume)
The fluid should then be absorbed by an inert material such as dry sand (not a combustible material such as
sawdust), which should be disposed of in a chemical waste container
Vapours should be dispersed by ventilating the room (or vehicle), and the contaminated item should be put in a
plastic bag until it can be washed and/or dried safely

Fighting a
large (i.e.
bulk storage)
alcohol fire

Water or aqueous (water) film-forming foam (AFFF) should be used; other types of extinguishers may be ineffective
and may spread the fire over a larger area rather than put it out

Ingestion

In areas where there is thought to be a high risk of ingestion, a staff-carried product is advised
If a wall-mounted product is used, consideration should be given to small bottles
If bottles with a greater capacity than 500 ml are used, consideration should be given to providing them in secured
containers
Consideration should be given to the labelling of the handrubs, including an emphasis on the sanitizing properties
and warning of dangers associated with ingestion
National and local toxicology specialists should be involved in developing and issuing national/local guidance on
how to deal with ingestion (based on products available within a country)
139

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Figure I.23.1
Situations requiring and not requiring glove use

STERILE
GLOVES
INDICATED
Any surgical
procedure; vaginal
delivery; invasive radiological
procedures; performing vascular access
and procedures (central lines);
preparing total parental nutrition and
chemotherapeutic agents.

EXAMINATION GLOVES INDICATED IN

CLINICAL SITUATIONS
Potential for touching blood, body fluids, secretions,
excretions and items visibly soiled by body fluids
DIRECT PATIENT EXPOSURE: contact with blood; contact with
muscous membrane and with non-intact skin; potential presence
of highly infectious and dangerous organism; epidemic or emergency situations;
IV insertion and removal; drawing blood; discontinuation of venous line; pelvic
and vaginal examination; suctioning non-closed systems of endotracheal tubes.
INDIRECT PATIENT EXPOSURE: emptying emesis basins; handling/cleaning
instruments; handling waste; cleaning up spills of body fluids.

GLOVES NOT INDICATED (except for CONTACT precautions)

No potential for exposure to blood or body fluids, or contaminated environment
DIRECT PATIENT EXPOSURE: taking blood pressure; temperatureand pulse; performing SC and IM injections;
bathing and dressing the patient; transporting patient; caring for eyes and ears (without secretions); any vascular
line manipulation in absence of blood leakage.
INDIRECT PATIENT EXPOSURE: using the telephone, writing in the patient chart; giving oral medications;
distributing or collecting patient dietary trays; removing and replacing linen for patient bed; placing non-invasive
ventilation equipment and oxygen cannula; moving patient furniture.

Gloves must be worn according to STANDARD and CONTACT PRECAUTIONS. The pyramid details some clinical examples in wich gloves
are not indicated, and others in which examination or sterile gloves are indicated. Hand hygiene should be performed when appropriate
regardless indications for glove use.

140

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Figure I.23.2
How to don and remove non-sterile gloves

141

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Figure I.23.3
How to don and remove sterile gloves
14
2

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Figure I.23.3
How to don and remove sterile gloves (Cont.)
143

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Figure I.23.4
Blood safety: crucial steps for hand hygiene action

Collection of
blood from
blood donors

Production
of blood
products

Hand
hygiene*
Sterile blood
collection
bags
Donors arm
cleansing
Gloves**

Hand
hygiene*
Clean
equipment
Gloves**

* Hand hygiene before and after the procedure.

** Clean non-sterile gloves.
Figure I.23.5
Different types of dispensers at the point of care

Storage and
transport

Issue of
safe blood
and blood
products to
patients

 Hand

Hand

hygiene*
Gloves** for
safe handling
Correct
temperature
to avoid
physical
damage and
bacterial
overgrowth

hygiene*
Gloves** for
safe handling
Safe bedside
transfusion
procedures

Pocket bottle with clip

Pocket bottle

144

Figure I.23.5
Different types of dispensers at the point of care (Cont.)

Pocket bottles (snap-cap and pump) and clip-on dispensers

Dispenser fixed to the medicine trolley

Pump dosing device for placement on the container/bottle

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND

HYGIENE

Euro dispenser with spill tray

145

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

24.
Hand hygiene research agenda
Although the number of published studies dealing with hand hygiene has increased considerably in recent years,
many questions regarding hand hygiene products and strategies for improving HCW compliance with
recommended policies remain unanswered. Table I.24.1 lists a number of areas that should be addressed by
researchers, scientists and clinical investigators. Table I.24.2 includes a series of open questions on specific
unsolved issues that require research activities and field testing. Some of the research questions will be covered
by studies conducted within the framework of the World Alliance for Patient Safety.
Table I.24.1
Hand hygiene research agenda
Area

In both developed
and developing countries

Education and
Survey on perceptions among HCWs regarding
indications for hand hygiene
promotion
Identify more effective ways to educate HCWs
regarding patient-care activities that can result in
hand contamination and cross-transmission
Assess the key determinants of hand hygiene
behaviour and promotion among the different
populations of HCWs
Evaluate the impact of different definitions and
approaches to the Five moments
Explore avenues to implement hand
hygiene promotion programmes in
undergraduate courses
Study the impact of religion and culture on
population-based education on hand hygiene
behaviour
Identify effective methods and models for patient
participation in the promotion of hand hygiene
compliance among HCWs in different cultural or
social contexts

More focus on developing

countries
Document
benefits
and
disadvantages
of
patient
empowerment/participation
in
the promotion of hand hygiene
in health-care settings, in
particular, its impact on hand
hygiene compliance
Implement and evaluate
the impact of the different
components of multimodal
programmes to promote
hand hygiene
Ascertain the impact of social
marketing on hand hygiene
compliance
Develop and evaluate methods
to obtain management support

Test different
strategies
for hand
hygiene
promotion in
developing
countries
Conduct
costbenefit,
cost utility,
and cost
effectivenes
s analyses
of improving
hand
hygiene in
developing
countries

Evaluate hand hygiene practices

in traditional medicines and
explore the possibility of
promoting hand hygiene among
practitioners

1
4
6

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.24.1
Hand hygiene research agenda (Cont.)
Area

In both developed
and developing countries

More focus on developing

countries

Agents,
indications,
choice of
hand hygiene
product,
technique,
hand care

Identify the most suitable agents for hand hygiene based on a set of valid criteria

Study skin adverse events in

different ethnic groups and in
tropical climates

Determine the role of alcohol-based handrub (gloving + handrubbing vs gloving +

handwashing) to prevent the transmission of spore-forming pathogens
Determine if preparations with sustained antimicrobial activity (based on various
components, e.g. triclosan, chlorhexidine, silver) are more effective to reduce
infection rates than those whose activity is limited to an immediate effect when used
for hygienic hand antisepsis
Develop and field-test devices to facilitate the optimal application of hand hygiene
agents
Develop hand hygiene agents with lower skin irritancy potential
Study the possible advantages and interactions of hand care lotions, creams, and
other barriers with hand hygiene agents
Conduct market research on handrub products and their cost at country level
Determine if bar soap is acceptable; if yes, establish if single-use, small pieces
should be recommended
Establish appropriate duration (90 seconds vs 3 minutes) of surgical hand
preparation, in particular, using alcohol-based handrubs
Establish whether there is a need to perform a second handrub for surgical
procedures of more than a two-hour duration and, if so, determine the duration of
the handrubbing.
Establish which skin areas must be cleansed (up to the wrist, forearm or elbow?)
during surgical hand preparation
Determine the effect of changing the sequence of steps or reducing the number of
steps for hand decontamination on efficacy
Ascertain the need for handrubbing before using non-sterile examination gloves
Establish a feasible method (e.g. disinfecting gloves) for performing hand hygiene
between patients for HCWs who are gloved for designated procedures (e.g.
phlebotomists)
Assess the effect of glove use on compliance with hand hygiene
Investigate the impact of wearing a watch on the efficacy of hand hygiene

14
7

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.24.1
Hand hygiene research agenda (Cont.)
Area

In both developed
and developing countries

Laboratorybased and epidemiological

research and
development

Conduct experimental studies to understand different aspects of transmission,

colonization and infection role of casual contact and the environment (surface
contamination) in the transmission of pathogens, transmission dynamics from
colonization to infection, etc.

More focus on developing

countries

Develop and evaluate new standardized protocols to test the efficacy of hand
hygiene agents considering, in particular, short application times and volumes that
reflect actual use in health-care facilities
Establish if hand antisepsis prior to donning non-sterile examination gloves reduces
transmission of pathogens to patients
Conduct further studies to determine the relative efficacy of alcohol-based solutions
vs gels and other formulations in reducing transmission of HCAI
Compare the utility of different methods (new devices, surrogate markers, etc.) to
assess hand hygiene compliance that allow frequent feedback on performance
Compare the results of hand hygiene monitoring methods using different
denominators (e.g. indications vs opportunities)
Determine the percentage increase in hand hygiene adherence required to achieve a
predictable risk reduction in infection rates
Assess compliance with recommendations for surgical hand preparation
Conduct further studies to determine the consequences of soap contamination
Evaluate contamination of tap/faucet water at the sink with P. aeruginosa and nonfermenting Gram-negative bacilli and its role in hand contamination
Evaluate the frequency of recontamination (when rinsing) after surgical hand scrub
and its impact on surgical infection rates
Conduct additional in vitro and in vivo studies of both alcohol-based formulations
and antimicrobial soaps to establish the minimal level of virucidal activity required to
interrupt direct contact transmission of viruses in health-care settings
Evaluate the effectiveness of handrubbing or handwashing to interrupt transmission
of pathogens such as noroviruses
Identify the most appropriate surrogate virus for human norovirus for use in
laboratory studies of hand hygiene agents
Gather evidence on reduced susceptibility to antiseptic agents and evaluate whether
resistance to antiseptics influences the prevalence of antimicrobial resistance
Determine the actual risk of triclosan-inducing resistance in in-use situations
Establish sample size requirements for studies designed to answer different
research questions in hand hygiene epidemiology and research

148

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE

Table I.24.1
Hand hygiene research agenda (Cont.)
Area

In both developed and developing countries

More focus on developing

countries

System

Determine the effect of quality (or lack of it) and temperature of water on hand
hygiene

Establish the requisite quality

of water for handwashing

Develop and evaluate models for inexpensive and sustained supply of products in
different countries

Establish the most

appropriate method to keep
water safe for care and hand
hygiene purposes when it
needs to be stored at point of
use (containers)

Develop a cost-utility tool for large-scale production, storage, and distribution of

alcohol-based handrubs
Establish correlations between hand hygiene compliance rates (ideally by direct
observation), product consumption, and HCAI rates
Investigate the potential for aerosolization of water-borne pathogens associated with
air dryers

Establish the recommended

number of sinks per bed
Evaluate the costbenefit of
glove reuse in settings with
limited/poor resources

149

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table I.24.2
Unsolved issues for research and field testing
Area

Outstanding questions to be resolved

Water quality and

its availability in
health care

Should water for handwashing be drinkable or simply the cleanest possible?

Should water requirements be differentiated according to the resources available in different settings?
Are the water quality requirements at the tap/faucet in the operating room different from those in the rest of the
health-care setting?
Should high-risk populations (e.g. immunosuppressed) who need guaranteed high standards of water quality be
identified?

Soap

What is the potential for actual soap contamination during use?

What is the best storage method between uses?

Hand drying

What quality of paper should be used for hand hygiene?

What should be the standards for paper? Is there a preferred type of paper?
Does the quality of paper have an impact on hand hygiene compliance?
What are the best approaches when single-use towels are not available?
Use of recycled paper for hand drying:
What type of in vitro studies may be appropriate to assess the level of contamination of recycled paper?
Could there be an impact of the type of paper (recycled vs not-recycled) on HCAI or colonization rates by
multidrug-resistant pathogens?
What is the costbenefit of using recycling paper?

Antimicrobicidal
activity of products

When handling norovirus, is handrubbing or handwashing preferred?

Is there an impact of resistance to antiseptics on the prevalence of antibiotic-resistant strains?

Use of gloves

Should hand hygiene be recommended before donning non-sterile gloves?

What are the costbenefits of glove reuse in settings with limited/poor resources?
How many times could gloves be reused?
What type of gloves could be reused?
Could gloves be decontaminated between different patients? How?
Should the reuse of gloves definitely be forbidden: during outbreaks; if there is direct contact with blood or body
fluids; and during the care of patients colonized and/or infected with multidrug-resistant pathogens? In other
situations?

Surgical hand
antisepsis

What are the different types of surgical hand antisepsis currently performed in different countries?
What elements are to be included in a standardized protocol to define the status quo?
What is the appropriate time for surgical hand preparation? A 5-minute or a 3-minute scrub? Are times < 2
minutes inappropriate?

Hand hygiene
promotion

Is there a consequential impact of low budget, educational interventions on compliance with hand hygiene in
countries with limited resources?
What are the cognitive determinants of hand hygiene behaviour?

150

PART II.
ENSU
S
CRECO
OMMEN
NDATIO
SNS

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Ranking system for evidence

The consensus recommendations listed below (Part II, Sections 19) are categorized according to the CDC/
HICPAC system, adapted as follows:
Category IA. Strongly recommended for implementation and strongly supported by well-designed
experimental, clinical, or epidemiological studies
Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or
epidemiological studies and a strong theoretical rationale.
Category IC.

Required for implementation, as mandated by federal and/or state regulation or standard.

Category II. Suggested for implementation and supported by suggestive clinical or epidemiological studies
or a theoretical rationale or a consensus by a panel of experts.

1. Indications for hand hygiene 2. Hand hygiene technique

1.

1.
Wash hands with soap and water when visibly dirty or
visibly soiled with blood or other body fluids (IB) or after

surfaces of the hands.

Rub hands until dry

using the toilet (II).179,248,249,287,339,899,1001-1005

2.

3.

2.

Use an alcohol-based handrub as the preferred means

for routine hand antisepsis in all other clinical situations
described in items D(a) to D(f) listed below, if hands are
not visibly soiled (IA).60,221,329,333,484-487,665If alcohol-based
handrub is not obtainable, wash hands with soap and water
(IB).60,195,196

4.

(IB).201,814 (The technique

for
handrubbing
is
illustrated in Figure II.1)

If exposure to potential spore-forming pathogens is strongly

suspected or proven, including outbreaks of Clostridium
difficile, hand washing with soap and water is the preferred
means (IB).419-421,432

Perform hand hygiene:

1.

before and after touching the patient (IB);50,52,73,88,110,114,

121,125,126,1006

When washing hands with

soap and water, wet
hands with water and
apply the amount of
product necessary to
cover all surfaces. Rinse
hands with water and dry
thoroughly with a singleuse towel. Use clean,
running water whenever
possible. Avoid using hot
water, as repeated
exposure to
hot water may increase the
risk of dermatitis

2.

b
e
f
o
r
e
h
a
n
d
l
i
n
g
a
n

i
n
v
a
s
i
v
e
d
e
v
i
c
e
f
o
r

(IB).255,586,587 Use towel to

turn off tap/faucet
(IB).151,220,222,1010,1011 Dry
hands thoroughly using a
method that does not
recontaminate hands. Make
sure towels are not used
multiple times

Apply a palmful of
alcohol-based handrub
and cover all

p
a
t
i
e
n
t

l
e
s
s

c
a
r
e
,

w
h
e
t
h
e
r

r
e
g
a
r
d

o
f

o
r
n

or
by
multiple
people
(IB).75,115,257,671 (The
technique
for
handwashing
is
illustrated in Figure
II.2).

3.

Liquid,
bar, leaf
or
powdered forms of soap
are acceptable. When bar
soap is used, small bars
of soap in racks that

facilitate drainage should

be used to allow the bars
to dry
(II).265,266,640,1012-1015

o
t

a
r
e

g
l
o
v
e
s

u
s
e
d

4.

(IA);50,125,127,179

if moving from a
contaminated body site
to another body site
during care of the same
patient (IB);73,88,125-127

5.

after
contact
with
inanimate
surfaces
and objects
(including
medical
equipment)
in
the
immediate vicinity

6.

of
the
patient
(IB);73,111,112,114,125-127,129,130

after removing sterile

(II)
or
non-sterile
gloves
(IB).73,123,139,520,1008

5.

(
I
B
)
;

6.

Before handling medication

or preparing food perform

hand
hygiene
using an
alcoholbased
handrub
or wash
hands
with either
plain or
antimicro
bial soap
and water
(IB).10011004

So
ap
and
alc
oho

3.

Recommendations for surgical

hand preparation membranes,

non-intact skin, or wound dressings

lbas
ed
han
dru
b
sho
uld
not
be
use
d
con
co
mit
antl
y
(II).

1.

after contact with body fluids or

excretions,
mucous
3.

Remove rings, wrist-watch,

and
bracelets
before4. Brushes
are not
beginning
surgical hand preparation
(II).962,965,966,968,1016
Artificial
nails
are prohibited (IB).154,167,534,974,977

2.

Sinks should be designed

to reduce the risk of
splashes

recomme
nded for
surgical
hand
preparatio
n
247,261,46
(IB).
3,511,545-547

(II).235,552

3.

617,1
009

If hands are visibly soiled,

wash hands with plain
soap before surgical hand
preparation (II). Remove
debris from underneath
fingernails using a nail
cleaner, preferably under
running water (II).63

152

10. After application of the alcohol-based handrub as

recommended, allow hands and forearms to dry
thoroughly before donning sterile gloves (IB).463,482

4. Selection and handling of hand hygiene agents

5.

Surgical hand antisepsis should be performed using either

a suitable antimicrobial soap or suitable alcohol-based
handrub, preferably with a product ensuring sustained
activity, before donning sterile gloves (IB). 162,227,282,336,463,482,524,
525

6.

If quality of water is not assured (as described in Table

I.11.3) in the operating theatre, surgical hand antisepsis
using an alcohol-based handrub is recommended before
donning sterile gloves when performing surgical procedures
(II).250,282,463,482

7.

1.

Provide HCWs with efficacious hand hygiene products that

have low irritancy potential (IB).219,220,262,264,329,548,549,572,607

2.

To maximize acceptance of hand hygiene products by

HCWs, solicit their input regarding the skin tolerance,
feel,
and fragrance of any products under consideration (IB).221,
329,488,549,598,608,610,633,1017

3.

When selecting hand hygiene products:

When performing surgical hand antisepsis using an

antimicrobial soap, scrub hands and forearms for the
length of time recommended by the manufacturer, typically

1.

determine any known interaction between products

used to clean hands, skin care products, and the
types of glove used in the institution (II);342,946

25 minutes. Long scrub times (e.g. 10 minutes) are not

2.

solicit information from manufacturers about the

risk of product contamination (IB);160,643,644

3.

ensure that dispensers are accessible at the

point of care (see Part I.1 for the definition)
(IB);335,486

4.

ensure that dispensers function adequately and reliably

necessary (IB).284,378,380,460,511,512,525,541,542

8.

When using an alcohol-based surgical handrub product

with sustained activity, follow the manufacturers
instructions for application times. Apply the product to

dry hands only (IB).562,564 Do not combine surgical

hand scrub and surgical handrub with alcohol-based
products sequentially (II).617

9.

When using an alcohol-based handrub, use sufficient

product to keep hands and forearms wet with the handrub
throughout the surgical hand preparation procedure
(IB).328,557,568 (The technique for surgical hand preparation
using alcohol-based handrubs is illustrated in Figure
I.13.1.)

and deliver an appropriate volume of the product

5.
6.

(II);60,983

ensure that the dispenser system for alcohol-based

handrubs is approved for flammable materials (IC);
solicit and evaluate information from manufacturers
regarding any effect that hand lotions, creams, or
alcohol-based handrubs may have on the effects

PART II. CONSENSUS RECOMMENDATIONS

antimicrobial soap is not recommended (II).

5.

Soap and alcohol-based handrub should not be

used concomitantly (II).617

6. Use of gloves
of antimicrobial soaps being used in the institution

7.

4.

(IB);342,563,1018

1.

cost comparisons should only be made for products

that meet requirements for efficacy, skin tolerance,
and acceptability (II).464,488

(IB).73,123,139,520,913,914,931

2.
Do not add soap (IA) or alcohol-based formulations (II)
to a partially empty soap dispenser. If soap dispensers
are
reused,
follow
recommended
procedures
for
cleansing.161,358

Include information regarding hand-care practices designed

to reduce the risk of irritant contact dermatitis and other skin

(IC).906,1019,1020

3.

3.

4.

Remove gloves after caring for a patient. Do not wear

the
same pair of gloves for the care of more than one patient
(IB).73,114,123,139,520,941,1021

4.

Provide alternative hand hygiene products for HCWs

with confirmed allergies or adverse reactions to
standard products used in the health-care setting (II).

When wearing gloves, change or remove gloves during

patient care if moving from a contaminated body site to
either another body site (including non-intact skin,
mucous membrane or medical device) within the same
patient or the environment (II).72,123,139

5.

Provide HCWs with hand lotions or creams to minimize

the occurrence of irritant contact dermatitis associated
with hand antisepsis or handwashing (IA).549,607,623-626

The reuse of gloves is not recommended (IB).956 In the

case of glove reuse, implement the safest reprocessing
method (II).952

7. Other aspects of hand hygiene

damage in education programmes for HCWs (IB).618,624

2.

Wear gloves when it can be reasonably anticipated that

contact with blood or other potentially infectious materials,

mucous membranes, or non-intact skin will occur

5. Skin care

1.

The use of gloves does not replace the need for

hand hygiene by either handrubbing or handwashing

When alcohol-based handrub is available in the healthcare facility for hygienic hand antisepsis, the use of

1.

Do not wear artificial fingernails or extenders when

having direct contact with patients (IA).154,155,159,856,976,977

153

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

1.

2.

K
e
e
p
n
at
ur
al
n
ail
s
s
h
or
t
(ti
p
s
le
ss
th
a
n
0.
5
c
m
lo
n
g
or
a
p
pr
o
xi
m
at
el
y

in
c
h)
(II
).

support for
implementati
on.(IA)
60,651,657,676,701,

provide
them with
performanc
e feedback
(IA).
60,633,651,657,66
3,666,670,676,686
,687,715,939

4.

(II).803-805

9.
Government
al and
institutional
responsibiliti
es
9.1 For healthcare
administrators

1.

809,813,814,816,8
20,834,939,1022

2.

Educate
HCWs
about the
type
of
patientcare
activities
that
can
result
in
hand
contaminat
ion
and
about the
advantage
s
and
disadvanta
ges
of
various
methods
used
to
clean their

4,939,1022

Monitor
HCWs
adherence
to
recommen
ded hand
hygiene
practices
and

It is
essentia
l that
administ
rators
ensure
conditio
ns are
conduci
ve to the
promotio
n of a
multifac
eted,
multimo
dal hand
hygiene
strategy
and an
approac
h that
promote
s

a
patien
t
safety
cultur
e by
imple
menta
tion of
points
BI
below
.

hands
60,657,663,666
(II).
,670,715,716,727,81

3.

Encourag
e
partnershi
ps
between
patients,
their
families,
and HCWs
to promote
hand
hygiene in
health care
settings

708,713,725,732,767
,802,

97

8.
Educa
tional
and
motiva
tional
progra
mmes
for
health
-care
worker
s

In hand
hygiene
promotion
programm
es for
HCWs,
focus
specificall
y on
factors
currently
found to
have a
significant
influence
on
behaviour,
and not
solely on
the type of
hand
hygiene
products.
The
strategy
should be
multifacet
ed and
multimoda
l and
include
education
and senior
executive

2.

Provide

HCWs
with
access
to a
safe,
continuo
us water
supply
at all
5.
outlets
and
access
to the
necessa
ry
facilities
to
perform
handwa
shing
(IB).939,9
81,1023

3.

Provide
HCWs
with a
readily
accessi
ble
alcoholbased
handrub
at the
point of
patient
care
(IA).60,485,
486,615,647,6
65,855,

Make
impro
ved
hand
hygien
e
adher
ence
(comp
liance)
an
institut
ional
priorit
y and
provid
e
appro
priate
leader
ship,
admini
strativ
e
suppo
rt,
financi
al
resour
ces,
and
suppo
rt

activities
(IB).
13,728 60,657,708,7

Ensur
e
HCW
s
have
dedic
ated
time
for
infecti
on
contro
l
trainin
g,
includ
ing
sessi
ons
on
hand
hygie
ne
(II).732
,1026

6.

1024,1025

4.

for
hand
hygiene
and other
infection
prevention
and control

Implemen
ta
multidisci
plinary,
multifacet
ed and
multimod
al
program
me
designed
to
improve
adherenc
e of
HCWs to
recomme
nded
hand
hygiene
practices
(IB).60,713,
719

7.

With
regard to
hand
hygiene,
ensure
that the
water
supply is
physicall
y
separate

d
from
drainage
and
sewerag
e

9.

within
the
health
-care
settin
g, and
provid
e
routin
e
syste
m
monit
oring
and
mana
geme
nt
(IB).22
8

8.

Provi
de

Alco
holbase
d
hand
rub
prod
uctio
n
and
stora
ge
must
adhe
re to
the
natio
nal
safet
y
guid
eline
s
and
local
legal
requi
reme
nts
(II).

implemen
tation
program
me, while
ensuring
monitorin
g
and
long-term
sustainab
ility
(II).875,1027
-1029

2.

0,1031

3.

stron
g
leade
rship
and
suppo
rt for

9.2 For
national
governments

1.

hand
hygie
ne
and
other
infecti
on
preve
ntion
and
contr
ol
activit
ies
(II).713
154

Make
improv
ed
hand
hygien
e
adhere
nce a
nation
al
priority
and
consid
er
provisi
on of a
funded
,
coordi
nated

Support
strengthe
ning
of
infection
control
capacities
within
healthcare
settings
(II).1026,103

Promote
hand
hygiene at
the
community
level
to
strengthen
both selfprotection
and the
protection
of others
(II).248,249,451
454,899

4.

Encourag
e healthcare
settings to
use hand
hygiene
as a
quality
indicator
(Australia,
Belgium,
France,
Scotland,
USA)
(II).726,727

PART II. CONSENSUS RECOMMENDATIONS

Figure II.1
How to handrub

Hand Hygiene Technique with Alcohol-Based Formulation

Duration of the entire procedure: 20-30 seconds

1a

1b 2

Apply a palmful of the product in a cupped hand, covering all surfaces;

Right palm over left dorsum with

interlaced fingers and vice versa;

Rub hands palm to palm;

Palm to palm with fingers interlaced;

Backs of fingers to opposing palms

with fingers interlocked;

8
safe.
forwards with clasped fingers of right
hand in left palm and vice versa;

Rotational rubbing of left thumb clasped in right palm and vice

versa;

Rotational
rubbing,
backwards and
Once dry,
your hands are

155

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Figure II.2
How to handwash

Hand Hygiene Technique with Soap and Water

Duration of the entire procedure: 40-60 seconds

Wet hands with water; Apply enough soap to cover

Rub hands palm to palm;
all hand surfaces;

Right palm over left dorsum with

interlaced fingers and vice versa;

Palm to palm with fingers interlaced;

Backs of fingers to opposing palms

with fingers interlocked;

8
forwards with clasped fingers of
right
hand in left palm and vice versa;

Rotational rubbing of left thumb clasped in right palm and vice

versa;

10
11

Dry hands
thoroughly
Use towel
to turn off
faucet;
Your hands

Rotational rubbing,
backwards and
Rinse
hands with water;

are now safe.

with a single use
towel;

156

PART III.
SS
AND
POUTC
ROME
OMEAS
CUREM
EENT

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

1.
Hand hygiene as a performance indicator
Monitoring hand hygiene adherence serves multiple functions: system monitoring, incentive for performance improvement,
outbreak investigation, staffing management, and infrastructure design.60,648,651,663,666,670,676,684,686,713,714 It has to be kept in
mind, however, that hand hygiene performance is only one node in a causal tree leading

to the two major infectious outcomes: HCAI and health care-associated colonization with multi-resistant
microorganisms. As a process element in this causal chain, hand hygiene performance itself is influenced by
many factors, not least the structural aspects related to the quality and availability of products such as alcoholbased handrub at the point of care.
The correct moment for hand hygiene is usually termed
opportunity. According to an evidence-based model of hand
transmission,1,885 the opportunity corresponds to the period
between the moment in which hands become colonized
after touching a surface (either environment or patient) and
the moment in which hands touch a receptor surface. This

transition can potentially result in a negative infectious

outcome. Opportunities constitute the denominator in the
calculation of compliance with optimal hand hygiene. As a
consequence, measurement technologies and methods can
be divided into two main categories: those with a measured
denominator, and those without.
An ideal indicator of hand hygiene performance would produce an
unbiased and exact numerical measure of how appropriately
HCWs practise hand hygiene so that its preventive effect on
negative infectious outcomes is maximized. Ideally, such an
indicator implies a technology that does not interfere with the
behaviour of those observed, assesses the microbiological
outcome of each hand cleansing action in real time, and reliably
captures each moment requiring hand hygiene even during
complex care activities. Furthermore, the method used should not
require excessive staffing time and other incurred costs to provide
sufficient data to exclude selection bias and underpowering. Bias
and insufficient sample size represent the two major threats to
meaningful monitoring outputs (see Part III, Section 1.1 below).

sequence of care.
Observations are usually
performed by trained and
validated observers who
observe care activity directly
and count the occurring hand
hygiene opportunities and
determine the proportion being
met by hand hygiene actions.
It is essential that hand
hygiene opportunities,
indications, and actions are
clearly defined (see Part
III, Section 1.2). The

validation of observers is
essential for the quality of
observation data (see under
1.2.3).

Opportunities for hand

hygiene action using
alcohol-based handrubs
can be distinguished from
those requiring
handwashing with soap
and water. If preestablished in the
selected methodology, direct
observations allow to collect
Today, such an ideal method does not exist. All current
measurement approaches produce approximate information more detailed information.
This can comprise glove use,
on real hand hygiene performance, each with certain
handrubbing technique,
advantages and disadvantages (Table III.1.1).
application time, and other
Hand hygiene performance in health care can be monitored quality parameters that affect
hand hygiene efficacy such as
directly or indirectly. Direct methods include direct
the wearing of jewellery and
observation, patient assessment or HCW self-reporting.
Indirect methods include monitoring consumption of products, fingernail status (see Part I,
Sections 23.4 and 23.5).
such as soap or handrub, and automated monitoring of the
Whereas routine monitoring
use of sinks and handrub dispensers.
needs to be kept simple and
straightforward, observations
for research purposes can be
1.1 Monitoring hand hygiene by direct methods
even more detailed. A major
drawback of direct observation
Detection of hand hygiene compliance by a validated observer
is the large effort required
(direct observation) is currently considered the gold standard in
(trained and validated staff
hand hygiene compliance monitoring.58 It is the only method
and many working hours). For
available to detect all occurring hand hygiene opportunities and
actions and to assess the number of times and appropriate timing example, with a typical
average density of 10 hand
when hand hygiene action would be required in the
hygiene opportunities per
hour, a total observation time
of 80 hours is required to
obtain 500 opportunities.

Causes of potential bias

arising from hand hygiene
direct observation are listed in
Table III.1.2. The most
important are observation,
observer, and selection bias.
Observation bias is generated
by the presence of an observer
who influences the behaviour
of the observed HCWs towards
a higher compliance or by an
increased attention to the topic
under study. In a recent study,
compliance found to be 45%
with overt observations was in
reality only 29% when
observations were covert.736
Observation bias can also
induce increased recourse to
hand hygiene action at
inappropriate times during the
sequence of care, i.e. not
associated with true
improvement in compliance.
If observational surveys
are conducted
periodically, this bias
would be equally
distributed among all
observations.831
Observation bias might be
eliminated by keeping
observations covert. Such
observations, however, are
not recommended
in conjunction with
promotional interventions
because they can induce
mistrust in the observed
HCWs. Furthermore,
hiding the true reason for
the presence of an
observer can hardly be
maintained in the case of
repeated observations. If a
baseline observation is
covert, then the results of
overt follow-up
observations would be
confounded by the change
in method. The
observation bias can also
be attenuated by

desensitizing HCWs through the frequent presence of observers

or an unobtrusive conduct during observation sessions. Some
158

PART III. PROCESS AND OUTCOME MEASUREMENT

investigato
rs call this
effect the
Hawthorn
e effect
following
ergonomic
studies in
the early
20th
century at
the
Hawthorne
factory of
Western
Electrics in
the
USA.334,810,
1032,1033
On
the other
hand, this
effect can
be used
deliberatel
y to
stimulate
hand
hygiene
complianc
e in a
promotiona
l intention,
rather than
to obtain
objective
quantitativ
e
results.334,8

bias refers to
the
systematic
error
introduced by
inter-observer
variation in
the
observation
method (Table
III.1.2). To
reduce this
bias,
observers
have to be
validated. It is
noteworthy
that even the
same
observer can
unconsciously
change
his/her
method over
time.
Selection
bias results
from
systematical
ly selecting
HCWs, care
settings,
observation
times, or
health-care
sectors with
a specific
hand
hygiene
behaviour.
In practical
terms, this
bias

can be
minimized by
Obtaining
randomly
a
sustained choosing
and never- locations,
times during
ending
Hawthorne the day, and
HCWs.
effect
10,1033

associated
with
improved
complianc
e with
hand
hygiene
and
decreased
infection
and crosstransmissi
on rates
could
certainly
represent
an ideal
perspectiv
e.810

Observer

Another threat to
meaningful hand
hygiene
compliance
results is the
inclusion of a
small sample
size. In a
comparative
quantitative
analysis of hand
hygiene
performance
during two
different periods,
a large enough
sample is
needed to
exclude the

influence of
chance. A
sample size
calculation
should therefore
be performed at
the design stage
of every hand
hygiene
monitoring
scheme. For
example, to
show a
difference
between 40%
and 60%
compliance in
two different
measurements
with

a power of
90% and an
alpha error of
5%, twice 140
(140x2)
opportunities
have to be
observed. The
sample size
increases to
twice 538
(538x2)
opportunities
when a
difference
between 40%
and 50% is to
be detected.
Another more
innovative
statistical
approach for
measuring
improvement
over time and
determining
whether
statistical
improvement
has really
occurred is
described in
Appendix 4.
However,
because this
method has
not yet been
applied to the
analysis of
hand hygiene
data, further
research is
needed to
consolidate its
use in this
field.
If hand
hygiene
monitoring
is used for

compar
patient
ison
s were
betwee
encour
n
aged
healthto find
care
out if
sectors
HCWs
or
had
periods
washe
,
d their
confou
hands
nding
before
factors
patient
should
contact.804,805
be
Patient
include
monitoring of
d in the
hand hygiene
compliance is
dataset
not well
and
documented,
correct
however, and
ed for
has never
by
been
stratific
objectively
ation,
evaluated.103
adjust
6
Patients
ment,
may
not feel
or by
comfortable
keepin
in a formal
g them
role as
unchan
observers
ged
and are not
betwee
always
n the
monitoring physically or
mentally able
sets.
to execute
Typical
this
confounder
task.737,1037
s in this
field
areSelfprofessiona assessment
l category,by HCWs can
time of day,be carried
and health-out. It has
been
care
demonstrated
setting.
, however,
Critical
reviews ofthat selfreports of
observation
compliance
methods
do not
have been
correlate well
published.8 with
09,1034,1035
compliance
measured by
Pati
direct
ents
observation,
coul
and selfd be
assessment
obs
markedly
erve
overestimates
compliance
rs of
with
HC
Ws
hand
han
218,220,666,
hygiene.
667,676,733
d
hygi
ene
com
plia
nce.
In
two
stud
ies,

1.2
The
WHO
reco
mme
nded
meth
od for
direct
obser
vation
Observation
is a
sophisticated
activity
requiring
training, skill
and
experience.
Observers
have to be
aware of the
multiple
potential
biases
introduced
with the
observation
process and
they can help
to minimize
these by
gaining a full
understanding
of the
methodology.
A stringent
adherence to
the same
methodology
over space
and time is
required.
WHO
proposes a
standardize
d hand
hygiene
observation
method
based on
an
approach
validated
through
several
studies.60,65
2,686,738
All
relevant
theoretical
and
practical
aspects
related to
this method

are
detailed
in the
Hand
Hygiene
Referen
ce
Technica
l Manual
that is
included
in the
Impleme
ntation
Toolkit
(availabl
e at
http://ww
w.who.in
t/gpsc/

task of
observer
s is to
observe
HCWs
during
their
usual
care
activity
and to
assess
their
complia
nce with
the
recomm
ended
indicatio
ns for
en/). An
hand
Observati hygiene.
on form To be
for data
able to

feasible,
depending on
the setting.
They have
then to be
instructed in
hand hygiene
observation
according to
the present
methodology.
This should
take a
relatively short
time if they
have already
proved to be
proficient in
the application
of the five
moments.

collection, accomplish
consistent this task,
with the
observers
proposed have to be
method
able to
and
understand
including the logic of
concise
care.
user
Ideally, they
instruction have
s, is also training and
availableto experience
gether
in patient
with a
care as
Complian professional
ce
s.
calculation
form to
facilitate 1.2.2 Training
the
of observers
immediate
performan Observers
ce
have to be
feedback. trained
Observatio according to
n of hand the principles
hygiene
of My five
practices moments for
is an
hand
essential hygiene
componen and, ideally,
t of the
have become
WHO
excellent
Hand
monitors of
Hygiene the
Improvem application of
ent
hand hygiene
Strategy during
(See Part health-care
I, Sections delivery.
21.2 and Their
21.3).
excellence

1.2.3
Validation of
observers

should be
confirmed

1.2.1
through
Profile and
observations
task of
performed by
observers
The

a senior
observer, if

Once
knowledg
eable in
the use of
the
observati
on form
and
process,
observers
must be
validated
either by
parallel
observation
jointly with a
confirmed
observer, or by
being tested
through the
use of the
WHO Training
Film included
in the WHO
Implementatio
n Toolkit
(available at
http://www.wh
o.int/gpsc/
en/). In the
first case, two
observers
engage in an
observation
session during
a real-life care
situation and
each
completes an
observation
form
separately
while
observing the
same HCW
and the same

care
sequence.
Results are
then
compared
and
discordant
notification
s
discussed.

This process
is repeated
until
concordance
is reached in
the number
and nature of
each
occurring
hand
159

hygiene
opportunity.
It is
recommend
ed that the
person in
charge of
validation
remains the
same for

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

all
new
potential
observers
in a given
setting. It
is
advisable
to perform
validation
in
each
care
setting
that is to
be
monitored
by
the
future
observer.
The WHO
Training
Film
provides
visual
examples
of the five
moments
for HCWs
and
observers.
Observers
can be
trained and
tested
through the
use of the
scenarios,
which
include
different
sequences
of health
care where
hand
hygiene is
necessary.
Observers
are asked
to complete
the form
while
watching
the film,
and the
trainer can
then judge
their
performanc
e by
comparing
the results
with the
those
provided in
a slide
show
presentatio

n that
accompanies
the film. The
subsequent
discussion is
usually very
valuable

however, that
local
specificity
related to the
application of
the five
moments

for learning
purposes. If
a time grid of
opportunities
can be
established
in a scenario,
kappa
statistics can
be calculated
to quantify
the level of
coincidence
between two
observers.

is
established
and known
by
everyone.
For
example,
the
delimitation
of the
patient
zone in a
given
setting
needs to
be
specifically
determined
.

1.2.4
Understanding
the five
moments for
hand hygiene
The concept
of My five
moments for
hand
hygiene has
been created
as a robust
framework
for
understandin
g, training,
measuring,
and
communicati
ng hand
hygiene
performance.
1

Understandin
g this
concept (see
Part I,
Section 21.4)
is a
prerequisite
for any future
observer. It is
a simple
concept that
should not
leave any
knowledge
gap between
the insight of
observers
and
observed
HCWs once
they are
adequately
trained in
hand
hygiene. It is
essential,

Health-care
activity must
be imagined
as a
succession of
tasks during
which the
HCWs hands
touch different
types of
surfaces prior
to and after
patient
contact. Each
contact is a
potential
source of
contamination
for HCWs
hands.
A crucial
point specific
to
observations
is the
distinction
between
indications
and
opportunities,
which is more
extensively
described in
the Hand
Hygiene
Reference
Technical
Manual. The
indication is
the reason
why hand
hygiene is
necessary at
a given
moment to

effectively
interrupt
microbial
transmissio
n during
care, and it
correspond
s to
precise
moments
in patient
care. Very
close to
the
concept
of
indication,
the term
opportunity
is much
more
relevant to
the
observer: it
determines
the need to
perform
the hand
hygiene
action,
whether
the reason
(the
indication
that leads
to the
action) be
single or
multiple.
From the
observer
point of
view, the
opportunity
exists
whenever
one of the
indications
for hand
hygiene
occurs and
is
observed.
Several
indications
may arise
simultaneo
usly and
create a
single
opportunity
. Very
importantly
, the
opportunity
constitutes
the
denominat
or for
calculating
compliance
, i.e. the
proportion
of times

that HCWs

perform hand
hygiene action
of all observed
moments
when this was
required.
For this
purpose,
hand hygiene
action is
defined as
either rubbing
hands with an
alcoholbased
handrub
accepted by
the institution
or
handwashing
with soap and
water. Neither
the duration
nor other
quality
aspects of
hand hygiene
such as the
quantity of
product used,
glove use,
length of
fingernails, or
the presence
of jewellery
are
assessed.

It is important
to understand
that hand
hygiene
actions not
corresponding
to an
opportunity,
and therefore
additional
and not
required,
should not be
taken into
account by the
observer.

1.2.5
Understanding
the
observation
form
Observa
tions are
noted on
a paper
form
using a
pencil
and
rubber.
Each
form
represen
ts a
separate
observat
ion

session.
Experience
shows that
this material
is ergonomic
for
observations.
The surface
of a sheet of
paper
provides the
necessary
overview of
the past
evolution of
observed
activity in
several,
simultaneousl
y observed
HCWs. Using
a pencil and
an eraser,
errors can
easily be
corrected.
The form has
three main

sections:
1) a
header
contains
information
on the
institutiona
l level
(country,
city,
hospital,
site
identity); 2)
a second
header
contains
information
on the
session
(observer
identity,
date, start
and end
time,
duration,
period
number,
session
number,
form
number,
departmen
t, service
name,
ward
name);
and 3) four
columns
below the
header
represent
the
sequence
of actions
for
different
HCWs
observed
during the
same
session.
Each
column is
usually
dedicated
to one
HCW and
therefore
the form
can
include up
to four
HCWs.
Alternativel
y, in
situations
with low
activity,
each
column
can be
dedicated
to a
different

professional
category and
therefore the
HCWs
belonging to
the same
professional
category can be
grouped within
one column.
This method
can be practical
when the
observer
chooses to
observe more
than four HCWs
during the
same session.
This results,
however, in a
loss of the
possibility to
calculate a per
person density
of hand hygiene
opportunities
and individual
feedback after
the session.
The header of
each column
contains
information
about the
observed HCW
(professional
category, code,
number). The
rest of the
column consists
of equal blocks
that are
incrementally
numbered from
1 to 8 from top
to bottom. Each
block
represents one
of the
sequentially
occurring
opportunities
for hand
hygiene. For
each
opportunity, the
observer notes
in the
corresponding
block all the
applicable
indications and
if hand hygiene
was executed
by
handrubbing,
handwashing or
missed.

1.2.6
Determining

the scope of
an observation
period
Before starting
an observation
period, the
investigators
and project
coordinators
must
determine the
scope of
observations.
Possible
scopes are
listed in Table
III.1.3. If the
scope is to
build a
comparison
between two or
more
observation
periods to
assess the
evolution of
hand hygiene
compliance
over time,
special
attention
should be paid
to control for
the potential
confounding
factors. This
can be
achieved by
predefining a
target number
of
opportunities
by profession,
wards, and
time of day. To
minimise interobserver
variability, the
observer or the
team of
observers
should remain
the same
across the
different
periods of the
project. The
best unit for
calculation is
the
denominator,
i.e.
opportunities
for hand
hygiene,
because this
will directly
influence the
results.

1.2.6.1

Selection of wards and time

location and of day should
time
be sought.
Naturally,
A
observers tend
representativ to undertake
e mix of
160

their activity at
times

and in
locations with
a high density
of care to
gather a higher

PART III. PROCESS AND OUTCOME MEASUREMENT

be observed
during a
session.
Selection bias
should be
minimized by
choosing at
number of random. In
opportunit the case of
ies more
repeated
quickly.
observation
Observer periods in
s have to particular,
be aware observers
that
may know the
changing intrinsic
the
performance
method of of individual
selecting HCWs and
time and
this could
location
easily
for
influence the
observati overall
ons
observation
between
result by
observati always
on
selecting
periods
HCWs with
can lead
extreme
to bias
behaviour.
because
there is
usually an
1.2.6.3
associatio
Starting,
n
continuin
between
g, and
density of concludi
opportunit ng an
ies and
observat
complianc ion
e.
session
Therefore
, we
Once a healthsuggest
care situation
to
is identified,
establish a the observer
rough
may introduce
location
himself/herself
plan and
by indicating
timetable unobtrusively
ahead of the scope of
planned
his/her
observation presence. The
s that will way in which
be remain this
stable over introduction is
observation handled
depends on
periods.
local social
and medical
culture. A
1.2.6.2
Selection balance
of HCWs should be
sought
Once
between
location
increased
and time observation
are
bias through a
determined too overt
, observers presence and
have to
inducing the
choose the feeling of
HCWs to being cheated

in the
observed by
pretending to
be there for
another scope.
This includes
also a discreet
positioning of
the observer.
After
completing
the form
header,
each
observed
opportunity
is noted on
the form
(see above).
Only
opportunitie
s for which
the entire
time
between the
two
delimiting
hand-tosurface
exposures
can be
observed
are noted.
During
the
observation
session, the
observer
must
not
interfere with
observed
staff.
The
session
should
be
concluded
after
20
minutes 10
minutes
according the
duration
of
care activity.

The observer
may want to
give feedback
to the
observed
HCW(s) about
the observed
hand hygiene
performance.
This depends
on the scope
of the
observation,
but it was
found to be
very efficient
and
appreciated
by HCWs.

1.2.7
Analysis
Followi
ng data
entry
(Epi
Info
databa
ses for
enterin
g data
collecte
d
accordi
ng to
the
WHOrecom
mende
d
method
for
direct
observ
ation
are
availabl
e), the
simples
t form
of
results
is the
overall
complia
nce.
This is
calculat
ed by
dividing
the
number of
observed
hand
hygiene
actions
performed
when an
opportunity
occurs, by
the total
number of
opportunitie
s. It has
been found
useful to
stratify
compliance
by
institutional
sector,
professiona
l category,
and
indication
(moment)
for hand
hygiene
using the
My five
moments

for hand
hygiene as
strata.1

strong
internal
identity. A
short
delay
between
observatio
n activity
and
reporting
of results
might
increase
the effect
of
feedback.
Continual
feedback
of
unchangin
gly bad
results
without
any
interventio
n should
be
avoided,
as it may
lead to
desensibil
ization
and
demotivati
on.
Special
attention
should be
given to the
potentially low
number of
observed
opportunities
when using
percentages to
report
compliance.
Low numbers
occur
especially with
stratified
results. It is
good practice
to calculate
95%
confidence
intervals and
include these
in graphics.
For instance,
for 30
opportunities
with a
compliance of
50%, the
confidence

interval
liquid
would
soap60,334,
stretch from 429,486,489,713,803,
852
31% to
to estimate
69%
the number of
compliance. hand hygiene
With 100 actions. To
opportunitie make these
s and 50% monitoring
compliance, techniques
the
more
confidence meaningful,
interval
the quantity of
would
handrub was
shrink to
translated into
4060%, a number of
and for 200 hand hygiene
and 50% actions by
compliance using the
opportunitie average
s to 43
amount per
action as a
57%.
divider. The
Finally,
observation missing
denominator of
s can be
reported to the need for
hand hygiene
HCWs
actions was
directly
after each either ignored
by only
session,
following the
which
produces evolution over
time, or
an
immediate substituted by
impact. For a surrogate
statistical measure such
methods to as patient days
measure or workload
indicators
hand
drawn from a
hygiene
compliance computerized
over time database of
nursing
see also
851
Appendix 4. activities.
Some
studies60,334,48
1.3
6
have shown
Indirect
that
the
monitorin
consumption
g of hand
of products
hygiene
used for hand
performanhygiene
ce
correlated
with observed
In the quest hand hygiene
for less
compliance,
expensive whereas
monitoring others have
approaches not.1039 Thus,
, experts
the use of this
have used measure as a
the
surrogate for
consumptio monitoring
n of hand hand hygiene
hygiene
practices
products
deserves
such as
further
paper
validation.
towels,1038 Other studies
alcoholfound that
based
feedback
handrub or based on

measured
soap and
paper towel
consumption
did not have
an impact on
hand
hygiene.802,103
8

Methods
based on
product
consumption
cannot
determine if
hand hygiene
actions are
performed at
the right
moment during
care or if the
technique is
correct. The
advantages,
however, are
that they are
simple, can be
continuous,
and provide a
global picture
that remains
unaffected by
selection or
observer bias
and, most
likely,
observation
bias. The
amount of
alcohol-based
handrub used
by health-care
settings has
been selected
as
one of the
indicators.
Nevertheless,
it has to be
considered
that this
measure may
not exactly
reflect the
product
consumption
by HCWs, but
could include
the amount
used by
visitors or
patients,
especially if
the
dispensers
are located
also in public
areas of the
health-care
setting and
they are wallmounted.

ack of

1.4
results

ul

able to identify

electron promotional tool

ically.699 and should firstly

1.2.8 to
,710,852,98 address groups
Repor those
6
ting of concer
with a HCWs
result ned is
System when using a sink
s
a very
s that or a handrub
The
use of sinks
handrub dispensers
can be
are anddispenser
powerf
are
even
Feedb
under
161

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

development. These methods allow precise quantitative

results on hand hygiene activity to be obtained, with the only
costs being the installation and maintenance of the system.
Changes over time can be assessed. Some studies have
attempted to measure the need for hand hygiene by
monitoring patient room entries and linking each entry to the
use of a sink or a handrub dispenser. For the moment, no
comparative studies exist to validate the appropriateness of
electronic detection of hand hygiene opportunities.
Wireless devices placed inside handrub or soap dispensers
can provide useful information regarding patterns of hand
hygiene frequency. A recent study evaluated wireless devices
that were placed inside handrub dispensers on a general
medical ward and in a surgical intensive care unit.1040 During a
3-month trial period, 17 304 hand hygiene episodes using
handrub were recorded on the medical ward for a rate of 9.4
hand hygiene episodes/patient-day. A total of 50 874 hand
hygiene episodes using handrub were recorded in the ICU for
a rate of 47.7 hand hygiene episodes/patient-day. Average

usage was highest between 10:00 and 19:00; the lowest was
at 05:00. By mapping the location of each device, it was
observed that dispensers located in rooms with patients on
contact precautions were used significantly less often than
those located in other rooms on the ward (P = 0.006).
Table III.1.1
Advantages and disadvantages of various hand hygiene monitoring approaches
Monitoring approach

Advantages

Disadvantages

Direct observations
by expert observers

Only way to reliably capture all hand

hygiene opportunities
Details can be observed
Unforeseen qualitative issues can be
detected while observing hand hygiene

Time-consuming
Skilled and validated observers required
Prone to observation, observer, and selection bias

Self-report by healthcare workers

Inexpensive

Overestimates true compliance

Not reliable

Direct observations
by patients

Inexpensive

Potential negative impact on patientHCW relationship

Reliability and validity required and remains to be
demonstrated

Consumption of
hygiene products
such as towels, soap,
and alcohol-based
handrub

Inexpensive
Reflects overall hand hygiene activity
(no selection bias)
Validity may be improved by surrogate
denominators for the need for hand
hygiene (patient-days, workload
measures, etc.)

Does not reliably measure the need for hand hygiene

(denominator)
No information about the appropriate timing of hand hygiene
actions
Prolonged stocking of products at ward level complicates and
might jeopardize the validity
Validity threatened by increased patient and visitor usage
No possibility to discriminate between individuals or
professional groups

Automated monitoring
systems

Absence of observer may reduce

observation bias
May potentially produce valuable
detailed information about hand hygiene
behaviour and infectious risks

Scarce real world experience so far

Potential ethical issues with tracking of individual activity
Unknown impact on staff and patient behaviour
Systems may be costly and failure-prone

162

PART III. PROCESS AND OUTCOME MEASUREMENT

Table III.1.2
Potential bias in hand hygiene observation
Bias

Description

Observation bias

Presence of an observer induces better than usual hand hygiene behaviour

Observer bias

Observers systematically interpret the observation method and definitions for hand hygiene opportunities and
actions in their own way; consequently, their results are different from those of other observers

Selection bias

Observers systematically select certain times, care situations, health-care sectors, HCWs or opportunities for
their observations; consequently, their results do not reflect the overall hand hygiene compliance

Table III.1.3
Potential scope of hand hygiene observations

Compare the evolution of compliance over time in the same institution or sector

Compare different sectors

Perform a baseline measurement of compliance in an institution

Perform formal observations with immediate feedback to the observed HCW for training purposes

Establish the impact of system changes and multimodal interventions on compliance (before/after study)

Compare the quality of care in different hospitals

Evaluate hand hygiene practices in the framework of an outbreak investigation

163

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

2.
Hand hygiene as a quality indicator
for patient safety
Patient safety has become the touchstone of contemporary medical care. Medical errors and adverse events
occur with distressing frequency, as outlined persuasively in the USA Institute of Medicines To err is human.1041
HCAIs are second only to medication errors as a cause of adverse events in hospitalized patients. Hospital
infection control provides a mature template for patient safety with a long track record of research, evidencebased practice standards, and practice improvement efforts. Moreover, infection control professionals and hospital
epidemiologists have pioneered real-time methods to detect the occurrence of HCAI and monitor compliance with
infection control standards. Nonetheless, as documented in these WHO guidelines, compliance with hand hygiene
the pillar of infection control remains woeful in the vast majority of health-care institutions. The current
emphasis on hand hygiene by the WHO World Alliance for Patient Safety and many regulatory and accrediting
agencies reflects the slow progress of the health professions in meeting even modest performance standards.

Donabedians quality paradigm of structure, process and

outcome1042,1043 provides a useful framework for considering
efforts to improve hand hygiene compliance. Clearly, if sinks
and alcohol dispensers are not readily accessible (faulty
structure) and hand hygiene is not performed (inadequate
process), the risk of infection and its attendant morbidity,
mortality, and cost (outcomes) will increase. Quality indicators
can be developed according to Donabedians framework.

While such a high degree of

reliability seems impossible in
many aspects of health care, it
is worth noting that most
institutions have hand hygiene
defect rates of six per ten
opportunities

or greater. Moreover, these

rates do not even reflect
current thinking about
Hazard analysis critical control point (HACCP) is another
rigorous reliability, in which
valuable method to examine the system of patient care as it
the entire system either
relates to hand hygiene. Originally developed to provide
performs correctly or does
astronauts with pathogen-free food, HACCP is now widely
not. For example, defect-free
employed in good manufacturing practice, food and drug safety, care of a central venous
and blood banking. In brief, the method identifies error-prone
catheter would require
aspects of systems (critical control points), evaluates the risk they selection of the optimal
pose, and designs them out. Critical control points are scored
insertion site, perfect hand
according to their probability of occurrence, probability of avoiding hygiene, maximal barrier
detection, and severity of downstream impact. Failure mode and precautions, correct skin
effects analysis is closely related to HACCP and is being exploited preparation, and prompt
increasingly in patient safety. A desirable feature of both HACCP removal of the catheter as
and failure mode and effects analysis
soon as it is no longer
is their emphasis on system errors and their consequences. An
needed. Failure at any one of
empty alcohol dispenser, failure to educate staff in proper hand
these steps means no
hygiene technique, and failure to practise hand hygiene after
credit. Clearly, current defect
glove removal are serious failures at key points in the patientrates in the hand hygiene
care system. When multidisciplinary care teams map their
system are no longer
institutions system for hand hygiene, they not only identify error- tolerable. Even in a setting
prone critical control points and barriers to compliance,
with severely constrained
but also identify which aspects of the system are most critical resources, basic hand
to improve and monitor. This collaborative approach to
hygiene can and should be
identifying key quality indicators vastly improves these
performed very reliably with a
indicators local credibility and relevance and provides a guide defect rate of less than 5
to ongoing improvement and auditing efforts.
10%.
Failures at critical control points in the hand hygiene system can
be seen as problems in the reliability of the system. The concept
of reliability is the bedrock of modern manufacturing (e.g., it
transformed the quality of automobile production), but has been
applied to health care only recently. Reliability looks at
the defect or failure rate in key aspects of production (i.e. patient
care). Industry often seeks to achieve defect rates of one per
million or less (a component of so-called six-sigma reliability).

Although health-care
providers particularly
managers in relatively
complex organizations
will find it valuable to
understand and apply
Donabedians quality
paradigm, HACCP, failure
mode and effects analysis,
and reliability theory, it should
be relatively easy for health-

care providers in virtually

every setting to start
evaluating, improving, and
monitoring
the reliability of the hand
hygiene infrastructure and
practice immediately. Table
III.2.1 provides a variety of
structure and process
quality indicators that are
derived directly from these
WHO guidelines. Healthcare providers and
multidisciplinary teams (in
collaboration with quality
improvement and infection
control experts where
available) may want to
begin by considering some
of these indicators. The
emphasis is

on structure and process

because the ultimate
outcomes reduced
infection and antibiotic
resistance rates are
likely to be linked closely
with improvements in
structure and process, are
more time-consuming to
measure, and may not be
immediately discernible.
Many indicators in Table
III.2.1 are relatively easy
to measure and provide
real-time feedback to
caregivers and managers.
For example, at the most
basic level, are userfriendly, clear policies in
place, and are these
accessible to HCWs in the
workplace? Is the design
of the work space,
including the placement of
sinks, alcohol-based
handrub dispensers, and
other hand hygiene

equipment and supplies, conducive to compliance? Are the

alcohol-based handrub
164

dispensers

PART III. PROCESS AND OUTCOME MEASUREMENT

and rationale
for hand
hygiene and
the efficacy
and relative
merits of
various hand
convenientl hygiene
y placed
products and
near every procedures?
bed space It is
(or are they particularly
hiding
important to
behind the verify the
ventilator)? competency
Are the
of all HCWs in
sinks fully performing
operational hand hygiene
, and are procedures
soap and a critical
clean
certification
towels
step that is
always
applied all too
available? rarely,
Are
especially to
alcoholdoctors. Can
based
HCWs
handrub
actually
dispensers
demonstrate
full and
proper
operational
technique
? Are
when washing
appropriate
hands or
education
using alcoholprogramme
based
s available
handrubs?
to all
Are hand
HCWs,
lotions always
including
available to
trainees
HCWs and
and
conveniently
rotating
placed?
personnel,
and is
continuing
education
provided
on a
regular
basis?
What is the
actual
attendance
at these

These types
of questions
are asked in
technical
tools included
in the WHO
Multimodal
Hand
Hygiene
Improvement
Strategy and
programm
conceived for
es and are
evaluation
they
such as the
mandatory
WHO Facility
? Can
Situation
HCWs
Analysis and
answer
the WHO
basic
Questionnair
questions
e on Ward
about hand
Structure for
hygiene
Hand
(either by
Hygiene
survey or
(Implemenmt
web-based
ation Toolkit,
learning
available at
modules),
http://
such as
www.who.int/
the
gpsc/en/).
indications

Quick,
simple realtime checks
of
the
health-care
environment
can
be
extremely
useful
for
monitoring
barriers to
compliance,
e.g. checks
to see if
alcoholbased
handrub
dispensers
are full and
operational.
Random
audits of
actual
practice are
indispensable
(see Part III,
Section 1.1).
While hand
hygiene
practice can
be
considered a
process of
care, when it
is not
performed
appropriately
it
can also be
viewed as an
important
intermediate
step in the
chain leading
to the
colonization
and infection
of patients.
Moreover,
audit and
feedback of
compliance
data is a
major
component of
any
multifaceted
behaviour
change
programme.
Simple
graphics of
compliance
rates (or,
alternatively,
defect rates)
should be
prominently
displayed
where they
can be seen

during
routine
work. Data
should be
incorporat
ed into
HCWs
education
and fed
back in
real time.
Efforts to
improve
hand
hygiene
performan
ce will be
more
successfu
l if they
take
advantag
e of basic
behaviour
al science
principles.
Sustained
improvem
ent
requires
knowledg
e do
providers
understan
d the
indication
s and
rationale
for hand
hygiene?
Are
HCWs
enabled
to do the
right thing
by
ensuring
that sinks
or
alcoholbased
handrubs
are
available
at the
point of
care, and
has this
been
verified by
observing
HCWs
work
habits?
Are
staffing
ratios
adequate,
or are
HCWs so
harassed
that they
cannot

perform even
the most
basic
procedures
reliably? Are
they
motivated,
and do they
have a
strong sense
of selfefficacy?
How do they
view the unit
or
departments
social norms
regarding
hand
hygiene?
Can they
identify an
opinion
leader in
their unit or
department
who takes
the lead in
education
and the
promotion of
hand
hygiene? If
HCWs are

educated,
competent,
have
convenient
access
to
hand hygiene
facilities and
supplies, and
have
sufficient
staffing, are
they
held
accountable
for defects in
their
performance
?
The
ultimat
e
custo
mer, of
course
, is the
patient
.
Patient
s and
their
familie
s can
be
given
a tip
sheet
to help
them

understand
their role as
partners in
patient
safety. They
should be
encouraged
to point out
lapses in
hand
hygiene
technique
without fear
of retribution.
Surveys can
help HCWs
determine if
patient
perceptions
match their
own view of
their
performance
(see Part V,
Section 6).
In conclusion,
hand hygiene
is an important
indicator of
safety and
quality of care
delivered in
any healthcare setting,
because there
is substantial
evidence to
demonstrate
the correlation
between good
hand hygiene
practices and
low HCAI rates
(see Part I,
Section 22). It
is embedded
in the HCAI
planks of the

5 Million
Lives
Campaign
(http://www.ih
i.org/IHI/Prog
rams/
Campaign/)
and is
emphasized
in the WHO
Collaborating
Centre on
Patient
Safety
Solutions as
one of the
highest
priority

solutions
to improve
patient
safety

(www.who.int
/patientsafety
/
solutions/pati
165

entsafety/en/)
.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table III.2.1
Examples of quality indicators which may be used in relation to hand hygiene in health-care settings
(not including pre-surgical hand preparation)
Indicators*

Measure option**

Measure option**

Suggested frequency**

Functioning sinks with clean, running water

available in clinical rooms/wards/treatment
areas for hand washing

One per ward

Sink to bed ratio

Annual or more frequent

depending on results and
action

Sinks equipped with liquid soap in clinical

areas

100% to zero

Monthly/weekly/daily

Sinks equipped with bar soap/soap flakes

100% to zero

Monthly/weekly/daily

100% through none

Monthly/weekly/daily

Liquid soap dispensers in working order

100% through none

Monthly/weekly/daily

Beds with alcohol-based handrub

dispensers within arms reach, e.g. affixed
to bed

100% through none

Alcohol-based handrub pocket bottles

carried by staff

all staff through 75%,

50%, 25%, zero

Alcohol-based handrub bottle affixed to

trolleys for use in clinical areas

100% through zero

Bottle to trolley ratio

Monthly/weekly/daily

Alcohol-based handrub bottle affixed to wall

in rooms/cubicles/treatment rooms

100% through zero

Bottle to room ratio

Monthly/weekly/daily

Alcohol-based handrub dispensers in

working order

100% through zero

Structure
Hand hygiene policies located near the
point of care
Hand hygiene education and training
program, including behaviour change
strategies, at least annually

in clinical areas1
Bar soap/flakes on a dish that drains
excess liquid
Sinks equipped with single use/disposable
towels in clinical areas

Monthly/weekly/daily

Monthly/weekly/daily

Supply of alcohol-based handrub pocket

bottles available in clinical areas
Hand care lotion bottles in rooms/cubicles/
treatment rooms

100% through zero

Bottle to room ratio

Monthly/weekly/daily

Posters (5 Moments) in rooms/cubicles/

treatment rooms

100% through zero

Poster to room ratio

Monthly/weekly/daily

Posters How to rub/rinse in rooms/

cubicles/treatment rooms

100% through zero

in rooms/cubicles/
treatment rooms

Monthly/weekly/daily

Glove boxes in patient rooms/cubicles/

treatment rooms

100% through zero

Bottle to room ratio

Monthly/weekly/daily

Clean gloves in a range of sizes available

for use at the point of care/each bed space

100% through zero

Glove stock to bed ratio

Monthly/weekly/daily

Hand hygiene monitoring and feedback (at

least monthly) showing adherence data of
staff and leadership, including prominent
display of clear graphs presenting trends
over time

166

PART III. PROCESS AND OUTCOME MEASUREMENT

Table III.2.1
Examples of quality indicators which may be used in relation to hand hygiene in health-care settings
(not including pre-surgical hand preparation) (Cont.)
Indicators*

Measure option**

Measure option**

Suggested frequency**

100% through zero

random choice of x staff,

overall and individual %s
of knowledge

Bi-annually

100% through zero

random choice of x staff,

% of staff wearing or not
wearing

Quarterly/weekly

Healthcare worker hand hygiene

compliance with Five Moments

100% through zero

% by ward/department

Depends on score, aim

annual or more frequently

Healthcare worker performance in relation to

correct technique for hand hygiene

100% through zero

% by ward/department

Depends on score

Volume of product usage (soap and alcoholbased handrub)

Mls per bed day

Need to set benchmarks.

Measure monthly

Soap and alcohol-based handrubs are not

used concomitantly

random choice of x staff,

% times used or not used
concomitantly

Quarterly/weekly

% by ward/department

Quarterly/weekly

Process
Correct answers by staff to a complete,
standard list of knowledge questions on
hand hygiene
Staff fully in compliance with institutional
hand hygiene policy
Healthcare workers do not wear artificial
finger nails or extenders
Healthcare workers perform all three key
hand hygiene procedures (hand washing,
handrub, glove removal) correctly

Where alcohol-based handrubs are available

antimicrobial soap is not in use

100% through zero

Multimodal strategy implemented

Annual

Outcome
Infection rates monitored
Transmission rates for epidemiological
pathogens (including antibiotic resistant
pathogens) monitored

Monthly/quarterly, if
surveillance in place
As above

Monthly/quarterly if
surveillance in place

Product tolerance and acceptability analysis

Annual

Product cost comparations/benefit analysis

Annual

* Those in bold indicate the first criterion that should be considered

** The suggested measure options are not based on evidence, but on expert consensus and local experiences 1
Where liquid soap not available
2

Where disposable towels not available measure availability of freshly laundered dry cloth towels

167

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

3.
Assessing the economic impact of hand hygiene
promotion

a number of widely differing

outcomes.

quo could even be

considered, i.e. doing
nothing. The consequences
Several choices are usually available to endeavour to deal with
of both interventions would
health problems. These choices are often referred to as
be reduction of HCAIs. While
interventions. Identification of interventions is usually based on
the identification of various
whether they lead to the desired outcomes or not i.e. does the
types of cost are similar
chosen intervention reduce death or disability, or improve the
across most economic
quality of life to the desired extent? This simplistic approach
evaluations, the overall
is often adequate as the first step. However, when more than process of economic
one intervention is available, which may be often the case, it evaluation can be of two
is necessary to choose the one that provides a greater return types: costbenefit analysis
on investment. In particular, when resources are limited, a
or costeffectiveness
choice has to be made in favour of the one that provides the analysis.
most output (reduction in disease, death or disability) at the
lowest cost.
3.2.1 Costbenefit analyses

3.1 Need for economic evaluation

Economic evaluation refers to the comparative analysis of

alternative courses of action in terms of both costs and
consequences. The basic task of any economic evaluation is
to identify, measure, value, and compare the costs and

consequences of the alternatives being considered.1044 Thus,

two features always characterize any economic analysis. The
first deals with obtaining information on inputs and outputs
(often called costs and consequences) of the interventions.
The linkage between costs and consequences usually
facilitates the reaching of a rational decision. The second
feature concerns available choices. An inherent assumption
underlying this characteristic is that resources are scarce and
only the most efficacious ones should be deployed. A full
economic evaluation thus means measuring the costs and
consequences of two or more interventions or between an
intervention and the status quo at the least.
In addition to hand hygiene, several infection control interventions
are available. According to Graves and colleagues,1045 those who
set budgets for infection control in hospitals and decide how those
budgets should be allocated between infection control
programmes must address two questions. First, should current
rates of HCAI be reduced, and if so, by how much? Second,
which infection control strategies are cost effective and/or
productively efficient? Answers to these questions can be found
by studying how economic costs and health benefits change with
different infection control strategies.1046 The framework below
provides basic information on how two of the more common types
of economic evaluation are carried out to select health
interventions (Figure III.3.1).

3.2 Costbenefit and costeffectiveness analyses

Figure III.3.1 illustrates two competing interventions, A and B.
Intervention A is the intervention of interest, e.g. hand hygiene
using alcohol-based handrub, and intervention B is the
comparator, e.g. hand hygiene using soap and water.
Intervention B does not necessarily have to be an active
programme; a second option of maintaining the status

Cost-benefit analyses (CBA)

measure both the costs and
the consequences of
alternatives.1044 The results of
these analyses may be
presented in the form of a ratio
of monetary costs to monetary
benefits or as a simple sum. A
typical example of a CBA
would be to compare the costs
and benefits of performing
hand hygiene using soap with
that of an alcohol-based
handrub. While there is
extensive evidence on the
added advantages of alcoholbased handrubbing as part of a
multimodal promotion strategy
in reducing the transmission
and disease rates, few studies
have compared costs of
alternative interventions using
a CBA approach. Haddix
and colleagues1047 state
that CBA is often the most
appropriate approach when
a policy-maker has a broad
perspective and is faced
with one or more of the
following situations: (1)
must decide whether to
implement a

specific programme; (2)

required to choose among
competing options; (3) has a
set budget and must choose
and set priorities from a
group of potential projects; or
(4) the interventions under
consideration could produce
168

3.2.2 Costeffectiveness
analyses
Analyses in which costs are
related to a single common
effect or consequence which
may differ in magnitude
between alternative
programmes are referred to
as costeffectiveness
analyses (CEA). Compared
with CBA, in a typical CEA
the consequence or
summary measure is
expressed in costs
per unit of health outcome,
e.g. costs per qualityadjusted life year (QALY)
saved, per life saved or per
life year gained.1047 A typical
example may be extension
of life after renal failure. Two
interventions that could be
compared may be renal
dialysis and kidney
transplantation. The outcome
of interest for both these
interventions is common, i.e.
life years gained. Normally,
we would compute the
differential costs and
consequences and then lean
towards the intervention with
the least cost. This measure
is called an incremental
costeffectiveness ratio

(ICER). If kidney
transplantation costs US$ 50
000 and extends life by 10
years, this would generate an
ICER of US$ 5000 for each
life year gained. Similarly, we
could compute the costs of
dialysis and compare the
ICERs of the two
interventions in order to
make a decision.
Cost utility analysis is one
form of CEA that uses QALYs
instead of merely looking at
costs per life year gained. The
QALY concept attempts to
place values (derived from
population-

PART III. PROCESS AND OUTCOME MEASUREMENT

based exercises) on different states of health. QALYs allow

for the comparison of different health outcomes as health
positions or utility value placed by society. To do this, any
state of health or disability is assigned a utility value on a scale
ranging from 0 (immediate death) to 1 (state of perfect health).
QALYs thus measure health positions and are a linear measure.
There are perhaps some issues with their use, as they discount
health gains among the elderly more severely and treat each
movement as of equal value. Such movements are probably
non-linear, however, with people valuing slight improvements
when they are ill more than they value similar improvement
increments from gains in fitness at the top end of their recovery.
The ability to compare directly the dollar cost of different health
outcomes is sometimes attractive to the decision-maker. For the
policy-maker, the health intervention that produces the greatest
QALYs at the least cost is often seen to be more attractive.
Cost utility is a difficult but interesting area to explore. This
is because most health infections are transient states and
assigning health utility states over a long term may be less
meaningful. Using QALYs, which are rather static instruments,
may be less applicable to infection-related illnesses, as these
may come and go, thereby making assessments difficult. The
DALY (disability-adjusted life year) is another outcome
measure used in CEA that combines life years gained in full
health

and life years gained in less than perfect health (seen as a

disability) in one combined measure. The DALY has been
used when examining health deficiencies or the burden of
disease in the international literature particularly that
relating to less developed countries. Thus one might
estimate the DALYs lost related to various illnesses, e.g.
eye disease, or infections, e.g. pneumonia.

3.2.3 Analyses perspective

Regardless of whether a CBA or CEA is performed, the
analyses perspective is a crucial element in decision-making.
Perspectives available for either analysis include societal, payer,
hospital or individual. Costs and consequences within the
analyses will differ based on the perspective chosen; the results
will thus also vary based on the perspective chosen. Most
studies to date have focused mainly on the hospital or institution
and have not captured costs and consequences from a broader
perspective.1048 A societal perspective is more useful for policymakers and governments who need to allocate budgets and
choose between different health programmes or interventions.

3.3 Review of the economic literature

Despite the availability of established methods of economic
evaluation, few prospective studies have been conducted to
establish the costbenefit or costeffectiveness of hand hygiene
in health-care settings. The Agency for Health Care Research
and Quality in their recent review of quality improvement
prevention strategies for HCAI concluded that the evidence
for quality improvement strategies to improve adherence to
preventive interventions for HCAI is generally of suboptimal
quality, consisting primarily of single-centre, simple beforeafter
studies of limited internal and external validity. Thus, we were

unable to reach any firm conclusions regarding actionable

quality improvement strategies to prevent HCAIs.1049
In general, studies have compared the costs of hand hygiene
promotion programmes versus the potential cost savings from
preventing HCAIs using a business case analytic approach.
Unlike a CBA or CEA, a business case analysis usually
provides an explanation of a providers expenditures for a
programme over a short period (often13 years), including the
effects of any offsetting savings.1050 Ritchie and colleagues
reviewed
all economic studies relating to the overall impact of alcoholbased hand hygiene products in health care1025 and concluded
that, while further research is required to measure the direct
impact of improved hand hygiene on infection rates, the
potential benefit of providing alcohol-based handrubs is likely
to outweigh costs, and their wide-scale promotion should
continue. The review also recommended that those planning
local improvements should note that multimodal interventions
are more likely to be effective and sustainable than singlecomponent interventions and, although these are more
resource-intensive, they have a greater potential to save costs
over the long term.
Examples of typical costs incurred and cost savings associated
with implementing hand hygiene programmes in institutions
are provided below. Furthermore, evidence is provided on the
costs and cost savings from a hospital/institutional perspective
through the use of a business case approach. While some
studies presented here have shown cost savings, it should be
noted that business cases usually fail to deliver projected cost
savings in the short or near term.1051 This is mainly because
hospitals are known to have high fixed costs (up to 85%).1052
This leaves the administration with limited scope to demonstrate
savings from a small percentage of remaining variable costs.

3.4 Capturing the costs of hand hygiene at

institutional level
The costs of hand hygiene promotion programmes include costs
of hand hygiene installations and products, plus costs associated
with HCW time and the educational and promotional materials
required by the programme. These can be categorized into fixed
and variable costs. Examples of fixed costs
include those associated with buildings, equipment and new
installations, salaried staff, and overhead costs such as heating,
air conditioning, and water. Examples of variable costs include
products needed for handwashing, including soap, water, and
materials used for drying hands (e.g. towels), while the costs
of hand antisepsis using an alcohol-based handrub include
the cost of the handrub product plus dispensers and pocketsized bottles, if made available. In general, non-antimicrobial
soaps are often less expensive than antimicrobial soaps. In
health-care settings, mainly in resource-poor countries, basic
handwashing equipment such as sinks and running water is
often not available or of limited quality. In calculating costs for
hand hygiene, these substantial construction costs need also
to be taken into account. In addition, overhead costs for used
water and maintenance need to be added to the calculation.
The cost per litre of commercially prepared alcohol-based
handrubs varies considerably, depending on the formulation,
the vendor, and the dispensing system. Products purchased
169

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

in 1.0
1.2 litre
bags
for use
in wallmounte
d
dispen
sers
are the
least
expens
ive;
pump
bottles
and
small
pocketsized
bottles
are
more
expens
ive;
and
foam
product
s that
come
in
pressur
ized
cans
are the
most
expens
ive.
Presu
mably,
a
locallyproduc
ed
solutio
n
compo
sed of
only
ethanol
or
isopropanol
plus 1% or
2% glycerol
would be
less
expensive
than
commerciall
y produced
formulations.
Boyce
estimated
that a 450bed
community
teaching

hospital in the
USA spent
US$ 22 000
(US$ 0.72 per
patient-day) on
2%
chlorhexidinecontaining
preparations,
plain soap, and
an alcoholbased hand
rinse.1053 When
hand hygiene
supplies for
clinics and nonpatient care
areas were
included, the
total annual
budget for
soaps

and hand
antiseptic
agents was
US$ 30 000
(about US$ 1
per patientday).
Annual hand
hygiene
product
budgets at
other
institutions vary
considerably
because of
differences in
usage patterns
and varying
product prices.
Countries/state
s/regions/localit
ies with
centralized
purchasing can
achieve
economies on
a scale that
can result in
considerable
cost reduction
of products. A
recent cost
comparison of
surgical
scrubbing with
an
antimicrobial
soap versus
brushless
scrubbing with
an alcoholbased handrub
revealed that
costs and time
required for
pre-operative
scrubbing were
less with the
alcohol-based
product.328 In a
trial conducted

in two ICUs,
Larson and
colleagues329
found that the
cost of using
an alcoholbased handrub
was half that of
using an
antimicrobial
soap for
handwashing
(US$ 0.025 vs
US$ 0.05 per
application,
respectively).
In another
study
conducted in
two neonatal
ICUs,
investigators
looked at the
costs of a
traditional
handwashing
regimen using
soap, use of an
alcohol-based
handrub
supplemented
by a nonantimicrobial
soap, use of
hand lotion,
and nursing
time required
for hand
hygiene.646
Although
product costs
were higher
when the
alcohol-based
handrub was
used, the
overall cost of
hand hygiene
was lower with
the handrub
because it
required less
nursing time.

3.5
Ty
pic
al
co
stsa
vin
gs
fro
m
ha
nd
hy
gie
ne
pro
mo
tio

n
p
r
o
g
r
a
m
m
e
s
To assess
the cost
savings of
hand
hygiene
promotion
programmes
, it is
necessary to
consider the
potential
savings that
can be
achieved by
reducing the
incidence of
HCAIs. One
of the
easiest
ways to
assess the
cost savings
is to
estimate the
excess
hospital
costs
associated
with the
excess
patient days
caused by
HCAIs. In a
recent study
by Stone
and
colleagues,
costs of
catheterrelated
bloodstream
infection
(CR-BSI),
surgical site
infection
(SSI),
ventilatorassociated
pneumonia
(VAP), and
hip SSIs
were
estimated
and found to
be a
minimum of
US$ 5500
per episode.
The authors
further
reported that
CR-BSI

caused by
MRSA may
cost as much
as US$ 38 000
per
episode.1054
Table III.3.1
provides a
summary of
the costs

of the four
most
common
HCAIs based
on a
systematic
review of
literature
published by
Stone and
colleagues
for periods
19902000
and 2001
2004.15,1055
In addition to
the costs
reported above,
there are
several hidden
costs that are
not included in
the calculation
of these
figures. These
costs could
instead be
referred to as
lost
opportunities
for saving.
Stone and
colleagues
provide several
examples.
An
unscheduled
revisit to the
operating
room
for
incision and
drainage
after an SSI
can limit the
number
of
procedures
that can be
performed in
a day. Holdups
often
cause
delays and

postponement
of scheduled
procedures.
Another
example of a
hidden cost
includes the
dissatisfaction
of the patient
and the
referring
doctor.
Research
suggests that
dissatisfied
customers
often have the
tendency to
tell more
people about
the
deficiencies in
their care.
Hence, the
loss of
existing
customers
(patients)
means higher
replacement
costs
associated
with attracting
and receiving
new patients.
These include
costs for
marketing and
registering
new patients
into the
medical
records
system and
the costs of
countering
any negative
publicity and
building
renewed trust.
Thus, it is not
surprising that
the excess
hospital costs
associated with
only four or five
HCAIs of
average
severity may
equal the entire
annual budget
for hand
hygiene
products used
in inpatient care
areas. Just one
severe SSI,

lower
provided
respiratory some
infection, or quantitative
BSI may cost estimates of
the hospital the cost
savings from
more than
hand
the entire
hygiene
annual
promotion
budget for
programmes
antiseptic
60,181
agents used .
Webster
and
for hand
18
1053 colleagues
hygiene.
1
For example, reported a
cost saving
in a study
of
conducted in
approximatel
a Russian
y US$ 17
neonatal
000 resulting
ICU, the
from the
authors
reduced use
estimated
of
that the
vancomycin
excess cost following the
of one health observed
caredecrease in
associated MRSA
BSI (US$
incidence
1100) would over a 7cover 3265 month period.
patient-days Similarly,
of hand
MacDonald
antiseptic
and
use (US$
colleagues
0.34 per
reported that
patientthe use of an
day).687The alcoholauthors
based hand
estimated
gel combined
that the
with
alcoholeducation
based
sessions and
handrub
performance
would be
feedback to
cost saving if HCWs
its use
reduced the
prevented
incidence of
approximatel MRSA
y 3.5 BSIs infections and
per year or expenditures
8.5
for
pneumonias teicoplanin
per year. In (used to treat
another
such
study, it was infections).489
estimated
For every
that cost
UK 1 spent
savings
on alcoholachieved by based gel,
reducing the UK 920
incidence of were saved
C. difficile- on teicoplanin
associated expenditure.
disease and
MRSA
Including both
infections far direct costs
exceeded the associated
additional
with the
cost of using intervention
an alcohol- (increased use
based
of handrub
handrub.429 solution,
poster
Several
reproduction,
studies
and

implementatio
n) and indirect
costs
associated
with HCW
time, Pittet
and
colleagues60
estimated the
costs of the
programme to
be less than
US$ 57 000
per year for a
2600-bed
hospital, an
average of
US$ 1.42 per
patient
admitted.
Supplementar
y costs
associated
with the
increased use
of alcoholbased
handrub
solution
averaged US$
6.07 per 100
patient-days.
Based on
conservative
estimates of
US$ 100
saved per
infection
averted, and
assuming that
only 25% of
the observed
reduction in
the infection
rate has been
associated
with improved
hand hygiene
practice, the
programme
was largely
cost effective.
A subsequent
follow-up
study
performed in
the same
institution
determined
the direct
costs of the
alcohol-based
handrub used,
other direct
costs, indirect
costs for hand
hygiene
promotion,
and the
annual
prevalence of
HCAI for
19942001.490
Total costs for

the hand
hygiene
programme
averaged
Swiss
francs
(CHF) 131
988
between
1995 and
2001, or
about CHF

3.29 per
admission.
The
prevalence of
HCAI
decreased
from 16.9 per
100
admissions in
1994 to
9.5 per 100
170

admissions
in 2001.
Total costs
of HCAIs
were
estimated to
be CHF
132.6 million
for the entire
study
period.

PART III. PROCESS AND OUTCOME MEASUREMENT

The
autho
rs
concl
uded
that
the
hand
hygie
ne
progr
amm
e
was
cost
savin
g if
less
than
1% of
the
reduc
tion
in
HCAI
s
observed
was
attributable
to
improved
hand
hygiene
practices.
An
economic
analysis of
the
cleanyour
hands
hand
hygiene
promotiona
l campaign
conducted
in England
and Wales
concluded
that the
programm
e would be
cost
beneficial if
HCAI rates
were
decreased
by as little
as 0.1%.
The impact
of the
cleanyour
hands
campaign
is the
subject of
a 4-year

research
programme
which will look
at the
effectiveness
of the various
components
of the
multimodal
approach.
A quasiexperimental
study in Viet
Nam to
assess the
impact of the
introduction of
an alcoholand
chlorhedixinebased hand
santizer for
hand
antisepsis on
SSI rates
among
neurosurgical
patients
revealed a
reduction in
the infection
rate by 54%
and
a reduction
in postoperative
length of
stay and
antimicrobi
al use from
8 days to 6
days
(P<=0.001).
717
Although
no costs
were
provided in
this study, it
is
reasonable
to assume
that the
reduction in
hospital
stay
allowed the
hospital to
generate
additional
revenue by
filling beds
with new
admissions

(increased
volume).
Antibiotic
costs were
also reduced
because of
earlier
discharge for
these

patients.
Despite the
fact that the
abovementioned
studies
strongly
suggest a
clear benefit
of hand
hygiene
promotion,
budget
constraints
are a fact,
particularly in
developing
countries, and
cost
effectiveness
analysis might
be used to
identify the
most efficient
strategies. To
achieve this
goal, data on
the incidence
of HCAI and
the resulting
opportunity
costs, as well
as on the cost
and
effectiveness
of competing
infection
control
strategies, are
required.1045
Because
these
variables may
vary by and
large
according to
the region and
institution,
local studies
may be
necessary to
help choose
the best
strategies.1045
Wellconducted
local studies
may suggest
other infection
control
interventions
of even
greater cost
benefit,
depending on
the
socioeconomic
and cultural
environments
of the healthcare system.
Although a

business
case
3.
approach 6
may be
Fi
beneficial to n
the hospital a
manageme n
nt in
ci
determining al
the cost of st
the
ra
infection
te
control
gi
programme e
s, it is
s
necessary to
to conduct s
economic u
evaluation p
from a
p
broader
or
perspective t
, i.e.
n
societal, so at
as to reflect io
the values n
of all
al
members of pr
society and o
not just the gr
preferences a
of select
m
individuals m
who
e
manage
s
hospital
services. Interventions
This
designed to
approach improve hand
will allow hygiene
policyacross a
makers and country may
payers to require
choose
significant
between
financial and
infection
human
control
resources,
intervention particularly
s that offer multifaceted
the greatest campaigns.
quality
Costs must be
output per balanced in
unit of cost. terms of
Clearly,
anticipated
hand
reduction in
hygiene
HCAI. The
would be
economies of
an
scale
intervention
achieved by
of interest
centralized
for many
design and
developing
production of
nations that
supporting
are often
materials will
faced with
logically result
several
in less cost to
competing
the overall
priorities
health
compounde
economy. This
d with
approach was
limited
used in the
resources.
cleanyourhan
ds campaign

conducted in
England and
Wales
(described in
the box
below).
Countries
without
centralized
distribution
networks
might not
achieve
sufficient
economies of
scale to make
such

strategy has
not only
resulted in
economies of
scale by
lowering the
cost of the
product, i.e.
alcohol-based
hand rub (see
Part

an
approach
feasible
without
additional
massive
I ,Section
investment 12), it has
from the
also
commercial fostered a
sector.
spirit of
Similar
campaign
approaches and
have been competitio
used by
n,
some other achieved
countries standardiz
and have ation
met with
across
success.
health
For
entities,
instance, and
according provided a
to the WHO foundation
recommend for
ations,
evaluation
Hong Kong of its
SAR has success in
adopted a the future.
centralized
system for Taking into
the
account the
production many financial
and
constraints in
distribution resource-poor
of alcohol- countries and
based hand the
rub to all its considerably
hospitals. high cost
This
investment
171

required (e.g.
secure water
supply and
sinks), the
investment in
programmes
using alcoholbased
handrubs as
the primary or
sole means of
hand hygiene
seems to be
an obvious
solution. It
should
nevertheless
be taken into
account that
investment

in the
infrastructure
of healthcare
facilities,
such as
secure water
supply and
sinks, is
necessary in
the long run
to improve
the quality of
health-care
delivery as a
whole. This
investment
can show
benefits
other than an
improvement
in hand
hygiene
practices.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

objectives.
The
Logistics
Authority is
responsible
for the
distribution
of the
Case-study: alcoholEngland and based
Wales
handrubs
national
and the
programme, campaign
a programme materials to
with potential every
benefits
hospital
implementin
National
g the
programmes campaign.

can achieve
economies of
The NPSA
scale in terms
campaign is
of the
funded
production
centrally for
and
its first year;
distribution of
thereafter, all
materials. In
campaign
England and
materials will
Wales, the
be produced
NPSA
and funded
cleanyourhan
by
ds campaign
commercial
is a
companies
collaboration
on the
between
national
national
alcoholgovernment
based
bodies and
handrub
the
contract. The
commercial
companies
sector in the
will fund this
development,
by paying a
piloting,
licence fee in
evaluation,
proportion to
and
their turnover
implementatio
on the
n of the
contract.
programme.
The national
procurement
body for the
National
Health
Service
(NHS) and
the national
NHS Logistics
Authority,
which

has
expertise in
distributing
products
across the
NHS, have
worked in
partnership
with the
NPSA to
ensure the
campaign
achieves
its

At the outset,
the six main
sources of
possible
financial
benefits to the
wider healthcare economy
resulting from
a successful
campaign
were identified
as those
relating to:

redu
ced hospital
costs;

redu
ced primary
care costs;

redu
ced
costs
incurred by
patients;

redu
ced costs of
informal
carers;

prod
uctivity
gains in the
wider
economy;

6
r
e
d
u
c
e
d
c
o
s
t
s
a
s
s
o
c
i
a
t
e
d
w
i

t
h
lit
ig
a
ti
o
n
a
n
d
c
o
m
p
e
n
s
a
ti
o
n
.
Though there
are some upfront costs
for hospitals
associated
with
implementing
the
campaign,

for a 500-bed
hospital it
would cost
around UK
3000 initially
to put alcoholbased
handrub at
each bedside.
The analysis
suggested
that the
campaign
would deliver
net savings
from the
outset. An
Excel
spreadsheet
for selfcompletion
by an
individual
health-care
institution has
been
produced,
which allows
for the input of
local data and
will indicate
likely cost
savings over

Lippinc
ott
William
s&
Wilkins.

Table
III.3.1 1056
Costs
of the
most
commo
n
health
careassocia
ted
infectio
ns in
the
USA

Type of infection

Bloodstream infection
Surgical site infection
Ventilator-associated pneumonia
Urinary tract infection

Reprod
uced
from
Cosgrov
e SE &
Perence
vich EN
with
permissi
on from

time (Appendix
4). Even if
financial
savings were
not to be
realized, the
likely patient
benefits in
terms of lives
saved and
relatively
modest costs
mean that the
intervention
would still be
highly cost
effective
compared with
many other
NHS activities.
The economic
evaluation
went on to
suggest that
the campaign
would be cost
saving even if
the reduction
in hospitalacquired
infection rates
were as low as
0.1%.

1
7
2
P
A
R
T
II
I.
P
R
O
C
E
S
S
A
N
D
O
U
T
C
O
M
E
M
E
A
S
U
R
E
M
E
N
T

F
i
B
a

I
n
(
C

C
o
C
h

1
7
3

PART IV.
DEL
OF
TCAMP
OAIGNI
WNG
AFOR
RBETTE
DR
SHAND
HYGIE
ANE A
NATIO
GNAL
EAPPR
NOACH
ETO
RHAND
AHYGIE
L NE
MIMPRO
OVEME
NT

PART IV. TOWARDS A GENERAL MODEL OF CAMPAIGNING FOR BETTER HAND HYGIENE A NATIONAL APPROACH TO HAND HYGIENE IMPROVEMENT

1.
Introduction
Guidelines do not implement themselves,1057 and simple dissemination strategies have been described as
unlikely to have any impact at all on implementation. 1058,1059 Health-care policy-makers and strategists have
therefore looked towards nationally coordinated and centralized health improvement programmes as an
acknowledged method of tackling significant health-related problems. National programmes do not necessarily
employ campaign approaches; however, national health improvement programmes have been shown in many
cases to use elements of campaigning and mass media involvement to good effect. This part reviews the
increasing shift towards national hand hygiene improvement programmes, with or without campaigning, as a
method of spreading hand hygiene improvement strategies in health care. 1060 It concludes with an account of
current national hand hygiene improvement programmes, drawing on the progress made by them and lessons
learnt from the countries that have embarked on such an approach. Based on the experiential learning and the
current literature, a blueprint is presented for developing, implementing, and evaluating a national hand hygiene
improvement campaign within health care.

2.
Objectives
The present guidelines recommend a multifaceted system and behaviour change intervention as the most
reliable method to improve hand hygiene in health care. To accompany the guidelines and aid implementation at
a local level, a comprehensive Guide to Implementation and a suite of facilitative tools have been developed.
This part is concerned with how to develop a successful improvement programme at a national level that will aid
in implementation at a local level. It reviews the literature on national health improvement programmes and
campaigns and explores the applicability of such an approach in relation to hand hygiene. Behaviour change
interventions in the health-care context are increasingly utilizing the popular media within an integrated campaign
framework and this has been shown to have numerous benefits, not least in terms of costeffectiveness. 1061
The background, risks, and benefits of national approaches to hand hygiene improvement are described within
the context of general public health or health improvement campaigning. This part further highlights the
developments of national hand hygiene improvement campaigns in the time period since the launch of the
WHO First GlobalPatientSafetyChallenge, and the publication of the 2006 Advanced Draft of the guidelines, and
concludes by presenting a blueprint for national campaigns.

17
5

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

3.
Historical perspective
The First Global Patient Safety Challenge of the WHO World Alliance for Patient Safety (www.who.int/
gpsc) entitled Clean Care is Safer Care has followed a classic approach to health improvement. It calls
for a concerted global effort to effect policy and intervention strategies to enhance patient safety through
implementation of a simple, low-cost health improvement (improved compliance with hand hygiene in health care)
to contribute to the prevention of HCAI. Achievement of its aims has required action on a country-by-country
basis, and has involved lobbying for national political action on hand hygiene improvement. This section positions
hand hygiene improvement in health care as one component of an infection control/quality and safety health
improvement programme. National health improvement programmes are historically associated with numerous
benefits, including the avoidance of fragmentation, cost inefficiency, and duplication of effort. 1062
providers.
raising awareness, and
Hand hygiene improvement in health care has not been seen
offering technical support to
conventionally as a public health issue, though it does concern a further the improvement
health issue of significance to a subset of the population,
agenda, national
i.e. those receiving treatment in a health-care setting. With in
campaigning has come to
excess of 700 million people hospitalized annually, and an
prominence as one
overall prevalence of HCAI ranging from around 5% in the
inspirational component of a
developed world up to 20% in some developing countries, the comprehensive infection
burden of associated disease is significant.479,835 Thus, there control strategy. Ministers of
is an argument for the application of public health strategies to health signing a statement of
change HCW behaviour to impact positively on the health of commitment to address HCAI
patients. Historically, public health behaviour change
as part of this Patient Safety
Challenge agree specifically to
campaigns have focused on persuasion as a major tool.1063
developing or enhancing
Until recently, national hand hygiene improvement programmes in ongoing campaigns at national
health-care settings were not widely reported. With the emergenceor sub-national levels to
of the WHO First Global Patient Safety Challenge and its three- promote and improve hand
pronged approach of gaining political commitment,
hygiene among health-care

The Millennium
Development Goals
(MDGs), agreed to by all
countries worldwide and all
leading development
institutions, offer a blueprint
for improvement. The goals
have galvanized remarkable
efforts to meet the needs of
the worlds poorest
populations.1064 The MDGs
are time-bound, have
political support, and are
ambitious in their scope.
These are common features
of successful health
improvement campaigns.

1
7
6

PART IV. TOWARDS A GENERAL MODEL OF CAMPAIGNING FOR BETTER HAND HYGIENE A NATIONAL APPROACH TO HAND HYGIENE IMPROVEMENT

4.
Public campaigning, WHO, and the mass media
Public campaigning is central to a number of WHO programmes. In The World Health Report 2002,1065 WHO
reported on a series of comprehensive approaches that have been implemented at the national level to reduce
specific risks in health care, taking into account a variety of interventions including the dissemination of information
to the public, mainly through media outreach. The use of mass media within public health campaigns forms one
component of broader health promotion programmes and can be useful in wide-scale behaviour
change.1061,1066,1067

A feature of conventional
As many international and national health campaigns have
campaigns, reflected in the
demonstrated, the media play a key role in mobilizing public
IHI approach, is their
support, influencing behavioural change, and setting the local
association with a focused
political agenda. A 2001 Cochrane review1068 showed that the use and time-bound effort.1063
of the mass media was a way of presenting information about
The IHI campaign was
important health issues, targeted by those who aim to influence the constructed around specific
behaviour of health professionals and patients. The review
targets and deadlines; it also
concluded that the mass media should be considered
won support from national
as one of the tools that may influence the use of health-care
professional organizations,
creating what they describe
interventions. Their usefulness in changing knowledge,
as a powerful national
awareness and attitudes makes mass media campaigning a
infrastructure to drive change
potentially significant component of attempts to impact on
and transform health-care
hand hygiene behaviour change strategies, since hand hygiene
compliance is predicated upon knowledge, attitudes, and beliefs of quality. IHI identified the
HCWs. Mass media campaigns are usually designed to generate target (described as
conceptually simple
a specific outcome in a relatively large number
interventions) and the
of individuals within a specific period of time and through an
1066
deadline and provided tools
organized set of communication activities.
With the growth in
and resources for
telecommunications, television and the Internet are increasingly
implementation. Berwick and
used as channels for promoting behaviour change1069 and could
colleagues1075 emphasize,
play a role in hand hygiene-related mass media campaigns,
however, that the ultimate
particularly if they target national and local opinion leaders.
results rest with the
participating hospitals to
reliably introduce the
4.1 National campaigns within health care
National health improvement programmes are designed to
mobilize action at local levels to implement accepted

methods to change behaviour and improve health care. Such

programmes rely on carefully constructed improvement and
spread methodologies, with the prominent model of the PDSA
cycle1070 incorporating quality improvement principles as a
central component.

interventions and engage

boards, executives, frontline
clinicians, patients, and
families.

National-level campaigns to
improve antibiotic use in
Europe and the USA have
been reported in the
1076
Such
As one approach to health improvement, there is a considerable literature.
body of evidence to support the positive impact of campaigning on campaigns have targeted the
population level and
health-related behaviours,1071,1072 although campaigns are
employed techniques of
not without their critics.1066,1073 The Institute for Healthcare
mass media distribution.
Improvement (IHI) in the USA turned to the campaign
Similar to hand hygiene
approach at a national, regional, and facility level to achieve a
improvement campaigns in
goal of transformational improvements in health care, using
health care, antibiotic
learning from electoral politics to reach a large number of
campaigns are multifaceted
1074
health-care facilities across the country.
In describing the
and are concerned with cost
subsequent IHI 100 000 Lives Campaign (Table IV.9.1),
effectiveness. According to
1075
Berwick and colleagues
outline a need to create a sense of Goossens and colleagues,
urgency and pace. This campaign, one of the largest attempts only two countries

and reported demonstrable

success.1076 The USA has
seen a dramatic reduction
in the use of antibiotics by
paediatricians.1077 In
conclusion, these authors
call for a wider use of the
campaign approach and
the incorporation of social
marketing, together with
cultural adaptation and
population targeting.
Campaigns are likely to be
more successful when they
are accompanied by
concomitant structural
changes that provide the
opportunity structure for the
target audience to act on the
recommended message.1063
These authors also suggest
that accompanying
campaigns with reinforcing
legislation and regulation
can influence the campaign
impact and sustainability. An
illustration of the impact of
legislation and

regulation can be seen in

England and Wales where
the national cleanyourhands
campaign (Table IV.9.1)
received considerable
leverage with a parallel
national target to reduce
MRSA rates by 50%.1078

to mobilize health care to focus on issues of quality and safety,

in Europe have undertaken
holds much relevance when considering hand hygiene
and evaluated national
improvement in health care.
antibiotic-use campaigns

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WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

5.
Benefits and barriers in national programmes
National political commitment to a health issue increases awareness and helps leverage additional resources. 1072
Translation of national political commitment into action yields benefits, and these can be quantified in terms of
avoiding a fragmented and cost-inefficient duplication of effort. 1062,1079 The focus should be on producing practical
tools that can be implemented across entire health-care systems. Pragmatic adaptations to these national
programmes are described as necessary in order to achieve maximum local ownership, which is critical to ensuring
successful implementation.
(CEOs) should be made
Dawson and colleagues1080 describe the ongoing oral polio
aware of any
vaccine campaign in India as an example of a mass populationrecommendations/
based intervention that illustrates both the benefits and problems requirements for hand hygiene
of mass campaigning. The authors highlight the importance of
promotion campaigns that are
establishing procedures for reviewing policy formulation and
issued by organizations that
implementation and emphasize monitoring
accredit or license health-care
and evaluation, with explicit, clear lines of responsibility for all
facilities. Accreditation can be
aspects of the programme. Evaluation is central to mass
a powerful driver for health
health-care improvement.1027,1081 The necessary expertise and
improvement and is cited as a
resources are essential in ensuring robust evaluation. Tilson
powerful driver for
Pietrow and colleagues1082 describe a number of new challenges improvement across many
WHO regions (see, for
for international health programmes of the 21st century and
conclude that health communication programmes will be under
example, AFRO Workshop
increasing scrutiny in terms of evaluation and documentation
Report 2007 and SEARO
of their impact, costeffectiveness, and sustainability. Data to
Workshop Report 2007,
facilitate impact assessment, while crucial to determine
available
at
success, are not always available in many published studies 1083
http://www.who.int/patient
and, where available, it is often difficult to prove a definite
safety/gpsc/en). The
correlation between the campaign and the desired outcome.1084
benefits and barriers
The NHS for England and Wales, where a national patient safety associated with national
alert1031 was issued instructing organizations to implement alcohol- improvements will be
based handrub at the point of care, provides further evidence of the influenced by how health
role of regulation. Its action was supported
care is regulated and
by built-in monitoring mechanisms via the national health
operated nationally,
watchdog (Health Care Commission), which examines whether,
regionally, and locally.1085
and to what extent, organizations have implemented both the
campaign and the near-patient handrubs.
Wachter and colleagues1027 in
their critique of the IHI 100 000
Lives Campaign describe the
modus operandi of the
campaign as being one of
leveraging unprecedented
social pressure
for participation, pressure
that was constructed upon a
set of realistic goals for
improvement. Risks to
Improvement is a dynamic process, and success will be affected by success associated with
internal as well as external factors.1085 Improvement must be
national-level health
preceded by an analysis and understanding of existing patient
improvements are further
safety and infection control structures, policies and programmes explored within the context
and this is emphasized by the WHO World Alliance for Patient
of the campaign, with the
Safety toolkit for the implementation of hand hygiene strategies.
need for regular
Political commitment and national ownership of programmes are
communication, clear role
essential but, inevitably, those strategies that are dependent on
definitions, and a clear
social and political dynamics are subject to risk. The integration of national agenda emerging
all levels of a health improvement programme is crucial; national
as critical factors for
and hospital programmes should be harmonized. At the hospital
success.1074
level, chief executive officers

When deciding on the suitability of a national approach to

improvement in relation to hand hygiene, politicians or leaders
need to consider a number of factors that can influence
success. Characteristics of national strategies will be
influenced by the key drivers for improvement868 which, in the
context of infection control in the developed world, relate to the
growing need to reassure patients and the public that care
provided is clean and safe.

178

If a decision is taken to
integrate campaigning into a
national health improvement
programme, cultural and
contextual alignment should
be considered. Pillsbury and
colleagues,1086 in their
reflection on a campaign to
raise community awareness
about reproductive and
sexual health, highlight a
lack of research into
understanding local
behaviours. They emphasize
the importance of evaluating
the local understanding and
appropriateness of
messages used; some of the
African examples cited by
them illustrate the risks
associated with
communication strategies
where messages do not
talk to the audience.

PART IV. TOWARDS A GENERAL MODEL OF CAMPAIGNING FOR BETTER HAND HYGIENE A NATIONAL APPROACH TO HAND HYGIENE IMPROVEMENT

6.
Limitations of national programmes
National hand hygiene improvements must acknowledge that hand hygiene is not the sole measure necessary to
reduce infection.49 An acknowledgment of the importance of other factors such as environmental hygiene,
crowding, staffing levels and education is emphasized by Jumaa as part of a total infection control improvement
package.51 Indeed, vertical programmes based on single interventions or diseases are under close scrutiny
in terms of their effectiveness and impact, and there is a growing movement towards horizontal programmes that
build capacity across the entire health system. The First Global Patient Safety Challenge, Clean Care is Safer
Care, and its main output, these WHO Guidelines on Hand Hygiene in Health Care, support this premise and
emphasize that hand hygiene is one of a range of interventions designed to reduce the transmission

of pathogenic microbes in health-care settings. Countries currently implementing national hand hygiene
improvement programmes have emphasized that an initial focus on hand hygiene improvement can open doors
to a broader focus on infection control improvement and result in renewed or intensified focus on infection control
practices themselves (http://www.who.int/gpsc/country_work/Bangladesh_pilot_report_Jan_2008.pdf) .
Africa that has successfully
Much of the literature relating to hand hygiene improvement in
promoted sexual and
health-care settings is concerned with developed countries, and it reproductive health
is accepted that the threat from infection in developing countries is messages. The importance of
high. The extra hurdles faced by developing countries in terms of
connecting with locally based
technical and human resource capacities have been cited as
groups described in this
potential barriers to national health improvement programmes. 1087 account mirrors the work of
In addition, the limited or non-existent public health infrastructure, Curtis and colleagues1088 with
including access to basic sanitation, and the wider geographical
womens nongovernmental
and cultural influences cannot be overlooked. Improving hand
organizations described as
hygiene compliance within health care in developing countries
ideally positioned to connect
must therefore
the target audience with
the body of scientific
take account of these constraints. The work of Curtis and
information concerning
colleagues1088 provides testimony to the fact that it is possible to
mount national programmes, including campaigns to improve hand the desired health
hygiene, in developing countries. In these settings, however, taking behaviour. Credibility of
account of local constraints, context, and cultures is paramount; this the messenger is key,
and the cultural context
observation is equally relevant in
including
the developed world.868 Pillsbury and colleagues1086 describe a
establishing beliefs on the
community-based nongovernmental organization approach in
importance of hand hygiene as

a contributor to HCAI within

the target audience is an
important starting point in the
development of any mass
campaign.1089

Mah and colleagues872

suggest that it is possible for
individual institutions (or
even wards) to run
successful, participatory
campaigns to improve hand
hygiene with a moderate
budget. The involvement of
industry sponsorship is
suggested as a means of
securing financial resources
and, when channelled
centrally, may yield more
promising returns,
particularly from an
economy-of-scale
perspective.

1
7
9

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

7.
The relevance of social marketing and social
movement theories
Part I, Section 20.3, provides a comprehensive account of the applicability of social marketing to hand hygiene
improvement. In a systematic review of hand hygiene behavioural interventions, 872 Mah and colleagues found
synergies in many modern-day approaches to hand hygiene improvement and the ethos of social marketing. Scott
and colleagues1089 extol consumer marketing as a new approach that might overcome some of the conventional
limitations associated with hand hygiene behaviour change outside health care. Social marketing might add value
to the global drive for better hand hygiene in health care, exactly because it has been applied in both developed
and developing countries.1090 Mah and colleagues872 suggest that social and behavioural theories and models are
underused in the design of current hand hygiene promotion interventions. They counter the commonly held belief
that social marketing is cost-intensive and conclude that social marketing is not necessarily an expensive activity
due to its scalability. One of the chief advantages of nationally coordinated campaigns with pooled financial input is
that it ensures resource provision that maximizes economies of scale and utilizes the expertise of the marketing
world in spreading hand hygiene improvement messages within health care.
In contrast to the evidence relating to social marketing, the
relevance of social movement theories to hand hygiene
improvement, or health improvement generally, is an unresolved
issue. Social movement theories concerned with largescale societal change have gained prominence within health
improvement literature in recent years and embody much of
what is aspired to by health policy-makers striving to improve
practices in health care. However, Brown and colleagues1091
urge caution in drawing conclusions regarding the usefulness of
such a comparison and emphasize that social movements are
defined by the emergence of informal networks based
on shared beliefs and solidarity that mobilize around issues of
conflict and usually involve some form of protest. These
possibilities of applying social movement theories within
general spread strategies offer a new angle to hand hygiene
improvement in health care, and this might hold relevance in
terms of pursuing a global hand hygiene improvement
movement. Within the context of broader patient safety

improvements and the need to mobilize HCWs in a different

way of working, there may be benefits in the concept.
Bate and colleagues1092 argue that social and organizational
change do have similarities with health-care improvement and
conclude that those considering large-scale change in health
care might benefit from consideration of change from a
perspective of social movements. There is no literature
specifically reviewing hand hygiene campaigns and social
movement theories, and this gap in the literature may benefit
from further study.

Social movements tend to occur spontaneously, and this

contrasts sharply with current examples of national hand
hygiene improvements that rely on centrally constructed
programmes of change implemented in a coordinated manner
using accepted methodologies of health improvement spread.
Whether it is possible to create a contagious hand hygiene
improvement movement using the vehicle of national
programmes is only recently being addressed, and emerging
results of the impact of these approaches are expected in the
coming years.

7.1 Hand hygiene

improvement campaigns
outside of health care
While there is little available
published literature on
national hand hygiene
improvement strategies in
health care, the Global
PublicPrivate Partnership
for Handwashing with Soap
(GPPHWS) illustrates a
comprehensive strategy for
improving hand hygiene in
the community. The
partnership was catalysed
around a bold objective: to
establish large-scale national
programmes on
handwashing,1088 which
involved putting into place a
number of collaborative
efforts for success at the
national level including
between government,
academia, the private sector,
and external support
agencies. The partnership
relied on the identification of
a national coordinator at the
governmental level.1088
Within a developing country
context, Scott and
colleagues1089 have used a
social marketing approach to
consider motivations,
environmental factors, and
habits that mitigate against the
desired behaviour within their
target audiences. This
approach has been rolled out
in Ghana and a number of
180

other countries. In developing

countries, this publicprivate
partnership1093 has attempted
to tackle the problems across
nations exacerbated by low
compliance with hand hygiene
in the community, rather than
in the health-care setting. This
campaign involves close
working with the private sector
with the aim of developing and
executing far-reaching
improvement strategies.
Transferring such an approach
to hand hygiene in health care
will raise ethical issues relating
to partnerships working with
corporate bodies. This may not
necessarily be a barrier, and
WHO is ideally placed to act as
a catalyst to this end.
A list of critical factors that
are necessary to drive
forward this improvement has
been drawn up: political will;
policies and strategies that
enable improvement; finance;
coalition and partnerships;
local governments and local
action; and external support
agencies. Fewtrell and
colleagues1094 emphasize the
importance of selecting
interventions for developing
countries based on local
desirability, feasibility, and
costeffectiveness. These
factors will differ in a number
of ways across developed
and developing countries, not
least in the absence of robust
public health infrastructure in
developing nations. Finally,
they

PART IV. TOWARDS A GENERAL MODEL OF CAMPAIGNING FOR BETTER HAND HYGIENE A NATIONAL APPROACH TO HAND HYGIENE IMPROVEMENT

market, consumer attitudes,

emphasize also the importance of making intelligent choices of behaviours, and most
appropriate promotional
interventions for specific settings.1094
strategies and
These non-health-care programmes to improve handwashing
communication channels.
behaviour appear to be feasible and sustainable, especially when These programmes have
they incorporate traditional hygiene practices and beliefs1095 and
achieved an effective
take into consideration locally appropriate channels of
partnership between private
communication.1096 Consumer and market studies were effectively industry and the public
employed to understand the nature of the
sector to promote

that
commercial
marketing
techniques
can be applied
to good effect,
even on a
large
scale.1096
Hand hygiene
improvement
in health care
presents
unique
challenges:
the target
audience is
not the public
or patients
with or at risk
of a disease,
but the HCW.
Lessons from the Global Public
Private Partnership for Handwashing Unlike other
health
with Soap suggest that mass
behaviour change is achievable and improvement
campaigns,

8.

Nationally
driven hand
hygiene
improvement in
health care

Since 2004, a further 25

countries
have
been
identified as running or
preparing to embark on
national programmes. A

network
of hand
hygiene
campai
gning
nations

is in an
embryonic
stage,
coordinated
through the
WHO World
Alliance

the target
behaviour
(hand hygiene
compliance)
contributes to
the prevention
of numerous
episodes of
infection and
not a single
disease. The
published
literature
illustrates few
examples of
national
campaigns
aimed at
improving hand
hygiene within
a health-care
context, thus
reflecting the
novelty of such
approaches.
However, WHO

handwashing with nonbranded soap; therefore,

many of the strategies
employed require further
consideration by those
involved in developing
national campaigns on hand
hygiene improvement in
health care.

has monitored the development of

national campaigning over the past
five years and has recorded
a rapidly increasing number of new
initiatives
(http://www.who.int/gpsc/national_camp
aigns/en/). The first documented
campaign, cleanyourhands (Table
IV.8.1), was launched in England and
Wales in 2004. It is centrally
coordinated and funded, has political
backing, and involves the provision of
campaign materials to support local
implementation of a multimodal hand
hygiene improvement strategy. The
campaign is the subject of a five-

year research evaluation

project,1028,1097 with early
indications suggesting a change in
hand hygiene behaviour. Although
not without its critics,787 the
campaign has demonstrated the
possibilities of running an
integrated behaviour change
programme on hand hygiene at a
national level.
for Patient
Safety.857
This network
will continue
to centralize
lessons
learnt and

share
examples
through its
National
Campaigns
web
platform.
1
8
1

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

9.
Towards a blueprint for developing,
implementing, and evaluating a national hand
hygiene improvement programme within health
care
Based on the current evidence and experience from existing national hand hygiene improvement programmes
(including national campaigns), this part concludes with an outline of the steps required in the development of a
national strategy for action on hand hygiene improvement. Central to the strategy is the process required to
progress from an initial desire to focus on hand hygiene improvement down to the actions required at a local
health-care facility level to implement the WHO multimodal strategy. The WHO Implementation Strategy
incorporates the evidence relating to implementation effectiveness within its core Guide to Implementation and
accompanying toolkit for improvement (http://www.who.int/gpsc/country_work/en/). Table IV.9.1 presents a
detailed framework for action, summarized in Figure IV.1.

10.
Conclusion
Avoidable harm continues to occur to patients receiving health care, because of the unreliable systems and
strategies that mitigate against optimal hand hygiene compliance. As part of the continued global effort to ensure
that no patient is unavoidably harmed through lack of compliance with hand hygiene, consideration should be
given to nationally-coordinated programmes (in some cases campaigns) to promote and sustain hand hygiene
improvement, keeping the issue in the national spotlight 1072 and ensuring effective implementation of guidelines
that have an impact on hand hygiene at the bedside. Noar1066 emphasizes that even taking into account the
numerous caveats associated with campaigning, it is likely that targeted, well-executed mass media health
campaigns can have some effects on health knowledge, beliefs, attitudes, and behaviour. The existence of
guidelines does not in itself improve hand hygiene compliance. Therefore, the added impetus provided by
a nationally coordinated campaign or programme, with some form of monitoring and evaluation, targets and
regulation, has been demonstrated to provide a powerful adjunct to local implementation. In particular, to raise
awareness of the issue and elevate it to a level of prominence that might not be realized in the absence of a
nationally coordinated activity. For hand hygiene improvements to succeed within an integrated safety and
infection control agenda, national-level approaches should be considered.

182

PART IV. TOWARDS A GENERAL MODEL OF CAMPAIGNING FOR BETTER HAND HYGIENE A NATIONAL APPROACH TO HAND HYGIENE IMPROVEMENT

Table IV.8.1
The public information component of two national campaigns focusing on the prevention of health care-associated infection

Campaign

Interventions and tools

Target audiences

Implementing bodies

Significant results

cleanyourhands
England and
Wales1029
(September 2004 to
date)

A multimodal
campaign based on
social marketing and
sustainable methodology
aimed at educating and
providing prompts. It
includes:
Implementation guide
with supporting
resources for HCWs with
ongoing support through
e-bulletins and local visits

HCWs
Senior management
within health-care
settings

NPSA

100% of all acute

trusts in England and
Wales signed up to the
campaign

A series of three posters:

the core campaign
posters; the staff
champion posters; the
patient posters

NHS Trusts
Department of Health

Patients
Hospital visitors
Partner organizations

Welsh Assembly
Government

80% of trusts say hand

hygiene is a top priority
Use of alcohol handrub
and soap has risen
threefold
Initiated patient
empowerment pilot
Expanded programme to
non-acute sector

Patient leaflets, badges,

stickers to encourage
patient involvement
Printed information
materials including staff
leaflet, multi-purpose
panels and pump
indicators
A media kit
A campaign web site
Screen saver
Media launches of the
campaign involving local
celebrities
Conferences
National televised debate

183

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table IV.8.1
The public information component of two national campaigns focusing on the prevention of health care-associated infection (Cont.)

Campaign

Interventions and tools

Target audiences

Implementing bodies

Significant results

100 000 Lives

USA863
(December 2004June 2006)

Information calls on the

campaign and on each
intervention

Health-care providers

IHI

3000 hospitals joined the

campaign

Partner organizations

Hospitals

Campaign brochure

Patients

Systems

Target lives saved

achieved according to IHI
data sources

Sign-up process: system,

state and regional events
Media kits, media events
Getting started kits
Campaign web site
Information to existing
partners on enrolling new
partners
Publicity of the
successes of
participating hospitals
in implementing the
campaign

184

PART IV. TOWARDS A GENERAL MODEL OF CAMPAIGNING FOR BETTER HAND HYGIENE A NATIONAL APPROACH TO HAND HYGIENE IMPROVEMENT

Table IV.9.1
Framework for action
Step

Actions/issues for consideration

References

WHO implementation tools

1. Readiness for
action

Considerations:

798,1072,1074,1088,1094

Pledge briefing pack

Patient Safety Strategy:

Is there an existing or planned regional (WHO) strategy on patient
safety, hand hygiene improvement and infection control?
Is the WHO country office driving infection control/hand hygiene
improvement?
Is there national political support/ leadership for patient safety, hand
hygiene improvement, and infection control?
Is there a national patient safety agenda?
Is there a national infection control agenda?
Is hand hygiene improvement integrated/ embedded within broader
patient safety agenda?
Is hand hygiene part of an accountability/ governance framework; does it
link with accreditation?

Commitment to Clean Care is Safer Care:

Has a national political pledge of support to Clean Care is Safer Care
been signed?
Do national or regional policies/guidelines exist on hand hygiene
improvement in health care?
Is the WHO strategy consistent with national policies/guidelines on
infection control/hand hygiene?

Is there broad support from policy-makers, professionals and the

public to prioritize effort and resource on hand hygiene at a national level?

Will the programme be coordinated through the ministry of health or

via another mechanism (e.g. regional or district authorities or a network of
experts)?

Country
situation analysis

Facility
situation analysis

Perception

surveys

WHO
guide to local
production
of
alcohol-based
handrub

WHO
Guidelines on Hand
Hygiene in Health
Care

WHO Guide
to Implementation of
the multimodal
strategy and
associated toolkit

Break-even
cost analysis tool

Do hand hygiene campaigns outside of health care already exist;

can links be made?

1
8
5

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table IV.9.1
Framework for action (Cont.)
Step

Actions/issues for consideration

References

WHO implementation tools

Infrastructure and resources:

Are national data available on the
economic cost of HCAI?
Are national data available on likely costs
of a hand hygiene programme?
Is there a HCAI national/local surveillance
system in place or anticipated?
Is technical infection control expertise
available to coordinate the campaign?
Are required products affordable/available
(soap and alcohol-based handrub)?
Is national or donor funding available for
the short, medium or long-term?
Are partnerships with commercial sectors
feasible?
How feasible will it be to produce, adapt
and translate (where necessary) the WHO
implementation toolkit?
How feasible will it be to produce the
WHO alcohol-based handrub formulation
nationally (if limited, affordable access to
commercial sector products)?
Does the national infrastructure support
rapid spread of improvement?

Once a decision is made to run a national

programme, proceed to step 2
2. Identify roles andActions:
responsibilities
1. Establish a national task force, headed by an
influential, technically competent (in infection
control or patient safety) national lead and
deputy to coordinate and champion the
campaign (credibility of the messenger in
conveying scientific information to the target
audience is key)

1086

WHO Guidelines on Hand Hygiene in

Health Care
WHO Guide to Implementation of the
multimodal strategy and associated
toolkit
Regional advocacy guide on hand
hygiene

2. Develop terms of reference for the task force

relating to implementation of hand hygiene
improvement programmes at local level, as
an integral part of national infection control
strategy
3. Task force membership should comprise
national safety and infection control
professionals and national bodies for infection
control
4. Task force membership should include ministry
of health officials concerned with infection
control/safety
5. Brief/sensitize a task force on all aspects of the
improvement, including local implementation
using the WHO Guide and technical and
advocacy toolkit

186

PART IV. TOWARDS A GENERAL MODEL OF CAMPAIGNING FOR BETTER HAND HYGIENE A NATIONAL APPROACH TO HAND HYGIENE IMPROVEMENT

Table IV.9.1
Framework for action (Cont.)
Step

Actions/issues for consideration

References

WHO implementation tools

3. Develop a
framework for
monitoring and
evaluation

Considerations:

1074,1075,1088

WHO Guide to Implementation and

associated toolkit

What will the realistic deadline be for action?

Evaluation tools (facility situation
analysis; hand hygiene compliance;
health care-associated infection
rates; soap consumption; alcoholbased handrub consumption;
knowledge surveys; perception
surveys; ward structure surveys)

What realistic targets will be used (e.g.

reduction in infection, increase in compliance
and product usage)
What parameters/baseline data are available to
measure the impact of the programme?
Is there a system for accreditation and
regulation? How will the hand hygiene
improvement fit into this system?
4. Establish
and strengthen
partnerships,
community
mobilization, and
the media

Considerations:

1072,1086,1098

Regional Advocacy Guide for Hand

Hygiene Improvement Strategies

1074,1094

Regional Advocacy Guide for Hand

Hygiene Improvement Strategies

Which agencies/professional bodies,

coalitions, voluntary organizations, partners,
and nongovernmental organizations will be
involved?
Will patient and public engagement feature in
the programme?
How will marketers and the mass media be
involved to ensure local hygiene practices and
beliefs are taken into account?
Will behavioural/industrial psychologists
be involved in the communications and
promotions activity to ensure alignment with
local culture?

5. Implementation:

National
Actions:

WHO Guide to Implementation

1. Prepare a national action plan, based on steps
1 to 4, including all issues raised in the WHO
Guide to Implementation
2. Establish a process for refining the plan in
response to learning during implementation
Considerations:
Consider a national and sub-national meetings
for hospital directors, managers, and other key
decision-makers (for sensitization, awarenessraising, and building commitment)
Consider awareness-raising activities
from national to local: including preparing
communications/briefings to circulate to
hospitals presenting an outline of the strategy
and its benefits
Develop and execute a plan to communicate
and implement the strategy
How many and what type of facilities will be
involved?
187

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table IV.9.1
Framework for action (Cont.)

Step

Actions/issues for consideration

References

WHO implementation tools

and
associated
toolkit

Will a pilot test occur or is mass roll-out anticipated?

Consider holding a training session(s) for infection control

teams using the WHO training tools

In parallel, work to ensure infection control and the WHO

strategy is incorporated within existing education programmes

Consider creation of networks to support change at

the front-line of care

Local

Actions:

1.

Local health-care facilities are provided with the WHO

Guidelines, Guide to Implementation and toolkit

2.

Local health-care facilities work through the five-step

implementation process

f
u
n

Policy-makers
3.

Develop a framwork for

monitoring
and
evaluation

4.

Local
implementers

WHO
Guide
to
Implementation

Action
framework

Figure IV.1

Parners
Advocates
Patient group

Regional
Advocacy Guide
for Hand Hygiene
Improvement
Strategies

Establish and
strengthen
partnerships,
community
mobilization and the
media

5
.
I
m
p
l
e
m
e
n
t

1. Readliness for action

d
er
s

e
n
2
.

Preparation and execution of

national action plan

Work though 5-step

implementation process
188

PART V.
PATIENT INVOLVEMENT
IN HAND HYGIENE PROMOTION

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

1.
Overview and terminology
Patient empowerment is a new concept in health care and has now been expanded to the domain of patient safety.
In developing countries, this has been influenced significantly by the USA IHI reports on health quality and safety,
with a focus on increasing the publics awareness of medical errors and national efforts to actively engage patients
in their care.1041,1099 Even though the term can have different meanings and interpretations, empowerment in health
care generally refers to the process that allows an individual or a community to gain the knowledge, skills, and
attitude needed to make choices about their care. The term patient participation is more often used when referring
to chronic diseases such as diabetes, in which patients are invited to participate in the ongoing decisions of their
care. Patient empowerment is generally required in order for patients to participate. Thus empowerment refers to a
process that, ultimately, leads patients to participate in their care.
Although there are many unanswered questions about how to
approach patient involvement, this part of the guidelines
presents the evidence supporting the use of programmes

report on the results of

the
WHO
Global
Patient
Survey
of
patients perspectives
regarding their role in
hand
hygiene
improvement;

propose a multifaceted
strategy for

aiming to encourage patients to take a more active role in their

care, especially with regard to hand hygiene promotion, using a
three-fold approach:

review the current literature on patient and HCW

empowerment and hand hygiene improvement;

2.
Patient
empowerment
reported
as being
WHO defines empowerment as fundament
al to the
a process through which
people gain greater control over process of
decisions and actions affecting patient
empower
their health and should be
seen as both an individual and ment: 1)
understan
a community process.1100
ding by
the patient
Four components have been
of his/her

and
health
care
role; 2)
aquisition
by
patients of
sufficient
knowledge
to be able
to engage
with their
healthcare
provider;

The term
chosen to
engage and
involve
patients will
depend on
what is
appropriate
for the
specific

empowerment that can

be incorporated into a
broader, multimodal,
hand hygiene
improvement strategy.

culture of a region or community.

Patient empowerment might be the
preferred term from a patient
advocacy point of view. However,
the less emotionally charged and
challenging term patient
participation might be a term more
acceptable to many HCWs, patients,
and cultures. For the purpose of
these guidelines, the word
empowerment is used.

3) patient skills; and 4) the

presence of a facilitating
environment.1101 Based on
these four components,
empowerment can be
defined as:

A process in
which
patients
understand
their role, are
given
the
knowledge
and skills by
their healthcare provider

to perform a
task in an
environment
that
recognizes
community
and cultural
differences
and
encourages
patient
participation.

190

PART V. PATIENT INVOLVEMENT IN HAND HYGIENE PROMOTION

3.
Components of the empowerment process
3.1 Patient participation
WHO recognizes that the primary responsibility for the delivery of
safe care is with the health-care system. Nevertheless, there are
now many ways in which patients can become involved in the
process of their own health care. Lyons1102 identifies three key
contributions patients can provide: 1) historical background about
their health; 2) self-interest and motivation for a beneficial
outcome; and 3) being physically present at all times during care
and treatment. Their age, culture, background, personality, and
level of intelligence have been identified as key characteristics
when engaging patients in participation.1102

responses such as moods,

emotional states, physical
reactions, and stress levels
also influence ones perception
of self-efficacy.

These skills can be applied to

the behaviour of empowering
patients to ask about hand
hygiene. Knowledge will give
mastery experience of the
behaviour, role modelling by
HCWs will provide vicarious
To sum up, the opportunity for patients to be involved experience, and patients
in their health care has evolved over the last decades from
asking their providers to
passive to more active. An understanding of this new role by
perform hand hygiene will
both patient and HCW is the foundation of an empowerment
give verbal persuasion. It is
programme.
likely that the high selfefficacious person will have
the skills to invest more
3.2 Patient knowledge
effort.1106
Patients can be empowered only after having gathered enough
information, understanding how to use the information, and being
convinced that this knowledge gives them shared responsibility
with their HCWs. In their review of materials given to patients,
Coulter and colleagues1103 found that relevant information was
often omitted, many doctors adopted a
patronizing tone, and few actively promoting a shared approach.
Studies have also shown that patients prefer information that

is specific, given by their HCWs, and printed for use as

prompt sheets if necessary.1103,1104

3.3 Patient skills

3.3.2 Health literacy

Health literacy is the ability to
understand health information
and to use that information to
make good decisions about
health and medical care.
Lower health literacy has been
reported among people who
are elderly, less educated,
poor, and members of minority
groups1107 and is associated

with lower health outcomes,

increased rates of
hospitalization, and higher
costs for care.1101,1108 Health
literacy is fundamental to
patient empowerment.1109
However, authors of health
education material often
attempt to encourage health
literacy by simply rewriting
existing materials in lay
language and fail to recognize
that information is only one
piece of the literacy
process.1110 To solve this
problem, an action plan has
been set forth to improve
literacy in the USA.1111
In summary, the skills of
self-efficacy and health
literacy have been linked
to the performance of a
task that requires a
change in behaviour. High
levels of self-efficacy
appear to be a motivating
factor to perform a task.
Health literacy and
community partnership
provide the structure
required by champions of
empowerment to deliver
the message of
engagement to their
communities.

3.3.1 Self-efficacy
efficacy.
Self-efficacy is defined as an individuals Vicarious
experience
belief that he/she has the capabilities to
refers to the
produce an effect or reach a certain
1105
goal.
Individuals with high self-efficacy increase in
ones selfregarding a given behaviour are more
efficacy upon
inclined to undertake this behaviour,
witnessing other
have greater motivation, and usually
individuals
undertake more challenging tasks than
completing
individuals with low self-efficacy.1106
successfully a
Promoting self-efficacy among patients is task. The third
fundamental in order to bring them to the source, verbal
persuasion,
stage where they will feel confortable to
ask HCWs about hand hygiene. Bandura relates to the
impact of
identified four major ways (dubbed
sources) to improve ones self-efficacy: encouragement
mastery experiences; vicarious experience; on an
individuals
verbal persuasion; and physiological
perceived selfresponses. Mastery experiences,
efficacy. Finally,
considered
physiological
as the most important, relate to the fact
that previous successes will raise self191

3.4
Creation
of a
facilitatin
g
environm
ent and
positive
deviance
The creation of
a facilitating
environment
can be defined
as the process
in which
patients are
encouraged to
develop and
practise open
communication
about their
care in an

envir patients be seen

onme as partners and
nt
to facilitate an
free environment for
of
empowerment.111
barri 2 These are: a) a
ers. workplace that
Ther has the requisite
e are structure to
three promote
prere empowerment; b)
quisit a psychological
es
belief in ones
that ability to be
HCW empowered; and
s
c)
requi acknowledgemen
re if t that the
they relationship and
are communication of
expe HCWs with
cted patients can be
to
powerful.
help

An individual
cannot create
personal
empowerment in
another
individual, but the
partnership of
HCWs and
patients can
facilitate the
process of
empowerment. If
patients are
given knowledge
and resources in
an environment
of mutual respect
and support, then
a facilitating
environment for
empowerment
will develop.

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

spread of
MRSA.1117,1118 It
is now being
seen as a
means to
provide a
framework for
facilitating
empowerment.

Positive
deviance is
based on
the
Positive
observation deviance
that, in most could be
settings, a used to
few at-risk promote
individuals hand
develop
hygiene
uncommon, and
beneficial
patient
practices
empower
and,
ment.
consequentl The
y,
strategy
experience involves:
better
1) social
outcomes
mobilization; 2)
information
than
neighbours gathering; and
with similar (3) behaviour
change.
risks.1113,1114
Recognition
of these
individuals
and
identification
and
explanation
of their
uncommon
behaviour
allows the
design of
behaviour
change
activities that
can lead to
widespread
adoption of
beneficial
behaviour.
This
approach,
which takes
advantage of
the
communitys
existing
assets, was
originally
developed
for
combating
childhood
malnutrition,1
115,1116
but
has also
been applied
to various
health-care
programmes
such as
newborn
care or
reducing the

Social
mobilization is
an opportunity
for health-care
settings to
identify
problems and
find solutions
to increase
compliance.
This can be
done by
bringing
together the
individuals
who have a
vested interest
in the problem.
Informationgathering
would offer an
opportunity for
individuals to
identify the
best ways

to involve
patients and
HCWs.
Behavioural
change can
be developed
through a
partnership
that takes
responsibility
for
implementatio
n. For some
communities,
the process of
positive
deviance may
reveal a lack
of hand
hygiene
products,
cultural
barriers to
empowerment
, or the need
to develop
networks of
champions.
The partnership
of HCWs and
patients
can
facilitate
the
process
of
empowerment if
HCWs
recognize
patients
as
equal partners.
Positive
deviance
can
be used to find

solutions towithin
a
common
community and
local issuesencourage

em
4. po
we
Ha rm
nd ent
hy
gie
Multim
ne odal
progra
co mmes
for
increa
m sing
hand
pli hygien
e
compli
an ance
are
ce now
recom
mende
an dtheas
reliabl
d most
e,

behaviour
change.

cenes. Although
based patient
metho empowerment
d for was already
ensuri referenced in the
ng
2006 Advanced
sustai Draft of the
nable Guidelines59 and
improv explicitly stated
ement. as one of the final
60,713
recommendations
WHO , the emphasis
has
placed upon it
develo within the
ped associated
and implementation
tested strategy has been
a
limited. WHO is
multim committed to
odal informing and
Hand educating
Hygienpatients about the
e
importance of
Improv hand hygiene and
ement their potentially
Strate powerful role in
gy
supporting
(see improvement.767
Part I, This is mirrored
Sectio across a growing
n 21) number of
to
countries of the
transla world that are
te into incorporating
practic patient
e the empowerment
presen into their national
t
strategies. (Table
guideli V.4.1)

eviden
c
w were mes within
satis their hospital. a
e
4.1 P r fied Responses m
m with revealed that p
a
ai
the 70% of
e
t
infor patients were g
n
i
n
mati concerned
t
e
on about the risk a
n
they of infection, n
t
recei 69% said the d
a
4.1.1
ved risk was never r
Willingne
n
abou explained, and e
dss to
t
57% said they p
be
hemp
owe
ered

a
l Mille
tr&
hFarr1
- 119
csurv
aeyed
r patie
ents
kno
wwled
oge of
r HCA
kI in
ethe
r USA
eby
maski
png if
othey

infec would be
tion willing to pay
contr for better
ol
infection
and control
if
program
they mes and
were informati
willin on on
g to infections
pay .
for
incre The NPSA
ased for England
inve and Wales
stme assessed
nt in patients
infec views on
tion involvemen
contr t as part of
ol
their
prog cleanyour
ram hands

o
rt
e
d
t
h
a
t
7
1
%
o
f
r
e
s
p
o
n
d
e
n
ts

w
a
nt
e
d
to
b
e
in
v
ol
v
e
d
in
i
m
p
r
o
vi
n
g
h
a
n
d
h
y
gi
e
n
e
p
r
a
ct

ic
es
.10
29

Si
mi
lar
re
su
lts
w
er
e
re
po
rte
d
by
an
ac
ut
e
ca
re
tru
st,
112
0

w
he
re
79
%
of
pa
tie
nt
s
th
ou
gh
t
th
at
th
ey
sh
ou
ld
be
in
vo
lv
ed
in
ha
nd
hy
gi
en
e
im
pr
ov
e
m
en
ts.

A
willi
ngn
ess
to
be
emp
owe
red
is
dep
end
ent
on
pati
ent
inpu
t
duri
ng
the
dev
elop
men
t of
the
pro
gra
mm
e.
Ent
wistl
e
and
coll
eag
ues
1121

revi
ewe
d
the
cont
ent
of
five
lead
ing
pati
ent
safe
ty
dire
ctiv
es
in
the
US
A;
they
rep
orte
d
that
the
pro
gra
mm
es
had
bee
n
deve
lope

d
ramme with
with input from
out patients and
input families,
from Patients and
patie Families in
nts Patient
and Safety:
lack Nothing About
ed Me, Without
infor Me, as a call
mati to action for
on health-care
abo organizations
ut at all levels to
what involve
the patients and
HC families in
Ws systems and
nee patient safety
ded problems.1122
to
do In 2004, WHO
and launched the
what World Alliance
supp for Patient
ort Safety to raise
shou awareness
ld be and political
give commitment to
n to improve the
patie safety of care
nts. in all its
In Member
200 States. A
1, specific area
the of work,
Nati Patients for
onal Patient Safety,
Pati was designed
ent to ensure that
Safe the wisdom of
patients,
ty
Fou families,
ndati consumers,
on and citizens,
Advi in both
sory developed and
Cou developing
ncil countries, is
central in
in
the shaping the
USA work of the
took Alliance. In
up 2007, as part
the of the WHO
conc First Global
ern Patient Safety
Challenge,
abo
Clean Care is
ut
Safe Care,
cons
the
ume
development
r
and
invol
vem
ent
and
deve
lope
da
new
prog

192

implementation of
an empowerment
model for hand
hygiene
was
initiated
in
collaboration with
Patients
for
Patient Safety. In
studies
undertaken in the
USA
and
the
United Kingdom,
McGuckin and colleagues
willingness

reported on patients

to be empowered
and involved in hand
hygiene by asking
their HCWs to clean
their hands. They
documented that
8090% of patients
will agree to ask in
principle, but the
percentage
of those that
actually asked
their HCW is
slightly lower at
6070%. A
recent survey of
consumers on
their attitudes
about hand
hygiene found
that four out of
five consumers
said they would
ask their HCW
did you
wash/sanitize
your
hands? if their HCW
educated them on the
importance of hand
hygiene.874 A patients
willingness to be
involved, empowered
or engaged is
dependent on the
overall environment
of the organization
and its attitudes
toward patient safety
and patient
involvement.876,1036,1123,1124

4.1.2 Barriers to
patient
empowerment
There are several
different theories
from various
disciplines that
provide insight into

the barriers of hand

hygiene compliance
that may apply to
patient involvement.
These theories
include cognitive,
behavioural, social,
marketing, and
organizational
theories
803-805
that
may be
valuable when
considering barriers
to
be overcome, or a
strategy to involve
and engage
patients.876 Pittet789
discusses in some
detail the
promising effect of
the theory of
ecological
perspective as part
of a multimodal
programme to
increase hand
hygiene compliance.
In this theory, similar
to that of positive
deviance,1115,1116
behaviour is viewed
as affecting and
being affected by
multiple factors, and
both influences and
is influenced by the
social environment.
Although further
assessment of these
theories is needed,
they do appear
to have a
bearing on
some of the
barriers of
patient
empowerment.
Three barriers
that can lessen
patient
involvement
are: 1)
intrapersonal;
2)
interpersonal;
and 3) cultural.1125.
Intrapersonal
factors include
psychological
vulnerability, acute
pain, and illness,1126
and each can be
influenced by a lack
of knowledge1127
and professional
domination.1128
Interpersonal
factors centre on
the importance of
communication and
the need to use
clear, simple
language so that

expectations are
apparent.1129
Cultural factors
such as cultural
marginalization,
caused by social
pressure, can have
a significant impact
on speaking
up.1130 In addition
to these barriers, a
significant factor
often perceived by
the patient is the
fear of a negative
impact/response
from their
HCWs.1131 This
barrier was
explored in an
acute care
rehabilitation unit
where patients are
often dependent on
their HCWs for
activities of daily
living. The authors
reported that 75% of
patients were
comfortable asking
their HCWs did you
wash/sanitize your
hands?805 It is
important to note that
empowerment is a
major part of the
rehabilitation process
and, therefore, this
may have been a
motivating factor for
empowerment in
these patients.
Although HCWs are
trained and
motivated to provide
the best care
possible, they are
often faced with
barriers that are
more system-related
than behavioural.
Empowering a
patient covers issues
that go beyond
decision-making and
involve more
individual interests
and cultural
parameters.
Acknowledging
different views on
patient
empowerment and
dealing with them in
the context of an
organization, culture,
or community will be
necessary when
removing barriers to
patient
empowerment,
involvement or
participation in hand
hygiene compliance.

PART V. PATIENT
INVOLVEMENT IN HAND
HYGIENE PROMOTION

Table V.4.1
Countries and
territories with
national strategies
for patient
empowerment (as
at October 2008)
Country

Australia

Belgium

Canada

England and
Wales
(http://www.npsa.nh
s.uk/cleanyourhand
s/in-hospitals/pep)

Ireland

Northern
Ireland

Norway

Ontario
(Canada)

9
10

Saudi Arabia

USA
(http://www.jointcom
mission.org/patients
afety/speakup)

193

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

5.
Programmes and models of hand hygiene
promotion, including patient and health-care
worker empowerment
5.1 Evidence
As only a few studies have been published to assess the
efficacy of patient involvement to increase hand hygiene,
an evidence-based review of programmes that have
empowered, involved or encouraged patient participation
in hand hygiene promotion cannot be evaluated by the
traditional method focused on quantitative data, linear
causality, and scientific reliability.1132 The complex
multidisciplinary approach to
hand hygiene compliance lends itself to evaluations that
are used more in health promotion.1133 These evaluations
use a theory-based approach that explore links between
activities, outcomes, and context and take into account
the relationship between individuals and their
environment.1134,1135 They determine not only what works,
but under what conditions, and the relationship
programmes have within an organization. Many
organizations, both at the national and local levels, have
developed programmes of empowerment for hand
hygiene that use various approaches. In most cases,
these do not have a strategy for evaluation. Therefore,
the following review of programmes that have used
empowerment has been limited to published articles and
reports in which there was some form of

evaluation for hand hygiene as a separate outcome or

as part of a multifaceted programme.

5.2 Programmes
Programmes for patient and staff empowerment in the
context of hand hygiene improvement can be
categorized into educational (including Internet),
motivational (reminders/

posters), and role modelling within the context of a

multimodal approach.

5.2.1 Educational programmes

Hand hygiene information for patients can be in the form
of printed matter, an oral demonstration, or audiovisual
means. In their patient empowerment model, McGuckin
and colleagues educated patients about hand hygiene by
using brochures that asked the patient to be a partner
with their HCWs. The materials presented discussed the
who, why, where and when
of hand hygiene. This programme has been evaluated in
several multicentre studies documenting that 8090% of
patients reported that they had read the educational
brochures.803,804 Petersen and colleagues1136 developed a
promotional campaign that included educational brochures
for patients on hand hygiene as well as bottles of alcoholbased hand rub. Although patients were encouraged to
speak up about hand hygiene, Petersen and colleagues
reported an overall increase of only 10% in compliance,

but believed this was

attributable to limitations in
their observation technique.
Using demonstrations as a
form of education and
empowerment about hand

hygiene was evaluated and

found to increase awareness
and compliance.1137 Chen &
Chiang compared the use of
a hand hygiene video to
illustrated posters to teach
hand hygiene skills to parents
of paediatric intensive care
patients and to empower
them about their role in hand
hygiene. They reported a
steady sustained increase in
compliance and
empowerment by parents
attributable to a strong
motivation to protect their
child.1138 In 2008, the CDC
released a podcast on hand
hygiene and patient
empowerment stating that it
is appropriate to ask or
remind health-care providers
to practise hand hygiene
(http://www2a.
cdc.gov/podcast/player.asp?
=9467). Empowering patients
about
patient
803-805
safety
issues using
Internet sources such as
home pages for hospitals or
national agencies has
become part of many hospital
systems as a result of
mandatory reporting
of quality and safety.
When 32 consumer
participants were
introduced to five
Internet sources on
quality care in order to
educate them about
patient involvement,
they reported a
significant improvement
in test scores after
exposure to the

Internet sources.1139 The

studies described here are
from health-care settings in
developed countries.

5.2.2 Reminders and

motivational messages
Patient empowerment
models often include visual
reminders

for both the HCW and the patient.

These visual reminders

usually include small badges or stickers worn by patients

with a message such as did you wash/sanitize your
hands? A multicentre, one-year evaluation of a model
using education and reminders as a route to
empowerment, found a statistically significant increase in
hand hygiene compliance with the model working equally
well for all sizes of hospitals and unit types.1140 Posters,
another form of reminder, are used in hand hygiene
programmes and campaigns to educate and empower
HCWs as well as patients. An evaluation of 69 hand
hygiene posters representing 75 messages found that
only 41% framed the message for motivation,
empowerment, and health promotion. Similar findings

were reported from a poster

campaign in a paediatric
ICU to encourage both
HCWs and patients/visitors
to practise hand hygiene.1141
If the message is framed
correctly, posters can serve
as a visual reminder and
encouragement

for both the patient and

the HCW to participate in
hand hygiene practices.
Educational videos,
posters, brochures, and
194

visual reminders targeted

to educate HCWs and
patients were evaluated
in three long-term care
facilities as part of a
comprehensive hand
hygiene programme. This
combination of HCW
education and patient
empowerment resulted in
an aggregate increase in
hand hygiene compliance
of 52% and a 32%
decrease in infections.806

PART V. PATIENT INVOLVEMENT IN HAND HYGIENE PROMOTION

speakers at the
nurses station.
Christensen &
Taylor1142
question the
use of
empowerment
5.2.3 Role
for the ICU
modelling
patient and
suggest that
Role
patients need to
modelling in
have control
which the
restored before
HCW
they can be
behaviour
empowered.
towards hand
Lankford and
hygiene is
colleagues802
influenced by
reported that a
either peers or
HCWs hand
superiors has
hygiene
been shown
behaviour was
to influence
influenced
compliance
negatively when
and motivate
the HCW was in a
the patient to
room with a
be
senior staff
empowered.732,802,85 member or peer
3,872,1142-1145
who did not
McGuckin
perform hand
and
hygiene. Sax and
colleagues
colleagues732
reported an
identified social
increase in
pressures that
hand hygiene
could be
compliance
considered a form
and alcoholof role modelling
based hand
as highly ranked
rub use by
determinants of
using
good hand
authority
hygiene
figures as
adherence: the
role models
influence of
for
superiors and
empowerment colleagues on
.853 The
staff and patients.
medical
director, nurse
manager,
director of
nursing, and
infection control
professional
dedicated to
the
medical/surgica
l ICU recorded
short audio
messages
about hand
hygiene, such
as we want
100%
compliance
with hand
hygiene in our
ICU and
remember to
use sanitizer,
that were
broadcast at
randomly timed
intervals from
the
announcement

In summary,
programmes and
models for
empowering
patients and
HCWs must be
developed with
an evaluation
component that
includes both
qualitative and
quantitative
measures to
determine not
only what works,
but under what
conditions, and
within which
organizational
context the
programme
works.
Programmes in
which there is
some evidence
of empowering
patients and
HCWs are
usually part of a
multifaceted
approach and
include one or all
of the following:
educational
tools, motivation
tools, and role
modelling. Many
aspects of
patient
empowerment
remain
unexplored; for
example, the
views of HCWs
on this topic are
largely unknown.
Also, as most
studies exploring
the impact of
patient
empowerment
on HCWs hand
hygiene
practices were
conducted in
settings with low
baseline
compliance
rates, the impact
has always been
significant and,
therefore, the
effect on settings
with higher
baseline
compliance
remains

unknown. In
addition,
because the
studies were
short term, any
sustainable
effect has not
been
determined.
Finally,
empowerment

programmes
require further
testing in
settings where
a multimodal
promotion
strategy
including
system change,
monitoring and
HCW

pati
6. ent
exp
WH erie
O nce
glo s
bal
sur
WHO
vey Asurvey
was
of underta
ken as
part of

report
ed in
AFR
In
summ and
SEAR
ary,
. Of
459
complethe
29%
ted
survey of
s were respo
receivendent
d, with s who
only report
13% ed
from askin
WHO g a
region HCW
s other to
than wash/
AMR saniti
ze
and
EUR. their
Infrastr han
ucture ds,
25%
to
suppor repo
t hand rted
hygien recei
e
ving
varied a
by
neg
region ative
with, resp
as
onse
anticip .
ated, One
major of
constr the
aints key

performance
feedback,
education,
reminders in
the workplace,
and promotion
of the
institutional
safety climate
is being
promoted.

the
to incorporate
work of geographical and
the
culturally diverse
Patient perspectives related
Involve to patient
ment empowerment and
Task
hand hygiene
Force improvement. A
establis two-phase, webhed
based survey was
during conducted between
the
March 2007 and
develop January 2008. The
ment survey sought views
process on infrastructure,
of these barriers and
guidelin facilitators, existing
es, to country strategies,
identify and case-study
existing examples. Detailed
gaps in results are
knowle presented in
dge and Appendix 6.

findi reporting that

ngs they would
is
the
impa
ct
that
HC
W
enco
urag
eme
nt
see
ms
to
have
on
the
likeli
hoo
d of
patie
nts
feeli
ng
emp
ower
ed
to
ask
abo
ut
han
d
hygi
ene,
with
86%

feel
comfo
rtable
doing
so if
invite
d to.
This
decre
ased
to
52%
when
not
invite
d,
and
increa
sed to
72%
when
prese
nted
with a
scena
rio
where
failure
to
compl
y was
obser
ved.
Furth
ermor
e,
respo
ndent

s who
had
direct
experi
ence
of an
HCAI
were
more
likely
to
questi
on
the
HCW
(37%
amon
g
those
who
had
direct
experi
ence
vs
17%
amon
g
those
who
did
not).
Detail
s of
the
study
desig
n,
data

analysi questi
s, and ons,
results as
of all well

as
s from caseentsaf
specif studies, can be ety/ch
ic
found at http:// alleng
detail www.who.int/pati e/en.
195

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

7.
Strategy and resources for developing,
implementing, and evaluating a patient/healthcare worker empowerment programme in a
health-care facility or community
Patient/HCW empowerment programmes should form one component of an evidence-based multimodal hand
hygiene improvement strategy. Table V.7.1 presents a template of a strategy to develop an empowerment
programme in a health-care community by providing several steps for ownership, programme review,
development, implementation, and evaluation. Each step identifies a task, or tasks, with the process that is
needed to complete each one. Background information and resources are cross-referenced with the text of the
guidelines, as well as with Appendix 6 for the survey results.
Table V.7.1
Template of a strategy to develop an empowerment programme)
1. Ownership: develop a shared responsibility
Task

Process

Introduce empowerment in the context of hand hygiene improvement to

key decision-makers

Guidelines (Part V)
Section no.

Present the evidence-based multimodal Hand Hygiene

Improvement Strategy to key decision-makers

4, 5

Discuss WHO commitment for improving hand hygiene

(through lobbying for adoption of recommendations in the
WHO Guidelines)

Highlight better outcomes by using multimodal Hand

Hygiene Improvement Strategy approach

3.4, 4

Share results of the WHO patient survey in your region

Appendix 6, Table 2

Determine the most appropriate

terminology to describe
empowerment in your culture or
community

Decide on wording that is positive, not easily

misunderstood, and appropriate for your community/
organization. Some of the most common terminology:
patient empowerment
patient involvement
patient participation
patient engagement

1, 2

Establish your core support

network

Identify sources for individual and organizational support.

Suggestions:
HCWs
community leaders
champions of health-care causes
patient advocates
advisers

3.4

Form a support/action team responsible for making hand

hygiene initiatives top priority

3.4, 4.1.1

To ensure involvement, implement the step of positive

deviance

3.4

196

PART V. PATIENT INVOLVEMENT IN HAND HYGIENE PROMOTION

Table V.7.1
Template of a strategy to develop an empowerment programme (Cont.)

2. Review existing empowerment models/programmes

Task

Empowerment models

Guidelines (Part V)
Section

Research existing empowerment

programmes for information on
how they are structured and
implemented. Four types are
listed here

Multimodal

Education

5.2.1

Motivation

5.2.2

Role modelling

5.2.3

3. Programme development: know your organization

Task

Process

Review and understand current knowledge, skills, and attitudes of

HCWs and patients at your health-care facility

Guidelines (Part V)
Section no.

Establish each team members role

Evaluate your current knowledge and perception of hand

hygiene and target areas to seek additional information
use WHO Knowledge and Perception Surveys

4, Appendix 6, Table 6

Review and understand patient

factors that may present
challenges to implementing the
programme. Use knowledge
and skills to design tasks that
overcome challenges

Review and understand HCW

factors which may present
challenges to implementing the
programme. Use knowledge
and skills to design tasks that
overcome challenges

Plan and develop educational

materials based on your
organizations norms

Evaluate your teams skills

Evaluate the degree to which you have a facilitating

environment for empowerment

Evaluate the willingness of patients and HCWs to

participate in empowerment

4.1.1, Appendix 6, Figure 4

Evaluate the barriers of patients and HCWs to participation

in empowerment

4.1.2, Appendix 6, Table 3, Figure 2

Understand WHO survey expectations

Appendix 6,Table 5

Understanding of self-empowerment

3.1, 4.1.1

Willingness to be in a partnership with HCWs

4.1.1

Understand how respect is shown towards HCWs

(reinforced directly or subliminally by HCWs)

4.1.2

Understand cultural barriers that patients may have

towards communicating with their HCW

4.1.2

Attitudes towards patient input

3.1

Availability and use of printed materials

5.2.1

Availability and use of visual reminders

5.2.2

Attitudes towards the message: HCW + patient partnership

5.2.3

Degree of agreement with the WHO survey patient

responses

6.6, Appendix 6, Figure 3, Table 2

Include patient input in the design and wording of your

materials

5.1, Appendix 6, Tables 4 & 5

Design printed materials

5.2.1, 5.2.2

Design visual reminders

5.2.2

All materials should promote the message: HCW + patient

partnership

Appendix 6, Tables 4 & 6

Incorporate insight and local understanding from WHO

survey patient responses

Appendix 6, Figure 1, Table 4

197

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table V.7.1
Template of a strategy to develop an empowerment programme (Cont.)

4. Programme implementation
Task

Process Guidelines (Part V)

Section no.

Put your programme designs into action. You should

include plans to overcome challenges in patient and
HCW factors, and have your educational materials
ready

Know your communitys or organizations

preferences for instruction techniques

4, Appendix 6, Table 2, Figure 3

Include HCW involvement and partnership

5, Appendix 6, Table 4

Identify barriers when the programme is

under way

4.1.2

Include WHO survey patient preferences

5.

6, Appendix 6,
Tables 3-5
Evaluation

Task

Methods

Guidelines (Part V)
Section no.

Design your evaluation process. Three

ideas are listed here.

Theory-based / health promotion

Patient satisfaction survey

Patient as observer of practices

1
9
8

PART VI.
F
NATIO
C NAL
O AND
MSUBP NATIO
A NAL
R GUIDE
I LINES
S FOR
O HAND
N HYGIE
O NE

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Guidelines for hand hygiene prepared by various other agencies, both prior to and after the publication of the
Advanced Draft of these guidelines, are currently available. An analysis of recommendations in guidelines
produced by 16 countries was published in 2001.635 However, several guidelines included in the analysis were not
formal publications agreed upon nationally or sub-nationally, and the level of details provided could be expanded
more extensively. This section examines the scope, approaches, and recommendations of some national and subnational guidelines.
Different strategies were used to identify available guidelines.
These included using search engines such as Google and
electronic resources such as PubMed and the Guideline
International Network. Keywords used in the search were
hand hygiene, hand washing, handwashing, hand
rubbing, handrubbing, hand decontamination and
guidelines in various combinations. Requests for hand
hygiene guidelines were also made to members of the WHO
First Global Patient Safety Challenge core group of experts,
national representatives of the European Union hospital
infection network (Hospital in Europe Link for Infection Control
through Surveillance) and WHO regional offices.

hand hygiene.1149,1154,1157,11621165
Developers of the advisory
type of documents focused
mainly on evidence-gathering
and making general
recommendations applicable
to different settings

and areas. The latter group

of documents focused more
on specific issues related to
implementation such as
technical details,
popularizing practices, and
logistics; they referred to
Twenty-one guidelines were obtained for comparison. These
documents in the advisory
included 15 national guidelines from Australia,1146 Belgium,1147
group for their evidence
Canada,1148 Egypt,1149 England,1150 France,1151 Germany,1152
base. Some documents
Ireland,1153 Nepal,1154 the Russian Federation,1155 the
belonging to the advisory
Netherlands,1156 Tunisia,1157 Scotland,1158 Sweden,1159 and the
group mentioned and
referred to companion
USA,58 and six sub-national guidelines from Ontario1160
materials, such as training
and Manitoba1161 (Canada), and Liverpool,1162 Southampton,1163 Mid
guides and other national
Cheshire,1164 and Bassetlaw1165 NHS Trusts (England). The
guidelines, for some details.
documents were analysed using a methodology adapted from the
Several documents
European HARMONY (Harmonisation of Antibiotic Resistance
measurement, Methods of typing Organisms and
contained a long detailed
ways of using these and other tools to increase the effectiveness of text in addition to the
evidence for
Nosocomical infection control) project approach,1166 a tool
recommendations.
developed originally to evaluate antibiotic policies in different
hospitals and since used in several other infection control-related
projects.1167 The main aspects considered by this method were:
information about the guidelines title, year of publication,
endorsing body, and mode of publication; aspects related to the
guideline development process (e.g. national vs sub-national,
developers, target population, and methods for evidence
evaluation and recommendation development); type of
recommendations, details about indications and technique, and
products recommended for hand hygiene; and recommended
strategies for hand hygiene improvement and guideline
implementation.

The extent to which

evidence was collected and
assessed varied
considerably. Only three
guidelines described clearly
the method used for
collecting or selecting
evidence. Seven national
and two sub-national
guidelines graded the
evidence

(Evidence-based Practice in
Infection Control) 2
guidelines.1150 Published
guidelines used as
references were assessed
using the AGREE (Appraisal
of Guidelines Research and
Evaluation) instrument in one
document.1150
Table VI.1 shows some of the
major aspects of the
evidence-grading systems
used in different documents.
There were additional
differences in the individual
statements. For example, the
CDC Category 1A is strongly
recommended for
implementation and strongly
supported by well-designed
experimental, clinical, or
epidemiologic studies and
that of France Category 1 is
strongly supported by welldesigned studies and do not
pose economical or technical
problems. In EPIC 2
guidelines, evidence grades 1
and 2 were further classified
into three (e.g. 1, 1+, and 1++).
In general, there were three to
five grades of evidence and
recommendations. The

quantum of evidence and

details of data from studies
presented varied considerably.
This probably reflects
differences in the rigour in
evidence-gathering and
assessment.

Eighteen of the 21 guidelines were available through web sites, 14 for recommendations.58,1148,1150of which were in English. These documents were developed either 1153,1159,1160,1162 However, they
by professional societies involved in infection prevention and in the used different grading
systems and definitions to
control of antimicrobial resistance or by governmental agencies
indicate the strength of
such as the ministry of health. In some cases, recommendations
evidence and
on hand hygiene were part of much longer infection control or
recommendations. The
antimicrobial resistance control guidelines. In the latter documents,
strength and quality of
details on important issues related
evidence was determined
to hand hygiene were generally insufficient or the information
based on expert consensus
was made available in different parts of the document or allied
in three
publications, thus making difficult the analyses.
1148,1152,1159

The recommendations
formulated were based on
expert consensus for most
documents. The validation
process was not clear for
most guidelines. Seven
described internal or
external peer reviews and
public consultations as the
methods of validation.

The documents varied in their scope, approach to the topic, and

The guideline documents

content. Some were primarily intended as advisory

directives,

58,1146,1150,1152,1153,1159

while the primary focus of others were

the technical issues of why, when and how to perform

documents.
The
evidence grading was
performed using the methods
adopted by the National
Institute for Health and
Clinical Excellence (NICE)
from the Scottish
Intercollegiate Guideline
Network (SIGN) for the EPIC

appeared to be still evolving.

Several guidelines stated that
they need to be revised
periodically based on new
evidence and some are currently
being revised, e.g.

the French and Belgian guidelines (personal communication).

200

PART VI. COMPARISON OF NATIONAL AND SUB-NATIONAL GUIDELINES FOR HAND HYGIENE

requirement.1151,1158
,1160-1165
All subnational guidelines
make this
statement.
Although the general
concepts concerning
indications and
methods to perform
hand hygiene
practices were similar
in essence in all
documents, the
terminology used to
describe various
issues differed
considerably between
2005 onwards), although,
documents, thus
interestingly, only three of
making exact
these six documents
comparisons difficult.
referred to the WHO
For example, terms
publication.1158,1160,1168
such as
decontamination and
HCWs were the main target
antisepsis were used
population in all guidelines.
synonymously in
Since all were national and
different documents.
sub-national documents, policySeveral documents
makers (local authorities,
included a list of
institutional authorities, etc.)
definitions, but the
were also possible intended
number of terms for
users, but this was specified
which an explanation
only in nine
was provided and
documents.58,1146,1150,1153,1158,1160-1162,1164 even its details
The intended settings were
varied. Definition of
also not exactly specified in most
terms used to classify
documents. Seven documents
situations where hand
mentioned health care in
hygiene practices
community settings in addition to
were indicated also
hospitals.1146,1158,1160-1162,1164,1165 As
differed between
far as it is possible to understand,
documents. For
the others are intended to be
example, in some
used primarily for care in hospital
cases, social
settings. Although not clearly
indications meant
specified in many documents,
contacts other than
most of the recommendations
patient care (between
relate to inpatient care.
HCWs, casual social
contact between
Most documents stated that the
patient and HCWs,
intended outcome was to
etc.). In some others,
produce improvement in hand
the same word was
hygiene so as to contribute to the
used to include all
reduction in pathogen
situations where plain
transmission and ultimately
soap and water was
HCAIs and/or antimicrobial
recommended as the
resistance. However, audit and
method, including
measurable indicators were
visible soiling with
mentioned in only nine of
blood and body fluids.
58,1148,1150,1151,1153,
them.
Others did not
1158,1160,1162,1164
classify indications,
but merely provided
Administrative approaches
lists. In the present
for implementation, such
evaluation, three
as the emphasis on the
types of indications
binding nature of the
for hand hygiene
document, varied.
were considered:
Fourteen documents
social
recommended the
(contacts different
implementation
from patient care),
of the guidelines as a
patient care, and
priority,58,1146,1147,1150,1151,1153,1157,1158,11601165
surgical hand
and eight stressed
preparation.
adherence to the guideline
According to this
as a
Based on the original CDC
evidence document, a How-to
Guide was made by the same
agencies a few years later.1168
Four guidelines,1148,1160-1162 one
revised guideline,1150 and the IHI
How-to Guide document1168
were published after the
publication of the Advanced Draft
of these WHO Guidelines
(October

classification, most
guidelines appeared
to have focused on
the latter two types

of indication. Five
guidelines, three
national and two
subnational,1148,1150,11
56,1161,1162
were
developed
primarily for
routine patient
care and had
only social and
routine patientcare indications.

Although indications and

methods for hand hygiene
were the focus for several
national and all sub-national
guidelines, the level of detail
described varied
considerably between
documents. In general, the
sub-national guidelines
tended to have more
technical details with easier
to understand illustrations
than the national documents,
which were more advisory in
nature. In some documents,
the approach was to
describe the methods
according to indications (for
example, before and after
indications and then the
appropriate

stated indication.

handrub in seven
others.58,1150-

Overall, there is an
overlap between
stated indications
from different
documents. An
analysis of what was
stated in the
documents was
performed (Table
VI.2). Among the
indications before an
activity for routine
patient care,
performing invasive
procedures was the
most mentioned.
Among indications

1152,1156,1159,1160

for hand hygiene

after procedures
during routine
patient care, visible
soiling of hands,
and contact with
blood, body fluids,
wounds, catheter
methods) and, in others, the sites or drainage
indications for a given method sites were the most
(e.g. all indications requiring frequently
handrubbing) of hand
mentioned.
hygiene.
A few documents listed
Most guidelines advocated handsituations where hand
hygiene for a variety of, but
decontamination was
similar, before and after
not required.1147indications. Some documents 1149,1151,1156
The
advised that the decision for
situations included
hand hygiene and choice of
were before nursing
methods be based on risk
1162,1165 care or the physical
assessment by the HCW.
examination of nonMany guidelines also had
immunocompromised
umbrella indications that could
patients, before and
include many different situations
after short or social
for hand hygiene. These meant
contact with nonthat it was up to the HCW to
immunocompromised
decide whether hand hygiene
patients, and after
was required or not for
contact with surfaces
individual situations. The
not suspected of being
indications which were listed
contaminated.
were meant to be examples
and not to fulfil a complete
Handwashing was the
list, at least in some. There
standard for routine
were also differences in
patient care in
wording between documents
seven
which led to differences in
documents,1146,1148,1149,1155 ,
situations included under one 1157 ,1164 ,1165 and alcoholbased
201

Either
handwashing or
handrubbing were
recommended in
seven.1147,1153,1154,1158,11611163

Most guidelines,
especially sub-national,
provided details of the
procedures for hand
hygiene and the
analyses of their content
in this regard are
presented in Table VI.3.
Handwashing was
recommended in all
documents for soiled
hands. Handwashing
with medicated soap
was recommended as
an alternative.

Several strategies
were considered for
promotion and
implementation of the
guidelines. Here again,
details were more
developed in the subnational guidelines. In
most cases, strategies
recommended for
implementation and
sustainability were
based on multiple
elements. Ongoing
education of HCWs,
making materials
required for hand
hygiene easily
available
and accessible,
monitoring
performance, and
attention to the skin
care of HCWs were
stressed to be the
most important
aspects: at least nine
documents had
some reference to all
of
these four
issues.58,1148,1150,1151,1153,1158,1
160,1162,1164 One document

had only a general

discussion on various
issues impacting on

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

ed
mon
itori
ng
of
perf
orm
implement anc
ation, but
e by
without
an
clear
audi
recommen t of
1154
dations.
han
Details
d
provided in
hygi
various
documents ene,
with
were
analysed. dire
ct
obs
Regular
training was erva
considered tion
important in bein
15
g
the
58,114
guidelines,
6,1148,1150,1151,1153,1
154,1157met
1162,1164,1165 and
hod
some
information sug
on areas to gest
be covered ed
was provided in
in
mos
five.58,1153,1157, t
1160 ,1161

documents.58,1148,1

Reminders in 150,1151,1153,1158,1160,116
2,1164 Audit of
the workplace
product
were
consumpti
recommende on was
d by
mentioned
eight.58,1153,115 in
8,1160-1164
Wall- three58,1150
,1153
mounted
and
dispensers
tools for
for hand rub were audit were
recommended in provided
1158,1147,11511153,1155,1158,1160,11
62-1164

in

and pocket
three.58,115
dispensers in 3,1160
58,1151,1164
3.
Aspects of Feedback
to HCWs
skin care
was
were
mentioned

dealt with in 19
58,114 only in six
documents.
6-1148,1150-1156,11581165

N
in
e
d
o
c
u
m
e
nt
s
r
e
c
o
m
m
e
n
d

guidelines
.58,1148,1150,
1151,1158,1160

Two
document
s
suggested
the
possibility
of
administra
tive
actions in
the case
of noncomplianc
e with
hand
hygiene
recomme
ndations.1
153,1160

Outlines on
how to
choose a
hand
hygiene
product
were
available in
eight
documents.
58,11511153,1158,11601162

Roles
and
responsibiliti
es of
stakeholder
s were
considered
at least in a
very basic
manner in eight
documents.1146,1150
,1151,1153,1158,1160,1162,1
164

Ten guidelines
stressed the
need for active
HCW
involvement for
successful
implementation,58
,1146,1148,1150,1153,1157
,
1158 ,1160 ,1161 ,1162

and
four had
recommendatio
ns for patient
participation.58,1
160,1161,1164

Outlines for the

location of
handwashing
facilities were
provided
in
13. 11461149,1152,1153,1156,1158,11
Reference
to wider safety
issues
60-1164

were made in
four
documents.58,1
153,1158,1160

Detailed
information
on costing
or
cost
effectivenes
s was not
provided in
any
guideline.
Two
documents
included
very basic
information
on
this
aspect.1147,11
50

In summary,
although the
overall aim of
all the
documents
included in the

comparison of the gaps. This

was to give is the most
recommend extensively
referenced and
ations for
comprehensive
optimal
guidelines for
hand
hygiene
hand hygiene
practices, available to date.
there were These guidelines
wide
are for use by
variations in policy-makers,
the scope, managers, and
goals,
HCWs in different
content,
settings and
breadth, and geographical
depth of
areas. In many
topics
countries,
covered.
guideline-and
Lack of
policy-developers
uniformity in are already using
terminology these guidelines
further
as a resource for
compounde adaptation to
d analytical local needs and
differences.
logistics.
Many
documents
did not
Guidelines
adequately developed by
cover
the CDC in
several
200258 are
aspects,
also used as
especially a reference
those
internationall
essential for y. Both WHO
proper
and CDC
implementatiguidelines
on and
are
sustainabilit documents
y. Some of prepared
the
specifically to
recommend promote
ations were hand
hygiene.
such that
the HCW
had to make
decisions as
to when and
how to
perform
hand
hygiene.
The WHO
Guidelines on
Hand Hygiene
in Health Care
were
developed in
2005 as an
advanced
draft and have
been finalized
as the present
document in
2008. This
document has
taken on
board the
abovementioned
concerns and
bridged most

Both
documents
reviewed
evidence
extensively
and used a
similar grading
system. The
layout and the
issues
discussed are
also broadly
similar and
include a wide
variety of
topics related
to hand
hygiene While
the CDC
guidelines are
primarily
intended for
use in the USA
and other
Western
countries, the
WHO
guidelines
were
conceived in a
more global
perspective
and, therefore,
are not
targeted at
only
developing or
developed
countries, but
all countries
regardless of
the resources
available.
Another
general, but
essential,
difference of
approach is that
the present
WHO
Guidelines
have been
validated and
finalized after a
pilot test phase
using a specific
implementation
strategy in
different healthcare settings
worldwide.
Furthermore,
in the present
guidelines,
evidence has
been derived

from more
recent
studies,
details of
how the
evidence
was
collected
are
provided,
and the
recommen
dations are
based on
extensive
internation
al
consultatio
ns.
Although
the CDC
guidelines
were
constantly
considered
as a very
valuable
framework,
many
innovative
aspects of
hand
hygiene are
dealt with in
the present
WHO
guidelines.
For
example,
there are
sections on
mathematic
al modelling
to
understand
the
transmission
of
pathogens
in healthcare
settings,
local
production
of alcoholbased
handrubs,

religious and
cultural
aspects of
hand hygiene,
promotion of
hand hygiene
on a national
scale, and
social
marketing, and
including the
detailed
analyses of
guidelines
presented
here. More
details are also
provided on
behavioural
aspects,
infrastructure
required for
hand hygiene,
and safety
issues. The
WHO
guidelines are
therefore more
extensive.
Details of hand
hygiene
procedures
including
pictorial
representation
s are made
available in the
WHO
guidelines, and
more detailed
strategies for
promotion for
use in a wider
range of
settings are
also
discussed.
Both
documents
present
recommendati
ons and
indicate the
grading of
recommendati
ons. Most are

similar, but the

WHO
document (see
Part II) has a
few that are
not considered
in the CDC
document and
vice versa.
Recommendati
ons for
handling
medicines and
food, and a set
of
recommendati
ons for
national
governments
provided in the
WHO
guidelines are
examples. The
respective
strength for
some
recommendati
ons also differs
between the
two
documents.
Outcome
measurements
are considered
at great length
in the WHO
document.
Other aspects
such as the
promotion of
hand hygiene
on a large
scale and
providing
information to
the public are
also given due
importance in
these
guidelines.
CDC
guidelines
provide links to
other web sites
for further
reference.

202

Table VI.1
Grading of evidence used in
different guideline documents

Case-control
studies
Non-analytical
studies
Theoretical
rationale

USA*
IA
Randomised
controlled trials
Well-designed
studies
Suggestive
studies

IB

IC

Most experts
Mandated by
government
Unresolved
Issue

* CDC guidelines
** EPIC 2 guidelines

203

PART VI. COMPARISON OF NATIONAL AND SUB-NATIONAL GUIDELINES FOR HAND HYGIENE

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Table VI.2
Guidelines mentioning indications for hand hygiene before, after, and between activities

Before an activity

No. of guidelines

References

Performing invasive procedures

18

58,1146-1148,1150-1156,1158-1164

Any direct patient contact

16

58,1146,1148,1150-1154,1158-1165

Preparing, handling, serving or eating food, and feeding a patient

12

1148,1150-1153,1156,1158,1160-1165

Beginning of workshifts

11

1147,1149,1151,1153,1157,1158 ,1159,1161-1164

Care of particularly susceptible patients

10

1147-1149,1151-1154,1156,1158,1164

Contact with catheter sites and drainage sites

10

58,1146,1147,1150-1152,1156,1159,1163,1164

Eating

10

1146,1148,1149,1151,1153,1154,1157,1158,1163 ,1164

Patient contacts that may pose an infection risk to the patient

1147,1150-1156,1159,1164

Contact with wounds

1147,1151-1153,1156,1159,1161,1163

Using (any) gloves

58,1146,1149,1154,1160,1162,1163

Using sterile gloves for invasive procedures (not surgical)

58,1152-1154,1157,1163

Direct contact with patients who have antimicrobial-resistant organisms

1147,1151,1154,1156,1157,1163

Preparing and giving medication

1158,1160-1164

Handling of clean materials

1149,1152,1157,1164

Entering the clean part of staff changing rooms of operation areas,

sterilization department, or other aseptic areas

1152,1158

Use of computer keyboard

1158

Caring activities after risk assessment

1147

Injections or venepuncture

1146

Contact with blood, body fluids, wounds, catheter sites or drainage sites

16

58,1146-1149,1151,1152,1154,1156,1157,1159-1164

Visible soiling of hands

15

58,1147-1159,1162

Glove removal

14

58,1146-1148,1150-1154,1158,1160,1161,1163,1164

Personal body functions

14

58,1146-1149,1152,1153,1156-1158,1161-1164

Contact with infectious patients

13

58,1147-1149,1151-1154,1156,1158,1162-1164

Contact with wounds

11

58,1147-1149,1151-1153,1156,1159,1160,1162

Contact with patients intact skin

11

58,1150,1151,1153,1154,1156,1158,1160,1162-1164

End of work shift

1149,1151-1153,1157,1158,1161,1163,1164

Contact with inanimate objects in the immediate vicinity of the patient

58,1147,1151,1153,1158,1160,1162

Microbial contamination

1147,1148,1153,1156,1159

Suspected or proven exposure to spore-forming pathogens

58

Contact with items known or suspected to be contaminated

1161

Using computer keyboard

1158

Contact with different patients

1147-1151,1155-1157,1164

Moving from a contaminated to a clean body site of the same patient

58,1147,1148,1151,1153,1160,1164

Different caring activities on the same patient

1148,1151,1162,1164

Contact with different patients in high risk units

1147,1153,1164

After an activity

Between activities

204

PART VI. COMPARISON OF NATIONAL AND SUB-NATIONAL GUIDELINES FOR HAND HYGIENE

Table VI.3
Guidelines including specific recommendations regarding hand hygiene techniques
Routine (n=21)

Surgical (n=16)

Preparation
(removal of rings, bracelets, etc.)

19

13

Surfaces to be cleaned

18

10

Brushing technique

Handwashing

Handrubbing

Handwashing

Handrubbing

Recommended

21

19

16

Agent

Soap 21
Liquid (plain or
medicated) 20
Bar soap as
alternative 3

Gel 4
Other not specified

Medicated bar or
liquid soap

Number of documents where the following are mentioned

Quantity of product*

10

10

Duration

18 (1015 sec in
most)

13 (1530 sec)
Some until dry

15

Drying
Disposable/sterile towel

21
21

13
12

*Some other documents refer to the manufacturers recommendations.

205
WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

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APPENDICES

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Appendix 1.
Definitions of health-care settings
and other related terms
HEALTH SYSTEM: all the activities whose primary purpose is to promote, restore or maintain health
(The World Health Report 2000 Health systems: improving performance)

DEFINITIONS FROM THE WHO GLOSSARY OF TERMS

laboratories,
industry, etc.

(available at:
http://www.wpro.who.int/chips/chip04/definitions.htm)

qualifications to be
registered and/or legally
licensed to practise
midwifery, and are
actually working in the
country. The person
may or may not have
prior nursing education.

Health infrastructure

General hospital. A hospital that provides a

range of different services for patients of
various age groups and with varying disease
conditions.

Specialized hospital. A hospital admitting

primarily patients suffering from a specific
disease or affection of one system, or reserved
for the diagnosis and treatment of conditions
affecting a specific age group or of a long-term
nature.

District/first-level referral hospital. A hospital at

the first referral level that is responsible for a
district or a defined geographical area
containing a defined population and governed
by a politico-administrative organization such
as a district health management team. The role
of district hospitals in primary health care has
been expanded beyond being dominantly
curative and rehabilitative to include
promotional, preventive, and educational roles
as part of a primary health-care approach. The
district hospital has the following functions:

Nurses. All persons

who have completed a
programme of basic
nursing education and
are qualified and
registered or authorized
to provide responsible
and competent service
for the promotion of
health, prevention of
illness, the care of the
sick, and rehabilitation,
and are actually
working in the country.

Pharmacists. All
graduates of any
faculty or school of
pharmacy, actually
working in the
country in
pharmacies,
hospitals,

it is an important support for other health

services and for health care in general in
the district;
it provides wide-ranging technical
and administrative Inpatient. A
person who is formally admitted to a
health-care

support and education

for a defined1
population, with
their
full
participation, in
cooperation with
agencies in the
district that have
similar concerns.

1
Health workforce

Primary
healthcare
centre.
A
centre
that
provide

Physi
cians/
doctor
s. All

and
trainin
g for
prima
ry

healt
h
facilit
y and
who

s
service
s which
are
usually
the first
point of
contact
with a

gradu
ates
of any
facult

Dentists. All graduates

of any faculty or school
of dentistry, odontology
or
stomatology,
actually working in the
country in any dental
field.

Other health-care
providers (including
community health
workers). All workers
who respond to the
national definition of
health-care providers
and are neither
physicians/doctors,
midwives, nurses,
pharmacists, or
dentists.

is discharged after one or

more days. care;
it provides an effective, affordable
health-care service Outpatient. A

person who goes to a health-care

facility for a
health professional.
consultati
of
They include services
on, and
consultatio
provided by general
who
n. An
practitioners, dentists,
leaves the
outpatient
facility
is not
community nurses,
within
formally
pharmacists and
three
admitted
midwives, among
hours of
to the
others.

y or school of
medicine, actually
working in the
country in any

the start
me
dica
l
field

(pra
ctic
e,
teac

facility.
hing,
admini
stration
,

research,
laboratory, etc.).

2
240

Midwiv

es. All
person
s who

have completed a
programme
of
midwifery education

and
have
acqu

ired
the
requi

site

APPENDICES

DEFINITIONS FROM THE EUROPEAN OBSERVATORY ON HEALTH SYSTEMS AND POLICIES

(available at http://www.euro.who.int/observatory/Glossary/TopPage?phrase=D)

Ambulatory care. All types of health services provided to

patients who are not confined to an institutional bed as
inpatients during the time services are rendered (USAID,

1999). Ambulatory care delivered in institutions that also

deliver inpatient care is usually called outpatient care.
Ambulatory care services are provided in many settings
ranging from physicians offices to freestanding ambulatory
surgical facilities or cardiac catheterization centres. In some
applications, the term does not include emergency services
provided in tertiary hospitals (USAID, 1999).
Day care. Medical and paramedical services delivered to
patients who are formally admitted for diagnosis, treatment
or other types of health care with the intention of
discharging the patient the same day.
Long-term care. Long-term care encompasses a broad range of
help with daily activities that chronically disabled individuals
need for a prolonged period of time. Long-term care is primarily
concerned with maintaining or improving the ability of elderly
people with disabilities to function as independently as possible
for as long as possible; it also encompasses social and
environmental needs and is therefore broader than the medical
model that dominates acute care; it is primarily low-tech,
although it has become more complicated as elderly persons
with complex medical needs are discharged to, or remain in,
traditional long-term care settings, including their own homes;
services and housing are both essential to the development

of long-term care policy and systems. Nursing homes,

visiting nurses, home intravenous and other services
provided to chronically ill or disabled persons.
Social care. Services related to long-term inpatient care plus
community care services, such as day care centres and social
services for the chronically ill, the elderly and other groups with
special needs such as the mentally ill, mentally handicapped,
and the physically handicapped. The borderline between health
care and social care varies from country to country, especially
regarding social services which involve a significant, but not
dominant, health-care component such as, for example, longterm care for dependent older people.

24
1

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Appendix 2.
Guide to appropriate hand hygiene in connection
with Clostridium difficile spread
Hand hygiene and infection control
Hand hygiene is a crucial action recommended for preventing
and controlling the transmission of pathogens within health-care
settings to ensure that patients remain safe and that their risks of
acquiring infection are minimized. Hand hygiene is
an essential practice for all health-care workers (physicians/
doctors, midwives, nurses, pharmacists, dentists, and other care
providers including community health workers and family
members) in order to protect the patients and themselves.

The method employed in ensuring that hand hygiene is

effective falls into one of two categories:

Handrubbing with an alcohol-based handrub

Handrubbing is the gold standard technique to perform hand
hygiene on all occasions except for those described for
handwashing with soap and water, i.e. handrubbing is the
action recommended for health-care workers for the routine,
day-to-day decontamination of hands.

when exposure to potential

spore-forming pathogens
is strongly suspected or
proven, including during
outbreaks of

C. difficile.

What is Clostridium
difficile?
Background information on
C. difficile is available from
a range of scientific and
patient support documents.
The following information is
an overview of what C.
difficile is and the problems
it can cause.

C. difficile is a bacterium
(germ) that is present
naturally in the bowel of
2 Handwashing with soap and water:
some individuals. It can
Handwashing still occupies a central place in hand hygiene
spread by touching
and should be employed when hands are visibly dirty or
faecally contaminated
visibly soiled with blood or other body fluids; after using the
surfaces and then touching
toilet; and when exposure to potential spore-forming
your mouth, e.g. when
pathogens is strongly suspected or proven, including during
eating. It can also spread
outbreaks of diarrhoea.
following contact with the
faeces of people who have
the infection, if the
Correct method at the correct moment
bacterium is ingested
through your mouth.
Understanding and employing the correct method and
technique at the correct moment is highly likely to result in
If someone is taking
optimum compliance with hand hygiene and maximum safety
antibiotics to treat an
of patients and staff.
infection, they can kill the
good bacteria living in the
The advantages and disadvantages of both alcohol-based
bowel as well as the bad;
handrubs and handwashing with soap and water can be found
when this happens C.
throughout the WHO Guidelines on Hand Hygiene in Health
difficile can grow quickly in
Care. The following information is intended to support healththe bowel and produce
care workers and others in understanding and explaining the
toxins that lead to disease.
challenges presented by patients with C. difficile infection,
C. difficile is passed out in
particularly in relation to hand hygiene.
the faeces of people who
are infected, including in the
form of spores (a hardy form
Specific challenges posed by patients with
of the bacterium), which can
diarrhoeal illnesses
survive for a long time in
patient surroundings on any
Preventing and controlling the spread of all diarrhoea-related
surface, e.g. toilet areas,
bacteria, viruses, and parasites is always important. One of the
clothing, sheets, and
main actions in this regard is to ensure that hands are washed
furniture, if these items are
thoroughly with soap and water when they are:
not regularly and
visibly dirty or visibly soiled with blood or other body fluids; appropriately cleansed. It is
after using the toilet;
possible

for anyone to spread the

infection (to themselves or
others) because they have not
performed hand hygiene
properly or kept patient
surroundings clean. Elderly
people and patients with
comorbidities or who have had
certain medical procedures to
the bowel are especially at risk
of getting C. difficile infection.

Why have there been

increasing numbers of
cases in certain countries
recently?
This is not entirely clear,
though it is known that a
number of factors may be
responsible, including natural
changes to the way in which
bacteria act in relation to
their circumstances; for
example, C. difficile
becoming more resistant to
antibiotics in response to
their increased and more
widespread use. The growing
numbers of elderly, sick
patients receiving care, the
pressures on health-care
workers to deliver care, and
the way in which services
such as cleaning are
provided to health-care
settings may all have had an
impact. New strains of C.
difficile
have evolved in recent years
that appear to spread more
readily and may cause more
severe cases of illness. It is
also possible that the
recommended practices for
preventing and controlling C.
difficile are not always applied
for a number of reasons and
may, as a result, be
contributing to the current
problem. Finally, in some
countries where there has
been no surveillance of C.
difficile until now, reports of
rising numbers may be
explained because they are
now looking for it.

242

APPENDICES

o
l
C
l
o
s
Ct
ar
ni
d
ai
pu
pm
r
od
pi
rf
if
ai
tc
ei
l
ie
n?
f
eYe
cs,
t th
i ey
oca
nn.
It

cis
ore
nco
tm
rm
oen
l de
d

pth
r at
aglo
cve
ts
i be
cwo
ern
s(to
ge

hth
eer
l wit
ph
go

pwn
r an
ed
vap
epli
ncat
t ion
of

aot
nhe
dr
co

cnt
oact
npr
t ec
r au

tio
ns
)
an
d
ha
nd
s
wa
sh
ed
ap
pr
op
ria
tel
y if
ex
po
su
re
to
po
te
nti
al
sp
or
efor
mi
ng
pa
th
og
en
s
is
str
on
gly
su
sp
ec
te
d
or
pr
ov
en
,
inc
lu
di
ng
C.
dif
fici
le
ou
tbr
ea
ks.
Th
e
m
et
ho
d
of
ha
nd
hy

ges
i ha
eve
nbe
een
wo
t rn,
oha
nd
bwa
eshi
ng
eis
mes
pse
l nti
oal.
yOf
enot
de,
it
mis
uim
spor
t tan
bt
etha
t
hthe
acor
nrec
dt
wtec
ahni
squ
he
i for
nha
gnd
wa
ushi
sng
i is
nap
gpli
ed.
sIn
oall
aoth
per
he
aalt
nhdcar
e
wsit
auat
t ion
es,
r alc
. oh
Eolvba
ese
nd
ha
wndr
hub
es
nre
gma
l in
othe
vpre

fer
re
d
me
tho
d
for
ha
nd
hy
gie
ne
an
d
the
mo
st
reli
abl
e
me
tho
d
to
en
sur
e
ma
xi
mu
m
co
mp
lia
nc
e
an
d
effi
ca
cy

t
o
r
e
d
u
c
e
h
e
a
l
t
h
c
a
r
e
a
s
s
o
c
i
a
t
e
d

i
n
f
e
c
t
i
oW
nh
sa

a
n
d
r
u
b
s

a
ni
ds

t
h
e

ct
rh
oe
s
sc
-o
tn
rc
ae
nr
sn
m
ia
sb
so
iu
ot
n

p
o
i
n
t

oe
fa

p
a
t
i
e
n
t
s

h
l

pt
ah
thc
oa
gr
ee
n
sw
.o

r
k
e
r
s
u
s
i
n
g
a
l
c
o
h
o
l
b
a
s
e
d
h

a
t

o
f
c
a
r
e
w
h
e
n

h
a
v
e
C
l
o
s
t
r
i
d
i
u
m
d
i
f
f
i
c
i
l
e
?
T
he

r ve
eon
so
i ile
sd
ha
cnd
os
nge
cne
eral
r ly
nan
d,
bsp
eec
cifi
aca
ully,
sw
ehe
n
ath
l er
ce
ois
hC.
odif
l fic
- ile
binf
aec
stio
en.
dT
hi
hs
ais
nbe
dca
r us
ue
bof
sth
e
aha
r nd
eru
bs
k
nin
oab
wilit
ny
to
t kil
ol
th
be
eC.
dif
l fic
eile
ssp
sor
es
eth
f at
f at
eti
cm
t es
i ca

n
be
pr
es
en
t.
Co
nv
eyi
ng
si
mp
le
me
ss
ag
es
to
he
alt
hcar
e
wo
rke
rs,
thr
ou
gh
ro
uti
ne
trai
nin
g
an
d
up
dat
es,
an
d
rei
nfo
rci
ng
the
se
du
rin
g
tim
es
of
out
br
ea
ks
will
hel
p
to
en
sur
e
tha
t
the
cor
rec
t

mien
ee
t are
hap
opli
ded
sat
the
f cor
orec
rt
hmo
ame
nnts
d.
To
hsu
ym
gup,

t
h

a
l
l
R
op
ua
tt
ii
ne
en
t
s
m
e
ta
ht
o
da
l
fl
o
rt
i
hm
ee
as
l,
t
hw
-i
ct
ah
r
et
h
we
o
re
kx
ec
re
sp
t
di
eo
an
l
io
nf
g:
v
w
i
is

the
se
me
ss
ag
es
ar
e
re
pe
ate
d
in
the
dia
gr
am
.

iy
b
l
ya
dw
i
r
t
y
o
r
v
i
s
i
b
l
y
s
o
i
l
e
d
h
a
n
d
s
(
w
i
t
h
b
l
o
o
d
o
r
o
t
h
e
r
b
o
d

fo
iu
cn
id
li
en
g
(s
d
i(
aa
rn
rd
h
ow
ee
aa
)r
u
sa
e
g
go
lw
on
v
ea
ss
fp
oa
rr
t
a
lo
lf
cc
oo
nn
tt
aa
cc
tt
s
p
wr
ie
tc
ha
u
pt
ai
to
in
es
n)
t
sw
h
ae
nn
d
h
ta
hn
ed
is
r
a
sr
ue
r
rv

i
st
iw
b
l
y
d
i
r
t
y
o
r
v
i
s
i
b
l
y
s
o
i
l
e
d
w
i
t
h
b
l
o
o
d
o
r
o
t
h
e
r
b
o
d
y
f
l
u
i
d
s
a
f
t
e
r
u
s
i
n
g

a
n
d
R
w
U
a
Bt
e
(r
u)
s
e
a
n
a
l
c
o
h
o
l
b
a
s
e
d
h
a
n
d
r
u
b
)

W
A
S
H
(
u
s
e
s
o
a
p

2
4
3
W
HO
GU
ID
ELI
NE
S
ON
HA
ND
HY
GI
EN
E
IN
HE
AL
TH
CA
RE

S
h
o
u
l
d
w
e
r
e
m
o
v
e
a
l
c
o
h
o
lb
a
s
e
d
h
a
n
d
r
u
b
s
fr
o
m
a
r
e
a
s
w
h
e
r
e

t
h
e
r
e
is
C
l
o
s
tr
i
d
i
u
m
d
if
fi
c
il
e
i
n
f
e
c
ti
o
n
?
N
o
.
A
l
c
o
h
o
l
b
a
s
e
d
h
a
n
d
r
u
b
s
a
r
e
r
e
q
u
i
r

e
d
a
t
t
h
e
p
o
i
n
t
o
f
c
a
r
e
f
o
r
a
n
u
m
b
e
r
o
f
r
e
a
s
o
n
s
:

T
h
e
y
a
r
e
e
a
s
y
t
o
u
s
e
a
n
d
t
h
e
r
e
f

o
r
e
m
o
r
e
l
i
k
e
l
y
t
o
r
e
s
u
l
t
i
n
g
r
e
a
t
e
r
c
o
m
p
l
i
a
n
c
e
w
i
t
h
t
h
e
n
e
e
d
f
o
r
h
a
n
d
h
y

g
i
e
n
e
b
y
h
e
a
l
t
h
c
a
r
e
w
o
r
k
e
r
s
.

T
h
e
y
a
r
e
p
r
o
v
e
n
t
o
b
e
e
f
f
e
c
t
i
v
e
i
n
k
i
l
l
i
n

g
a
r
a
n
g
e
o
f
p
a
t
h
o
g
e
n
s
a
n
d
t
h
e
r
e
f
o
r
e
r
e
d
u
c
i
n
g
p
a
t
i
e
n
t
s

r
i
s
k
o
f
a
c
q
u
i
r
i
n

en
t
in
hi
gh
er
nu
m
be
rs
th
an
th
e
sp
or
es
.

h
e
a
l
t
h
c
a
r
e
a
s
s
o
c
i
a
t
e
d
i
n
f
e
c
t
i
o
n
.

Th
ey
ar
e
eff
ec
tiv
e
in
kill
in
g
th
e
no
nsp
or
e
for
m
of
C.
dif
fic
ile
w
hi
ch
m
ay
be
pr
es

Si
nk
s
for
ha
nd
w
as
hi
ng
ar
e
no
t
al
w
ay
s
re
ad
ily
av
ail
ab
le
an
d,
ev
en
if
th
ey
w
er
e
m
ad
e
av
ail
ab
le
rig
ht
ne
xt
to
a
pa
tie
nt,
w
as

hi
ng
ta
ke
s
at
le
as
t
tw
ic
e
as
m
uc
h
ti
m
e
th
an
ru
bb
in
g

all
fa
ct
or
s
th
at
mi
tig
at
e
ag
ai
ns
t
ful
l
co
m
pli
an
ce
wi
th
ha
nd
hy
gi
en
e.
R
el
yi
ng
on
pr
o
m
oti
ng
ha
nd
w
as
hi
ng
on

ly
in
he
alt
h
ca
re
is
th
ou
gh
t
to
re
su
lt
in
lo
w
er
co
m
pli
an
ce
,
lo
w
er
eff
ic
ac
y
an
d
gr
ea
ter
ris
k
of
co
nti
nu
ed
sp
re
ad
of
pa
th
og
en
s.

E
vi
d
e
n
c
eb
a
s
e
d
re
s
e
ar
c
h

r
ei
nf
o
rc
e
s
th
e
n
e
e
d
fo
r
th
e
p
r
e
s
e
n
c
e
of
al
c
o
h
ol
b
a
s
e
d
h
a
n
d
r
u
b
s
to
e
n
s
u
r
e
m
a
xi
m
u
m
p
at
ie
nt
s
af
et
y.

T
h
e
r
e

i
s
n
o
e
v
i
d
e
n
c
e
t
o
s
u
g
g
e
s
t
t
h
a
t
t
h
e
i
r
u
s
e
h
a
s
b
e
e
n
c
o
n
n
e
c
t
e
d
w
i
t
h
i
n
c
r
e
a
s
e
d

C
.
d
i
f
f
i
c
i
l
e
i
n
f
e
c
t
i
o
n
s
.

T
h
u
s
,
a
l
c
o
h
o
l
b
a
s
e
d

o
v
e
d
f
r
o
m
h
e
a
l
t
h
c
a
r
e
s
e
t
t
i
n
g
s
;
t
o
r
e
m
o
v
e
t
h
e
m

h
a
n
d
r
u
b
s

w
o
u
l
d

s
h
o
u
l
d

l
i
k
e
l
y

N
O
T

t
o

b
e
r
e
m

b
e

r
e
s
u
l
t

i
n
g
r
e
a
t
e
r
r
i
s
k
t
o
p
a
t
i
e
n
t
s
f
r
o
m
h
e
a
l
t
h
c
a
r
e
a
s
s
o
c
i
a
t
e
d
i
n
f
e
c
t
i
o
n
s
.

A
r
e

v
i
s
i
b
l
y
c
l
e
a
n
(
n
o
t
s
o
i
l
e
d
)
h
a
n
d
s
s
t
i
l
l
a
t
r
i
s
k
f
o
r
c
r
o
s
s
t
r
a
n
s
m
i
s
s
i
o
n
?
It
is

ve
ry
u
nli
ke
ly.
B
ec
a
us
e
h
a
n
d
w
as
hi
n
g
wi
th
so
a
p
a
n
d
w
at
er
is
re
co
m
m
e
n
d
e
d
w
h
e
n
ex
p
os
ur
e
to
p
ot
e
nti
al
sp
or
efo
r
mi
n
g
p
at
h
o
g
e
ns
is
st

ro
ng
ly
su
sp
ec
te
d
or
pr
ov
en
(t
hi
s
in
cl
ud
es
ou
tb
re
ak
s
of
C.
dif
fic
ile
),
it
is
ve
ry
un
lik
el
y
th
at
us
in
g
al
co
ho
lba
se
d
ha
nd
ru
bs
on
vi
si
bl
y
cl
ea
n
ha
nd
s
wi
ll
pu
t
pa
tie
nt
s

at
ris
k
of
cr
os
sinf
ec
tio
n.
In
fa
ct
al
co
h
ol
b
as
e
d
h
a
n
dr
u
bs
ar
e
eff
ec
tiv
e
in
kil
lin
g
th
e
n
o
nsp
or
e
fo
r
m
of
C.
di
ffi
cil
e
th
at
ca
n
al
so
b
e
pr
es
e
nt
.
T
h
er
ef

or
e,
ap
po
pri
at
e
gl
ov
e
us
e
an
d
ad
op
tin
g
eit
he
r
m
ea
ns
of
pe
rf
or
mi
ng
ha
nd
hy
gi
en
e
on
no
nso
ile
d
ha
nd
s
wi
ll
en
su
re
cl
ea
n,
sa
fe
ha
nd
s.
T
h
e
b
ot
to
m
lin
e
is
to
re
m
e

m
b
er
th
e
m
e
ss
a
g
e
th
at
h
a
n
d
s
s
h
o
ul
d
b
e
w
a
s
h
e
d
th
or
o
u
g
hl
y
wi
th
s
o
a
p
a
n
d
w
at
er
w
h
e
n
th
e
y
ar
e
vi
si
bl
y
di
rt
y
or
vi
si
bl
y
s

oil
e
d
wi
th
bl
o
o
d
or
ot
h
er
b
o
dy
flu
id
s.

H
o
w
of
te
n
wi
ll
th
e
s
p
or
e
s
b
e
pr
e
s
e
nt
w
h
e
n
p
at
ie
nt
s
h
a
v
e
Cl
o
st
ri
di
u
m
di
ffi
cil
e
in
fe
cti
o
n
?

W
h
e
n
p
a
t
i
e
n
t
s
w
i
t
h
C
.
d
i
f
f
i
c
i
l
e
h
a
v
e
s
e
v
e
r
e
d
i
a
r
r
h
o
e
a
,
l
a
r
g
e
a
m
o
u
n
t
s
o
f

s
p
o
r
e
s
c
a
n
b
e
p
r
e
s
e
n
t
.
T
h
i
s
i
s
t
h
e
b
a
s
i
s
o
f
a
l
l
t
h
e
r
e
c
o
m
m
e
n
d
a
t
i
o
n
s
f
e
a

t
u
r
e
d
h
e
r
e
.
T
h
i
s
i
s
a
l
s
o
t
r
u
e
o
f
s
p
e
c
i
f
i
c

s
tr
a
i
n
s
o
f
C
.
d
if
fi
c
il
e
,
i
n
cl
u
d
i
n
g
t
h
o
s
e
t
h
a
t
a
r
e
e
p
i
d
e
m
ic
i
n
c
e
rt
a
i
n
c
o
u
n
tr
i
e
s
.
E
ff
e
c
ti

v
e
h
a
n
d
h
y
g
i
e
n
e
a
t
t
h
e
p
o
i
n
t
o
f
c
a
r
e
,
t
o
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e
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h
e
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w
it
h
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t
h
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r
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ll
a
c
c
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p
t
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d
c
o
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tr
o
l
m
e
a
s
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r
e
s

(i
n
p
a
rt
ic
u
l
a
r,
g
l
o
v
e
u
s
e
a
n
d
g
o
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n
i
n
g
a
s
p
a
rt
o
f
c
o
n
t
a
c
t
p
r
e
c
a
u
ti
o
n
s
,
a
n
d
i
n
d
iv
i
d
u
a
l
r
o
o
m
s
),
h

e
l
p
s
t
o
m
a
n
a
g
e
t
h
e
p
r
o
b
l
e
m
.

C
l
o
s
t
r
i
d
i
u
m
d
i
f
f
i
c
i
l
e
f
i
g
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r
e
s
a
r
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v
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h
i
g
h
i
s
s

o
m
e
c
o
u
n
t
r
i
e
s
,
a
n
d
s
e
e
m
t
o
h
a
v
e
b
e
c
o
m
e
w
o
r
s
e
.
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s
t
h
i
s
b
e
c
a
u
s
e
o
f
a
l
c
o
h
o
l
b

a
s
e
d
h
a
n
d
r
u
b
s
?
T
h
e
r
e
i
s
p
u
b
l
i
s
h
e
d
e
v
i
d
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n
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e
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t
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n
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u
s
e
o
f
a
l
c
o

h
o
l
b
a
s
e
d
h
a
n
d
r
u
b
s
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n
h
o
s
p
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t
a
l
s
h
a
s
n
o
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e
d
t
o
a
n
i
n
c
r
e
a
s
e
i
n
C
.
d
i
f
f
i
c
i
l

e
.

D
o
e
s
th
e
pr
o
m
ot
io
n
of
al
c
o
h
ol
b
a
s
e
d
h
a
n
dr
u
b
s
i
m
pl
y
th
e
d
o
w
n
gr
a
di
n
g
of
si
n
k
s
a
n
d
h
a
n
d
w
a
s
hi
n
g
?
N
o
.
G

u
i
d
a
n
c
e
u
s
u
a
ll
y
h
i
g
h
li
g
h
t
s
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f
a
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t
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a
t
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n
d
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s
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i
n
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is
e
s
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e
n
ti
a
l
i
n
s
p
e
ci
fi
c
si
t
u
a
ti
o
n
s
(
a
s
d

e
s
c
ri
b
e
d
a
b
o
v
e
).
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lt
h
o
u
g
h
w
a
s
h
i
n
g
h
a
n
d
s
w
it
h
s
o
a
p
a
n
d
w
a
t
e
r
r
e
m
a
i
n
s
a
n
a
c
c
e
p
t
e
d
m
e
t
h
o
d
f
o
r

r
o
u
ti
n
e
h
a
n
d
a
n
ti
s
e
p
si
s
,
a
lc
o
h
o
lb
a
s
e
d
h
a
n
d
r
u
b
s
s
h
o
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l
d
b
e
p
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m
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e
d
a
s
t
h
e
g
o
l
d
s
t
a
n
d
a
r
d
f
o

r
h
a
n
d
h
y
g
i
e
n
e
c
o
n
s
i
d
e
ri
n
g
,
i
n
p
a
rt
i
c
u
l
a
r,
t
h
e
ir
d
r
a
m
a
ti
c
i
m
p
a
c
t
o
n
i
m
p
r
o
v
i
n
g
c
o
m
p
li
a
n
c
e
w
it

h
h
a
n
d
h
y
g
i
e
n
e
a
n
d
e
n
s
u
ri
n
g
cl
e
a
n
,
s
a
f
e
h
a
n
d
s
.

W
ha
t
ot
he
r
ke
y
m
ea
su
re
s
sh
ou
ld
be
ta
ke
n
to
pr
ev
en
t
an
d
co
nt
rol
Cl
o
st
ri

di
u
m
di
ffi
cil
e
?
Th
er
e
ar
e
se
ve
ral
m
ea
su
re
s,
in
cl
ud
in
g
pe
rfo
rm
in
g
ha
nd
hy
gi
en
e,
th
at
sh
ou
ld
be
ap
pli
ed
to
pr
ev
en
t
an
d
co
ntr
ol
C.
dif
fic
ile
inf
ec
tio
n,
an
d
th
es
e
ha
ve
be

en
pu
bli
sh
ed
wi
de
ly.
Th
e
fol
lo
wi
ng
is
a
bri
ef
de
sc
rip
tio
n
of
th
es
e
ke
y
st
ep
s,
w
hi
ch
sh
ou
ld
be
in
pl
ac
e
w
he
n
C.
dif
fic
ile
inf
ec
tio
n
is
pr
es
en
t.

A
n
ti
m
i
c
r
o
b
i
a
l
p

r
e
s
c
r
i
b
i
n
g
i
s
a
c
r
u
c
i
a
l
p
a
r
t
o
f
p
r
e
v
e
n
t
i
n
g
,
c
o
n
t
r
o
ll
i
n
g
a
n
d
m
a
n
a
g
i
n
g
C
.
d
i
f
f
i
c
i

l
e
i
n
f
e
c
ti
o
n
.
G
u
i
d
a
n
c
e
i
s
w
i
d
e
l
y
a
v
a
il
a
b
l
e
o
n
t
h
i
s
.
A
n
ti
b
i
o
ti
c
s
t
e
w
a
r
d
s
h
i
p
i
s
t
h
e
r
e

f
o
r
e
a
n
i
m
p
o
r
t
a
n
t
p
a
r
t
o
f
h
e
a
l
t
h
c
a
r
e
s
e
r
v
i
c
e
s
t
o
c
o
n
t
r
o
l
C
.
d
i
f
f
i
c
i
l
e
,
a
s
i
s
t

h
e
a
p
p
r
o
p
r
i
a
t
e
p
r
e
s
c
r
i
b
i
n
g
o
f
o
t
h
e
r
d
r
u
g
s
i
n
c
l
u
d
i
n
g
a
n
t
a
c
i
d
s
a
n
d
p
e
r
h
a
p
s
p
r
o
t
o

n
p
u
m
p
i
n
h
i
b
i
t
o
r
s
.

P
ati
en
ts
wi
th,
or
str
on
gl
y
su
sp
ec
te
d
of
ha
vi
ng
,
C.
dif
fic
ile
inf
ec
tio
n
sh
ou
ld
be
ca
re
d
fo
r
in
a
si
ng
le
ro
o
m
wi
th
a
toi
let
or
de
di

ca
te
d
co
m
m
od
e
an
d
ot
he
r
de
di
ca
te
d
ca
re
eq
ui
p
m
en
t
un
til
th
ey
ar
e
sy
m
pt
o
mfre
e
for
at
le
as
t
48
ho
ur
s.
If
si
ng
le
ro
o
m
s
ar
e
no
t
av
ail
ab
le,
co
ho
rti
ng
of
pa
tie
nt
s

wi
th
C.
dif
fic
ile
inf
ec
tio
n
sh
ou
ld
be
co
ns
id
er
ed
in
co
nj
un
cti
on
wi
th
ris
k
as
se
ss
m
en
t
an
d
inf
ec
tio
n
co
nt
rol
ex
pe
rti
se
.

P
a
ti
e
n
t
s
w
it
h
C
.
d
if
fi
c
il
e
i
n
f
e
c

ti
o
n
s
h
o
u
l
d
h
a
v
e
t
h
e
ir
s
u
rr
o
u
n
d
i
n
g
s
a
n
d
o
t
h
e
r
a
r
e
a
s
o
f
c
o
n
c
e
r
n
,
e
.
g
.
t
o
il
e
t
a
r
e
a
s
,
c
l
e
a
n
e
d

a
t
l
e
a
s
t
d
a
il
y
u
s
i
n
g
c
l
e
a
n
e
q
u
i
p
m
e
n
t
a
n
d
a
fr
e
s
h
l
y
m
a
d
e
s
o
l
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ti
o
n
c
o
n
t
a
i
n
i
n
g
a
t
l
e
a
s
t
1
0
0
0

p
p
m
a
v
a
il
a
b
l
e
c
h
l
o
ri
n
e
(t
h
i
s
c
a
n
b
e
d
o
n
e
b
y
c
l
e
a
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a
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a

b
l
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a

c
h

t
o
c
l
e
a
n
a
ft
e
r
w
a
r
d
s
o
r
b
y
u
s
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a
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o
m
b
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d
d
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t
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t
a
n
d
c
h
l
o
ri
n
e
b
a
s
e
d
s
o
l
u
ti
o
n
).
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s
h

o
u
l
d
b
e
n
o
t
e
d
t
h
a
t
n
o
n
c
h
l
o
ri
n
e
b
a
s
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d
c
l
e
a
n
i
n
g
a
g
e
n
t
s
c
a
n
p
r
o
m
o
t
e
t
h
e
f
o
r
m
a
ti
o
n
o
f
C
.
d
if

fi
c
il
e
s
p
o
r
e
s
.
A
ir
d
r
y
i
n
g
s
h
o
u
l
d

b
e
a
ll
o
w
e
d
f
o
ll
o
w
i
n
g
c
l
e
a
n
i
n
g
.
24 4

APPENDICES

c
a
r
e

f
o
Hr
e
ap
la
tt
hi
-e
cn
at
rs
e
w
wi
ot
rh
k
eC
r.
s
d
si
hf
of
ui
lc
di
l
we
e
aa
rn
d
g
ls
oh
vo
eu
sl
d
a
nd
di
s
ac
pa
rr
od
n
st
h
we
hm
e
ni
m
pm
re
od
vi
ia
dt
ie
nl
gy

a
f
t
e
r
t
h
e
y
h
a
v
e
b
e
e
n
w
o
r
n
f
o
r
a
p
a
t
i
e
n
t
c
a
r
e
a
c
t
i
v
i
t
y
.
H
a
n
d
h
y
g
i
e
n
e
m
u
s
t

e
td
hu
ec
ne
s
b
eC
.
p
ed
ri
ff
of
ri
mc
ei
dl
.e
Ti
hn
ef
re
ec
t
ii
so
n
e
va
in
dd
e
ni
cs
e
t
th
he
ar
te
f
wo
er
ae
r
ic
nr
gu
c
gi
la
ol
v,
e
se
v
se
in
g
nt
ih
fo
iu
cg
ah
n
th
la
yn
d
rw

a
s
h
i
n
g
r
e
d
u
c
e
s
s
p
o
r
e
s
a
n
d
a
l
c
o
h
o
l
b
a
s
e
d
h
a
n
d
r
u
b
s
a
r
e
e
f
f
e
c
t
i
v
e
a
g
a
i
n
s
t
n
o

nb
-e
sd
p
li
o
n
r
e
en

fe
ot
rc
m.
s
ob
fo
t
Ch
.

i
n
d
i
h
f
e
f
a
i
l
c
t
i
h
l
e
c
.
a
r
e

W
s
a
se
ht
it
ni
gn
g

os
f
c
u
l
os
ti
hn
ig
n
gi
n
(
d
i
nu
cs
lt
ur
di
ia
nl

s
tr
ao
fc
fe
us
ns
ie
fs
o
r
ma
sn
)d
,

i
n
t
h
e
h
o
m
e

i
s
a
l
s
o
i
m
p
o
r
t
a
n
t
w
h
e
n
s
o
m
e
o
n
e
h
a
s
C
.
d
i
f
f
i
c
i
l
e
i
n
f
e
c
t
i
o
n
.
C

ae
r
es
fp
ur
le

n
s
i
d
e
r

a
hd
a
no
df
la
in
ny
go

f
o
r
l
a
u
n
d
e
r
i
n
g

f
ot
fh

e
c
ob
na
tc
at
me
ir
ni
aa
t
eo
dr

it
cs
ls
op
to
hr
ie
ns
gt
o

i
n
c
l
u
d
e
:

h
o
l
d

i
sh

l
a
u
n
d
r
y

en
sd
ss
eo
nr
to
it
ah
le

a
w
a
y
f
r
o
m

ir
nit

e
om
rs
d.
eK
re
ty
op
o
pi
rn
et
vs
et
no
t
tc
ho

a
l
w
a
y
s

y
o
u
r
s
e
l
f
;

d
o
n
o
t

r
sf
oo
rr
tm

h
t
a
h
n
rd
oh
uy
gg
hi
e
ln
ae
ua
nft
de
r
r
h
y
a
n
ud
nli
ln
eg
sl
sa
u
an
bd
sr
y
o
;
l
u
tu
es
le
yn
o
r
nm
ea
cl
ed
se
st
ae
rr
yg
e
an
nt
t
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45

a
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WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Appendix 3.
Hand and skin self-assessment tool
Rate the current condition of the skin on your hands on a scale of 17
Appearance
Abnormal:
red, blotchy, rash

Normal:
no redness, blotching, or rash

Completely intact:
no abrasions or fissures

Normal amount of moisture

No itching, burning, or soreness

Intactness
Many abrasions
or fissures
Moisture content
Extremely dry
Sensation
Extreme itching,
burning, or soreness

Sources: adapted from Larson E et al. Physiologic and microbiologic changes in skin related to frequent handwashing. Infection Control,
1986, 7:59-63 and Larson E et al. Prevalence and correlates of skin damage on the hands of nurses. Heart & Lung, 1997, 26:404-412.

246

APPENDICES

Appendix 4.
Monitoring hand hygiene by direct methods
The power calculations detailed in Part III, Section 1.1 of the WHO Guidelines for Hand Hygiene in Health Care are
critical for obtaining reliable estimates of the percentage of hand hygiene compliance at the organization level at a
single point in time. The objective of these calculations is to determine the sample size necessary to produce
results that can be generalized to larger populations and can meet the defined degree of confidence and margin of
error. These considerations are similar to those involved in conducting point-in-time research. Examples of this
approach can be found in political polling, market research, and educational testing. When measurements are
made in the context of an improvement initiative, however, the research questions and approaches to sampling are
different. An improvement team is typically interested in answering the following questions: (1) are we making
progress toward a goal of increased hand hygiene compliance? and (2) how will we know when we have reached
the goal?
them around. Without looking
at the pieces of paper, reach
into the bowl and select one
piece of paper. If the number
7 was on this piece of paper
then Clinic 7 would be the one
that you have randomly
selected to be the pilot clinic
for our hand hygiene test.
Once a unit of analysis has
been selected, you will need
to make decisions on two key
concepts related to
improvement studies: (1) the
number of data points needed
to represent accurately the
variation in the process and
In the case of improving hand hygiene, the improvement goal
typically is to bring compliance (i.e. the percentage of fulfilled hand (2) the number
hygiene opportunities) above 95% by introducing systems
of observations
improvements, behavioural incentives, education, and other
included in each data
interventions described elsewhere in these guidelines. The
point. Both of these
concepts are briefly
challenge for improvers, therefore, is to determine if progress is
being made towards the target, and when it has been reached. In described below.
order to judge the effects of the interventions, baseline measures
Whether you are using
should be taken on the units where improvement work is under
judgement sampling based
way; then performance over time can be compared with the
on your knowledge of the
baseline and the desired target or goal.
unit(s) of analysis or simple
Sampling strategies for tracking improvement initiatives draw from random sampling where all
units of analysis have an
both probability and non-probability sampling techniques. For
equal probability of being
ministries of health or other agencies that are interested
selected, you should try to
in gauging the impact of an initiative in a region, a province or a
obtain around 20 data points
health system, it may be desirable or necessary to start the work
(or subgroups) before
and track progress in a small sample of institutions or settings.
analysing the variation in the
For example, imagine that you have 12 clinics spread out across
process. The general
a region. Rather than collecting detailed data at all 12 clinics
assumption behind this
every day you might want to select one clinic to pilot test a new
strategy for hand hygiene compliance. You could select a clinic to guidance is that a relatively
stable distribution of the
be the pilot, based on your knowledge of the
results starts to form when
clinics (e.g. Clinic 4 has experience with improvement work and
you have 1525 data
would be more receptive to trying a new project related to hand
points.4-6 When you have
hygiene compliance). This is what Deming characterized as
fewer than 15 data points the
judgement sampling.3 Another approach would be to randomly
select one of the clinics to be the pilot. To do this you would write variation in the process has a
the numbers 112 on separate pieces of paper (it is best to use the tendency to be quite volatile
and the probability of
same size of paper) place them in a bowl and stir
improperly representing the
current variation due to a
type I or type II error
Studies aimed at improvement, known as analytical studies, 1
seek only enough data, collected repeatedly at suitable
intervals, to detect and track the effectiveness or efficiency of
improvement efforts over time. The requirements for data
collection and inference under such circumstances are different
from those required by clinical or population research aimed at
answering questions about efficacy.2 For instance, you do not need
a valid scale to monitor weight loss, only a consistent one. It does
not matter if the scale reads a few pounds too light or too heavy; as
long as the readings are reasonably consistent: you can
successfully track your progress over time, and you will know when
you have lost that extra 10 pounds because your daily readings will
hover around the desired level. Of course, if your goal is to weigh
exactly 150 lb, you will need a scale that is valid as well as reliable.

247

increases.7 Obtaining around

20 data points, therefore,
taken within the unit of
analysis where improvement
efforts are under way, can
provide a robust enough
estimate to gauge whether
improvement is occurring.
When tracking hand hygiene
compliance, the preferred
measure is typically a
percentage where the
numerator is the total number
of times an HCW was
observed to have appropriately
washed his or her hands
before and after a patient
encounter. The denominator is
the total number of
observations made. When
analysing data based on
percentages it is advisable to
have denominators that are at
least in the double digits. The
general guidance is that a
minimum of 1215
observations should be in the
denominator before a
percentage is calculated. For
example, if you have only 4
observations in the
denominator and 2 of the
HCWs (the numerator) properly
washed their hands this
produces a 50% compliance
number (2/4 = 50%). But this is
not as robust a 50% calculation
as one with a denominator
of 18 with 9 HCWs as the
numerator. Data collection for
improvement not only needs
to be based on sound
statistical methods but it also
needs to be practical and
reasonably easy for the data
collectors. Those interested in
gaining more insight on more
precise sampling estimates
than those offered in the

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

hand
hygiene
complia
nce;

3
general
guideline
s
describe
d above
should
consult
standard
referenc
es on
quality
improve
ment
methods
.2
A
practi
cal
yet
robus
t data
collec
tion
plan
for
tracki
ng
the
perce
ntage
of
work
ers
adher
ing to
prope
r
hand
hygie
ne
comp
lianc
e
could
be
set
up as
follow
s:

out of
these
oppor
tunitie
s
deter
mine
the
numb
er of
times
hand
hygie
ne
was
compl
eted
prope
rly
(this
is the
nume
rator);

comput
e
the
percent
age of
hand
hygiene
complia
nce for
that
week;

select a
unit of
analysis 6
to
be
the pilot
unit or
clinic;
select
a
rando
m
day
each
week
to
obser
ve

on
selected
days,
collect a
minimum
of
15
observati
ons
of
hand
hygiene
opportun
ities (the
denomin
ator);

repeat this
process
for
the
next 15
20 weeks,
as
work
goes
forward on
improving
complianc
e:
use a
run
chart
(see

below)
to
assess
the
succes
s
of
the
improv
ement
efforts.
As
measurements
will be used to
gauge which
interventions
are successful
for improving
compliance,
the pace of
data collection
should match
the pace of the
improvement
efforts. If you
can collect 12
15
opportunities
several times a
week, then
instead of
collecting 120
weeks of data
you can
analyse the
data each day
or several
days a week
rather than
wait for one
data point
each week. In
this regime,
feedback to
the improvers
will occur more
rapidly, and
they will be
able to make
more timely
adjustments in
their efforts.
Important
considerations
in the decision
about how
frequently to
measure are
(1) the ability
of the data
collectors to
gather data
more
frequently;
and (2) having
sufficient
opportunities
to observe
hand hygiene
compliance so
that the
denominators
are

appropriate. Run charts,

for example,
Note that
perform at
when you
roughly the
repeatedly 95%
gather
confidence
samples
interval, while
over time
the more
(e.g. daily or robust control
weekly) the chart
sample size functions at a
increases
level
quickly. For equivalent to
example, if the 99%
you perform confidence
25 hand
intervall.7
hygiene
observations A run chart
each week provides a
you will have running
record of a
100
observations process over
in a month. time. It offers
a dynamic
This
provides a display of
very robust the data and
and stable can be used
distribution on virtually
any type of
of data
data (e.g.
points for
counts of
analysis.
events,
percentages,
Once the
wait times or
data have
physiological
been
test results).
obtained,
Because run
statistical
charts do not
process
require
control
complex
(SPC)
methods are statistical
the preferred calculations
they can
way to
easily be
analyse
understood
process
performance and
constructed,
over time.
The basic
and can be
tools in this applied by
branch of
those
applied
statistics are
run charts
and
Shewhart
control
charts.
These tools
can provide
a degree of
statistical
confidence
similar

to that
achieved
by more
familiar
statistical
tests that
use p
values and
confidence
intervals.

who lack formal

statistical
training. Most
improvement
teams start out
with run charts
because they
are easy to
grasp, do not
require
computers to
develop, and
provide a good
foundation to
move
eventually to
the more
robust control
charts.
Interpreting run
charts for
significance
involves the
application of a
set of decision
rules based on
sequential
patterns of
observations
that refute the
assumption
that the
measures were
drawn from a
completely
random
system.8 Such
patterns are
based on the
notion of
runs. An
example is
shown in
Figure

1. Note that
time is
displayed on
the horizontal
axis, while the
measure of
interest is
plotted on the
vertical axis.
The centreline
on the graph is
the median.
Runs are
defined
relative to the
median. A run
consists of one
or more
consecutive
data points on
the same side
of the median.
Data points

falling on thee
median are
not counted. 3
In Figure 1 :
the chart
contains 4 T
runs as
o
shown by o
the circles
drawn
m
around the a
data
n
clusters.
y
Two data
points fall on
o
the median.
r

Once the
number of
runs has
been
determined
, the next
step is to
apply four
run chart
rules to
determine
if the data
on the
chart
display
random or
nonrandom
patters of
variation.
The run
chart rules
designed
to detect a
nonrandom
pattern in
the data
include:

Rule 1: A
shift in the
process, or
too many
data points
in a run (6
or more
consecutiv
e points
above or
below the
median).

t
o
o
f
e
w
r
u
n
s
(
u
s
e
a
t
a
b
l
e
t
o
d
e
t
e
r
m
i
n
e
t
h
i
s

Rule 2: A
trend
(5 or more o
consecutive n
points, all e
increasing )
or
.
decreasing).
R
u
l

Rule 4: An
astronomic
al data
point, which

is a point
that visually
is
dramaticall
y higher or
lower that
all the other
data points.
This is a
judgement
call when
using the
run chart
and should
be used not
to
determine
statistical
significance
but rather
as a signal
that more
rigorous
analysis
with a
control
chart is
needed.
Figure 1
shows that
the data
have, in fact,
shifted
upwards.
This is
determined
by seeing
that the last
run contains
6
consecutive
data points
above the
median,
which is a
signal of a
non-random
pattern. In
this particular
case this is a
desirable
outcome to
observe,
because it
shows that
the
intervention
the team put
in place
between
January and
February of
2008 had the
desired effect
(i.e. the
percentage
of hand
hygiene
compliance
increased).
As

improveme following
nt teams
exceptions:
become
1 the
more
median is
comfortable
replaced
with data
with
the
mean;
collection
and
analysis,
2 the
the next
upper
logical
and
progression
lower
analytically
control
is to place
limits
the data on
(known
a control
as
chart.
sigma
Control
limits)
charts are
are
very similar
compute
to the run
d;
charts with
the

248

more

robust
statisti
cal
tests
are
applied
to the
charts
to
detect
what
Walter
Shewh
art
(1931)
called
comm
on and
special
causes
of
variatio
n.

APPENDICES

The appropriate control chart for hand hygiene compliance is

what is known as a p-chart. In this case, the p stands for a
percentage or proportion (i.e., the percentage of HCWs properly
cleaning their hands). There are six other basic control charts
that form the foundation for SPC analysis. Given that there
is only one way to make a run chart and many ways to make
control charts, it is advisable to start out improvement teams
by making the run chart. As they gain greater knowledge of
and comfort with statistical methods, they can move to the
application of control charts. Standard texts will provide the
reader with a full background on the theory and application of
3-7,9-11
control charts.

A good

short treatment of Shewhart chart

construction can be found in Mohammed et al.12.

Figure 1.
Hand hygiene run chart

100
90

Median

80

Percentage

70
60
50
40

Lower control Limit

30
20
10

Aug-08

Jul-08

Jun-08

may-08

Apr-08

Mar-08

Fev-08

Jan-08

Dec-07

Nov-07

Oct-07

Sep-07

Aug-07

Jul-07

Jun-07

1.

Deming WE. On probability as a basis for action. The American Statistician, 1975, 29:146152.

2.

Brooke R, Kamberg C, McGlynn E. Health system reform and quality. JAMA, 1996, 276:476480.

3.

Lloyd RC. Quality health care: a guide to developing and using indicators. Boston, Toronto, London, Singapore, Jones and Bartlett Publishers, 2004.

4.

Shewhart WA. Economic control of quality of manufactured product. New York, NY, Van Nostrand, Inc., 1931.

5.

Wheeler DJ, Chambers DS. Understanding statistical process control. Knoxville, TN, SPC Press, 1992.

6.

Provost L, Murray S. The data guide: learning from data to improve health care. Austin, TX, Associates in Process Improvement, 2007.

7.

Grant EL, Leavenworth RS. Statistical quality control. New York, NY, McGraw-Hill, Inc.,1988.

8.
9.

Swed FS, Eisenhart C. Tables for testing randomness of grouping in a sequence of alternatives. Annals of Mathematical Statistics, 1943,

xiv:6687 (Tables II and III).

Gitlow HS et al. Tools and methods for the improvement of quality. Homewood, IL, Richard D Irwin, Inc., 1989.

10.

Carey RG, Lloyd RC. Measuring quality improvement in healthcare: a guide to statistical process control applications. Milwaukee, WI, ASQ Press, 2001.

11.

Carey RG. Improving healthcare with control charts: basic and advanced SPC methods and case studies. Milwaukee, WI, ASQ Press, 2003.

12.

Mohammed MA et al. Plotting basic control charts: tutorial notes for healthcare practitioners. Quality and Safety in Health Care, 2008, 17:137

145.
249

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Appendix 5.
Example of a spreadsheet to estimate costs
Prospective
New alcohol gel unit cost

A spreadsheet for completion by an individual healthcare institution allows the input of local data and will
indicate likely cost savings over time. The example
below is used in the

England and Wales

cleanyourhands
campaign. Values are for
Final annual alcohol gel usage (litres)
the purposes of example.
Final annual alcohol gel cost
Volume per 1000 patient-days

(, at current unit costs)

Final annual alcohol gel cost ()

Data in coloured cells can be changed

Data in coloured cells can

be changed

Central campaign costs

Upfront costs

Costs of posters, etc.

average cost per bed ()
HCAI information

This is the estimated additional upfront

cost of

Rate of HCAI (inpatient phase)

equipping each bed in your Trust with

alcohol rub

Achievable reduction in HCAI

Target reduction in HCAI

Trust information

Current annual deaths

Number of general and acute care beds

Excess inpatient cost for those with HCAI

Occupancy rate

Current estimated HCAIs

Total general and acute care admissions

Average QALYs lost (fatal infection)

Procurement

Average QALYs lost (non-fatal infection)

Do you intend to use PASA?

(choose Yes or No)

Additional costs incurred by patients ()

Average additional primary care costs ()

Hand hygiene compliance

Average costs of additional informal care ()

Initial handwashing compliance rate

Average production gains ()

Target handwashing compliance rate

(after 5 years)
Discount rates
Current usage and spending

Discount rate financial costs and benefits

Current annual alcohol rub usage (litres)

Discount rate QALYs

Current annual alcohol rub spend ()

Current annual alcohol unit cost ( per litre)

Perspective

Current volume per 1000 patient-days (litres)

Perspective for evaluation (choose hospital

or society)

Current cost per 1000 patient-days ()

PASA unit costs

PASA = Purchasing and Supply

Agency;
QALY = quality-adjusted life
year.

per litre

250

APPENDICES

Appendix 6.
WHO global survey of patient experiences in
hand hygiene improvement
A survey was undertaken during 20072008 to ascertain the views of patients in relation to health careassociated infection (HCAI) and, in particular, the role that patients can play in hand hygiene improvement (see
the summary included in Part V of WHO Guidelines on Hand Hygiene in Health Care).
Details of the study design, preliminary data analysis and
results for all questions, as well as specific details from casestudies, can be accessed at: http://www.who.int/patientsafety/
challenge/en.

In total, 457 questionnaires were collected during the study

period. The geographical distribution of respondents is shown
in Table 1.

Table 1.
Respondents by WHO region
WHO region

No. of respondents

Percentage

The Americas (AMR)

237

52%

Europe (EUR)

161

35%

South East-Asia (SEAR) and the Western Pacific (WPR)*

42

9%

Africa (AFR) and the Eastern Mediterranean (EMR)*

17

4%

* Because of the relatively low number of respondents, the results from SEAR/WPR and AFR/EMR have been merged.

Existing infrastructure
Availability and ease of access to products is the cornerstone this reason, respondents were asked to indicate whether such
of the WHO Hand Hygiene Improvement Strategy, described as
system change within the Guidelines recommendations. For

products were readily available (see Figure 1).

Figure 1.
Availability of products by WHO region
100
90
80

Percentage

70
60
No Response
50
40
No
30
20
Sometimes
10
0
AMRO

EURO

SEARO/WPRO

AFRO/EMRO

Yes

251

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

of patient
participation
by WHO region

The patient
experience
I was in a
special care
unit for three
days
recently, too
sick to think
about
handwashing
, but I never
saw even
one healthcare worker
wash/sanitiz
e her hands
before
coming to
my bedside

(survey
respondent,
USA).
Table 2.
Patient
experiences

Twenty-nine
percent of
respondents
stated that
they had
asked a
health-care
workers
(HCW) to
wash or
sanitize
his/her hands.
Regional
analysis
shows that the
greatest
percentage of
positive
responses
was from the
Region of the
Americas and
the least from
the European
Region (Table
2).

Have you ever asked your health-care worker to wash

or sanitize his/her hands (Q5)

AMR

EUR

SEAR/WPR

AFR/EMR

Yes

85 (36%)

28 (17%)

16 (38%)

5 (29%)

No

151 (64%)

132 (82%)

26 (62%)

10 (59%)

1 (0.3%)

1 (1%)

2 (12%)

No response

g
R
e
s
p
o
n
d
e
n
t
s
w
e
r
e
a
s
k
e
d
t
o
p
r
o
v
i
d
e
a
d
d
i
t
i
o
n
a
l
i
n
f
o
r
m
a
t
i
o
n
r
e
l
a
t
i
n

t
o
t
h
e
i
r
e
x
p
e
r
i
e
n
c
e
s
.
F
i
g
u
r
e
2
i
l
l
u
s
t
r
a
t
e
s
s
o
m
e
t
h
e
m
e
s
f
r
o
m
a
r
o
u

n
d
t
h
e
w
o
r
l
d
r
e
l
a
t
i
n
g
t
o
p
a
t
i
e
n
t
p
e
r
c
e
i
v
e
d
b
a
r
r
i
e
r
s
t
o
i
n
v
o
l
v
e
m
e
n
t

.
Figure 2.
Free text
related to
patientperceived
barriers to
patient
involvement

.
.
.
T
h
e
y

t
h
e
i
r
h
a
n
d
s

o
c
B
a

C
a
n
a
d
a

M
e

w
e
r
e
o
f
f
e
n
d
e
d
t
h
a
t
I
h
a
d
a
s
k
e
d
t
h
e
m
t
o
w
a
s
h

I would feel
UK

I thought
to tell
someone
to wash
their
hands, but
it made
me
ashamed
Argentina

cha
llen
ged
...
m
edi
cal
wo
rk
er
s
se
e
m
to
o
big
to
be
qu
est
ion
ed
Ni
ge You
ria dont
nor
mall
y
remi
nd
doct
ors
of
w
h
at
th
e
y
ar
e
d
oi
n
g
Mala
ysia

2
5
APPENDICES

Heatlh-care worker
response
First it is necessary
to change the
cultural barriers:
patients have no
right to tell the
physicians what to
do
(survey respondent,
Slovenia).

100
90
80

Percentage

70
60
50
40
30
20
10
0

Expectat
ions

The way in which

HCWs communicate
risk and the nature of
their response to
being asked was
central to the survey.
A sub-analysis of
responses (Figure 3)
to the question
related to the HCWs
reaction and/or
answer when asked
to practice hand
hygiene reinforces
the importance of
ensuring that HCWs
are prepared for
strategies that
include patient
participation.

If the
docto
r
said,
pleas
e
remin
d me,
I
would
find it
quite
easy
to
say,
you
asked
me to
remin
d you
to
wash
your
hand
s...it
would
be
simila
Tab
le 3.
Pati
ent
exp
ect
atio
ns
in
hyp
oth
etic
al
situ
atio
ns

r to When
my
presented
sayin with scenarios
g why in which a
I was HCW invited
there, the patient to
or
remind them
giving to clean their
the hands, 86%
docto reported that
r
they would
feel
an
updat comfortable
e on doing so. This
medi decreased to
catio
52% when not
n,
etc...t invited, and
hat increased to
is,
72% when
just they were
part presented
of the
with a
routin
scenario
e
(surv where failure
to comply was
ey
respo observed.
ndent These high
,
rates were
USA).probably
attributable in

some
part
to the
hypot
hetic
al
natur
e of
the
quest
ions.
Table
3
illustr
ates
overa
ll
respo
nses
to
these
scen
arios.

Yes

No

No response

If your doctor, nurse or other person providing health care to you

asked or invited you to remind them to wash/sanitize their hands
before examining you, would you feel able to do this? (Q8)

86%

11%

2%

If your doctor, nurse or other person providing health care to you did
not ask or invite you to remind them to wash/sanitize their hands
before examining you, would you feel able to do this? (Q10)

52%

44%

4.6%

If you saw a doctor or nurse taking care of the patient next to you
and then coming to you without washing or sanitizing their hands,
would you ask them to do so? (Q12)

72%

25%

3%

253

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

(survey
respondent,
Australia).

Patie
nt
views
on
best
metho
ds of
gettin
g
hand
hygie
ne
mess
ages
acros
s
Massive
education
all
levels/sector
s of society
Table 4.
Best
method
s of
getting
messa
ge
across
(numbe
r and
percent
age of
patient
s who
marked
the
method
as
either
useful
or
very
useful
, by
WHO
region

Respondents
reported that
the most
useful method
to educate
people in their
country/comm
unity about
hand hygiene
and

infection
control was
HCWs
showing the
importance of
hand hygiene,
e.g. by
cleaning their
hands in the
presence of
the patient;
398 of the 459
responders
reported that
this was either
useful or
very useful
(Table 4
illustrates this
by region).

Method of promoting hand hygiene

Total

AMR

EUR

SEAR/WPR

AFR/EMR

Through HCWs showing its importance,

e.g. by cleaning their own hands in the
presence of the patient

398 (87%)

206 (87%)

142 (88%)

36

12 (70%)

Through caregivers giving permission for

patient to ask about hand hygiene

328 (72%)

170 (71%)

123 (77%)

26 (62%)

8 (47%)

Through a media campaign explaining the

facts and encouraging involvement

342 (75%)

175 (74%)

123 (77%)

34 (81%)

11 (65%)

Through education in schools and colleges

344 (75%)

169 (71%)

131 (82%)

34 (80.5%)

9 (53%)

Through hospital campaigning

333 (73%)

167 (70%)

129 (80%)

27 (64%)

9 (53%)

Through clinics or other health-care

facilities actively promoting the importance
of hand hygiene

362 (79%)

184 (77%)

134 (83%)

32 (76%)

11 (64%)

Through the involvement of community and

country leaders

258 (57%)

116 (53%)

100 (62%)

22 (52%)

8 (47%)

Through visual aids or prompts

(e.g. posters)

331(76%)

176 (74%)

128 (79%)

34 (81%)

11 (65%)

2
5
4

(86%)

APPENDICES

Risk communication
Inform patients that they are in so much risk in medical care

(survey respondent, Republic of Moldova).

Table 5.
How useful do you think the following
methods are for encouraging patient
participation in hand hygiene improvement?
(Figures for respondents who replied useful or
very useful, and percentages of those from
each region who were asked the question)

Building on this series of

questions, the second
stage of the survey
attempted to explore in
more detail some of the
issues around risk
communication with
respondents asked for

their views on eight

possible methods (Table 5).

Methods to encourage patient

participation

Total

AMR

EUR

SEAR/WPR

AFR/EMR

Open verbal dialogue between patients

and health-care providers on the real risk
to patients caused by poor hand hygiene

176 (79%)

77 (83%)

87 (78%)

7 (78%)

5 (63%)

Open verbal dialogue, as described above,

and a clear invitation to patients to remind
health-care providers to, for example,
clean their hands

168 (76%)

81 (87%)

77 (69%)

6 (67%)

4 (50%)

The provision of written information to

patients describing the evidence linking
low levels of hand hygiene with the
development of HCAI

173 (78%)

77 (83%)

85 (76%)

6 (67%)

5 (63%)

The provision of written information as

described above and a clear invitation to
patients to remind health-care providers
to, for example, clean their hands

170 (77%)

78 (84%)

82 (73%)

6 (67%)

4 (50%)

Explicit communication, including

campaigns, describing the risk and the
harm (including the risk of mortality) that
HCAI can cause, and explaining the role of
hand hygiene as an important preventive
measure

187 (84%)

83 (89%)

92 (82%)

7 (78%)

5 (63%)

Explicit communication, as described

above, and a clear invitation to patients
to remind health-care providers to, for
example, clean their hands

168 (76%)

79 (85%)

78 (70%)

7 (78%)

4 (50%)

Providing HCWs with formal training in

patientHCW risk communication to ensure
they are receptive to the needs of patients
in relation to the prevention of HCAI

184 (83%)

83 (89%)

89 (79%)

7 (78%)

5 (63%)

Providing HCWs with formal training in

patientHCW risk communication, as
described above, and instructing HCWs to
invite patients to ask them to clean their
hands.

179 (81%)

83 (89%)

84 (75%)

7 (78%)

5 (63%)

2
5
5
WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

studies/ surveys asking for a patients preference for

involvement are shown in Table 6.
Table 6.
Comparison with other studies

Does experience of health care-associated infection

influence behaviour?
My family members who have been hospitalized have
acquired nosocomial infections this is a very serious
problem in my country
(survey respondent, Mexico).
People who had direct experience of an HCAI were more likely
to question the HCW; 37% among those who had direct
experience vs 17% among those who did not. Among
respondents who identified themselves as not working in any
aspect of health care, this is more pronounced: 31% of patients
who had had a direct experience of an HCAI had previously asked
their HCW to wash/handrub, while only 4% of those who did not
have a direct experience had done so (Figure 4).

Comparison of the study with previous work

Data comparing the results of this study with four other

Figure 4.
Does having a direct experience of a health care-associated
infection influence the likelihood that a patient will ask their
health-care workers to clean their hands (wash/handrub)?
100
90
80

Percentage

70
60
50
40
30
20

No

10
0

Yes

Patients who have

direct experience
of a HAI

Patients who do
NOT have direct
experience of a HAI

Study

Yes, patients should be

involved

Would you ask?

HCW permission

England and Wales NPSA (2004)1

71%

26%

NA

Ontario (Canada)2

32%

42%

NA

USA consumer survey3

NA

NA

80%

USA web survey4

NA

60% (20)

NA

Current study

NA

52% (29% had actually

asked in this survey)

86%

Patient
narratives
On
the
high
dependency ward
where we had to
request that the
nursing
staff
washed
their
hands,
wore
aprons
and
gloves,
their
attitude was that
we
were
ove
reacting

(narrative, United
Kingdom).
Respondents who 110 respondents were successfully contacted
indicated a
and a total of 11 completed standard
personal
narrative forms were received. At the time the
experience of
HCAI developed, the patients had been
HCAI were asked admitted because of a range of underlying
for their willingness medical conditions. Four respondents
to be contacted. Of specifically identified methicillin-resistant
Staphylococcus aureus (MRSA) as the HCAI.
these, 123
respondents (27%) The remaining descriptions included urinary
tract infection, wound infection, septicemia,
stated that they
were willing to be and C. difficile, and one patient acquired HIV
infection.
contacted;
2
5
6

APPENDICES

Risk communication
We were informed by the ward nurses that Mum had contracted a
little, of no concern infection. We were given a broadsheet A4
paper with the initials MRSA and what they stood for, there was no
other information given to my family whatsoever 20 hours later
she was in a coma and died 11 days later

(narrative, United Kingdom).

Table 7.
Patient narrative risk communication

Building on the earlier

questions exploring how best
to communicate risks within
the context of HCAI, the
narrative forms explored both
how the individuals had been
informed of the acquired
infection and whether they
had been informed
about any risk of HCAI whilst
receiving care/treatment (Table

7).

Country

Infection/organism

How told

Informed of risk of HCAI while in hospital?

India

HIV

Report

Not answered

United Kingdom

MRSA

Verbal

No

USA

Septicaemia

Verbal

No

Australia

Urinary tract infection

Not told

No

USA

Urinary tract infection

Not told

No

United Kingdom

MRSA

Verbal

No

USA

MRSA

Not told

No

USA

Septicaemia

Not told

No

USA

Wound

Verbal

No

United Kingdom

C. difficile

Leaflet

No

United Kingdom

MRSA

Had to ask

No

infra
structure
for
hand
hygiene;

Conclusion
The results of this study
reinforce a number of findings
from previous studies. Many
individuals who have had an
experience as a patient are
interested in the possibilities of
participating

in hand hygiene improvement

among HCWs in health-care
settings. Most respondents are
interested in and positive
about empowerment; however,
there were a number of
caveats. The following action
areas should be considered by
any country or facility intent on
introducing or strengthening
this component of the strategy:

pati
ent
and
HCW
information
and
education;

risk
communica
tion;

alig
nment with
culture.

In particular,
the survey
reinforces the
importance of
programme

purposes,

and further
work will be
required in
the future to
gain a
greater
understandi
ng of patient
perception
in these
regions.

docs
who
dont
wash:
Patients
shouldnt
be
shy
about
providers
to
uckin
M,
Waterman
20
6.
hit
theasking
sink,
say.
Microsoft
web
site,
Health
page,
2008
R,
Shubin
A.
(http://www.msnbc.msn.c
om/id/22827499,
accessed
26experts
November
2008).
Patient empowerment
Consumer
attitudes
,06
Zorzi R. Evaluation
ofhealth
a pilot
test of the provincial
hand hygiene improvement
program for
hospitals
- final report
about
care21
acquired
infections
:3
and
hand
hygiene.
42
American Journal
of
Aleccia
The
accessed 1 December
McG 2008) Medical
dirty
truth
Quality,
34
about J.
257

13
2

development
questions in a
manner that
and the need
Limitations of the study
might be
for any patient
considered as
empowerment
The survey was targeted at
a socially
strategy to be
individuals having a health-care
acceptable
at one with
encounter as a patient. However,
response.
the
distribution channels (WHO
Although
organizational Patients for Patient Safety
culture and Champions and members of the limited, the
context. The International Alliance of Patient number of
survey results Organizations) inevitably resulted responses
from the
present an
in sample bias with a high
endorsement percentage of respondents being African,
that patient both patients and also involved in South-East
Asia, Eastern
empowerment some way in the health-care
should form sector, which limits the capacity Mediterranean
, and Western
one
for generalizing these results to
Pacific
component of the population as a whole. It is
a multimodal probable also that respondents Regions
are useful
hand hygiene were sensitized to the issues
for
improvement surrounding HCAI during the
comparative
strategy.
survey and replied to certain

14

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

ABBREVIATIONS
AFFF
AFRWHO
AFRO
AIDS
AMR
AMRO
ASTM
BSI
CBA
CCM
CDC
CEA
CEN
CEO
CFU
CHG
CMCH
CoNS
CR-BSI
CR-UTI
CTICU
CTS
DALY
DDAC
EA
EDTA
EMR
EMRO
EN / prEN
ESBL
EUR
EURO
FDA
GPPHWS
HACCP
HARMONY

HAV
HBM
HBV
HCAI
HCP
HCW
HELICS
HICPAC
HIV
HLC
HNN
HSV
ICER
ICU
IHI

aqueous (water) film-forming foam

African Region
WHO Regional office for Africa
acquired immunodeficiency syndrome
WHO Region of the Americas
WHO Regional office for the Americas
American Society for Testing and Materials
bloodstream infection
costbenefit analyses
Centro per il Controllo delle Malattie
Centers for Disease Control and Prevention
costeffectiveness analyses
Comit Europen de Normalisation / European
Committee for Standardization
chief executive officer
colony forming unit
chlorhexidine gluconate
Chittagong Medical College Hospital
coagulase-negative staphylococci
cather-related bloodstream infection
catheter-related urinary tract infection
cardiothoracic intensive care unit
complementary test site
disability-adjusted life year
didecyldimethyl ammonium chloride
ethanol
ethylene-diaminetetraacetic acid
WHO Eastern Mediterranean Region
WHO Regional Office for the Eastern
Mediterranean
European norm / European norm in preparation
(prenorm)
extended-spectrum beta-lactamase
WHO European Region
WHO Regional Office for Europe
Food and Drug Administration
Global Public Private Partnership for
Handwashing with Soap
hazard analysis critical control point
Harmonisation of Antibiotic Resistance
measurement, Methods of typing Organisms and
ways of using these and other tools to increase
the effectiveness of Nosocomical infection
control
hepatitis A virus
Health Belief Model
hepatitis B virus
health care-associated infection
hexachlorophene soap/detergent
health-care worker
Hospital in Europe Link for Infection Control
through Surveillance
Healthcare Infection Control Practices Advisory
Committee
human immunodeficiency virus
Health Locus of Control
Hospital Nacional de Nios
herpes simplex virus
incremental costeffectiveness ratio
intensive care unit
Institute for Healthcare Improvement

INICC
IPA
IPA-H
JCAHO
JHPIEGO

KAAMC
LR
MDG
MIC
MICU
MRSA
MSICU
NHS
NICE
NICU
NIH
NIOSHA
NNIS
n-P
NPSA
OPD
PACU
PAHO
PASA
PCMX
PDSA
P-I
PICU
PMT
PPE
QAC
QALY
REP
RNAO
RSV
SARS
SEAR
SEARO
SEM
SICU
SSI
TFM
TPB
USA
USAID
UTI
VAP
VRE
v/v
WHO
WPR
WPRO

International Nosocomial Infection Control

Consortium
isopropanol
isopropanol + humectants
Joint Commission on Accreditation of Healthcare
Organizations
Johns Hopkins Program for International
Education on Gynecology and Obstetrics
(international health organization affiliated to
Johns Hopkins University)
King Abdul Aziz Medical Center
log reduction
Millennium Development Goal
minimum inhibitory concentration
medical intensive care unit
methicillin-resistant Staphylococcus aureus
medical/surgical intensive care unit
National Health Service
National Institute for Health and Clinical
Excellence
neonatal intensive care unit
National Institutes of Health
National Institute for Occupational Safety and
Health Administration
National Nosocomial Infection Surveillance
n-propanol
National Patient Safety Agency
outpatient department
post-anaesthesia care unit
Pan American Health Organization
Purchasing and Supply Agency
para-chloro-meta-xylenol
PlanDoStudyAct
povidone-iodine detergent
paediatric intensive care unit
Protection Motivation Theory
Personal Protective Equipment
quaternary ammonium compound
quality-adjusted life year
Replicating Effective Programs
Registered Nurses Association of Ontario
respiratory syncytial virus
severe acute respiratory syndrome
WHO South-East Asia Region
WHO Regional Office for South-East Asia
Self-efficacy Model
surgical intensive care unit
surgical site infection
Tentative Final Monograph
Theory of Planned Behaviour
United States of America
United States Agency for International
Development
urinary tract infection
ventilator-associated pneumonia
vancomycin-resistant enterococci
volume/volume
World Health Organization
WHO Western Pacific Region
WHO Regional Office for the Western Pacific

258

ACKNOWLEDGEMENTS

AKNOWLEDGEMENTS
Developed by the Clean Care is Safer Care Team
(Patient Safety Department, Information, Evidence and Research Cluster) with:
Critical contribution to content from:
John Boyce
Saint Raphael Hospital, New Haven, CT;
United States of America
Yves Chartier
World Health Organization, Geneva;
Switzerland
Marie-Noelle Chrati
University of Geneva Hospitals, Geneva:
Switzerland
Barry Cookson
Health Protection Agency, London;
United Kingdom
Nizam Damani
Craigavon Area Hospital, Portadown,
Northern Ireland; United Kingdom
Sasi Dharan
University of Geneva Hospitals, Geneva;
Switzerland
Neelam Dhingra-Kumar
Essential Health Technologies,
World Health Organization, Geneva;
Switzerland
Raphaelle Girard
Centre Hospitalier Lyon Sud, Lyon;
France
Don Goldmann
Institute for Healthcare Improvement,
Cambridge, MA: United States of
America
Lindsay Grayson
Austin & Repatriation Medical Centre,
Heidelberg; Australia
Elaine Larson
Columbia University School of Nursing
and Joseph Mailman School of Public
Health, New York, NY; United States of
America
Yves Longtin
University of Geneva Hospitals, Geneva;
Switzerland
Marianne McGuckin
McGuckin Methods International Inc.,
and Department of Health Policy,
Jefferson Medical College, Philadelphia,
PA; United States of America

Mary-Louise McLaws
Faculty of Medicine, University of New
South Wales, Sidney; Australia
Geeta Mehta
Lady Hardinge Medical College, New
Delhi; India
Ziad Memish
King Fahad National Guard Hospital,
Riyadh; Kingdom of Saudi Arabia
Peter Nthumba
Kijabe Hospital, Kijabe; Kenya
Michele Pearson
Centers for Disease Control and
Prevention, Atlanta, GA; United States of
America
Carmem Lcia Pessoa-Silva
Epidemic and Pandemic Alert and
Response, World Health Organization,
Geneva; Switzerland
Didier Pittet
University of Geneva Hospitals and
Faculty of Medicine, Geneva; Switzerland
Manfred Rotter
Klinishche Institut fr Hygiene und
Medizinische Mikrobiologie der
Medizinischen Universitt, Vienna;
Austria

Andreas F Widmer
Innere Medizin und Infektiologie,
Kantonsspital Basel und
Universittskliniken Basel, Basel;
Switzerland
Walter Zingg
University of Geneva Hospitals, Geneva;
Switzerland

Technical contributions from:

Vivienne Allan
National Patient Safety Agency, London;
United Kingdom
Charanjit Ajit Singh
International Interfaith Centre, Oxford;
United Kingdom
Jacques Arpin
Geneva; Switzerland
Pascal Bonnabry
University of Geneva Hospitals, Geneva;
Switzerland
Izhak Dayan
Communaut Isralite de Genve,
Geneva; Switzerland
Cesare Falletti
Monastero Dominus Tecum, Prad Mill;
Italy

Denis Salomon
University of Geneva Hospitals and
Faculty of Medicine, Geneva; Switzerland

Tesfamicael Ghebrehiwet
International Council of Nurses;
Switzerland

Syed Sattar
Centre for Research on Environmental
Microbiology, Faculty of Medicine,
University of Ottowa, Ottawa; Canada

William Griffiths
University of Geneva Hospitals, Geneva;
Switzerland

Hugo Sax
University of Geneva Hospitals, Geneva;
Switzerland
Wing Hong Seto
Queen Mary Hospital, Hong Kong
Special Administrative Region of China
Andreas Voss
Canisius-Wilhelmina Hospital,
Nijmegen;The Netherlands
Michael Whitby
Princess Alexandra Hospital, Brisbane;
Australia

Martin J. Hatlie
Partnership for Patient Safety; United
States of America
Pascale Herrault
University of Geneva Hospitals, Geneva;
Switzerland
Annette Jeanes
Lewisham Hospital, Lewisham; United
Kingdom
Axel Kramer
Ernst-Moritz-Arndt Universitt Greifswald,
Greifswald; Germany
259

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

Michael Kundi
University of Vienna, Vienna, Austria

Clean Care is Safer Care Team,

World Alliance for Patient Safety

Anna-Leena Lohiniva
US Naval Medical Research Unit, Cairo;
Egypt

Peer review from:

Nordiah Awang Jalil
Hospital Universiti Kebangsaan Malaysia,
Kuala Lumpur; Malaysia

Jann Lubbe
University of Geneva Hospitals; Geneva;
Switzerland
Peter Mansell
National Patient Safety Agency, London;
United Kingdom
Anant Murthy
Johns Hopkins Bloomberg School of
Public Health, Baltimore, MD; United
States of America
Nana Kobina Nketsia
Traditional Area Amangyina, Sekondi;
Ghana
Florian Pittet
Geneva; Switzerland
Anantanand Rambachan
Saint Olaf College, Northfield, MN;
United States of America
Ravin Ramdass
South African Medical Association;
South Africa
Beth Scott
London School of Hygiene and Tropical
Medicine, London; United Kingdom
Susan Sheridan
Consumers Advancing Patient Safety;
United States of America
Parichart Suwanbubbha
Mahidol University, Bangkok; Thailand
Gail Thomson
North Manchester General Hospital,
Manchester; United Kingdom
Hans Ucko
World Council of Churches, Geneva;
Switzerland

Editorial contribution from:

Rosemary Sudan
University of Geneva Hospitals, Geneva;
Switzerland

Victoria J. Fraser
Washington University School of
Medicine, St Louis, MO; United States
of America
William R Jarvis
Jason & Jarvis Associates, Port Orford,
OR; United States of America
Carol OBoyle
University of Minnesota School of
Nursing, Minneapolis, MN; United States
of America
M Sigfrido Rangel-Frausto
Instituto Mexicano del Seguro Social,
Mexico, DF; Mexico
Victor D Rosenthal
Medical College of Buenos Aires,
Buenos Aires; Argentina
Barbara Soule
Joint Commission Resources, Inc., Oak
Brook, IL; United States of America
Robert C Spencer
Bristol Royal Infirmary, Bristol; United
Kingdom
Paul Ananth Tambyah
National University Hospital, Singapore;
Singapore
Peterhans J van den Broek
Leiden Medical University, Leiden; The
Netherlands
Editorial supervision from:
Didier Pittet
University of Geneva Hospitals and
Faculty of Medicine, Geneva; Switzerland
Patient Safety Department
Secretariat
(All teams and members listed in
alphabetical order following the team
responsible for the publication)

Clean Care is Safer Care:

Benedetta Allegranzi, Sepideh Bagheri
Nejad, Pascal Bonnabry, Marie-Noelle
Chraiti, Nadia Colaizzi, Nizam Damani,
Sasi Dharan, Cyrus Engineer, Michal
Frances, Claude Ginet, Wilco Graafmans,
Lidvina Grand, William Griffiths, Pascale
Herrault, Claire Kilpatrick, Agns
Leotsakos, Yves Longtin, Elizabeth
Mathai, Hazel Morse, Didier Pittet, Herv
Richet, Hugo Sax, Kristine Stave, Julie
Storr, Rosemary Sudan, Shams Syed,
Albert Wu, Walter Zingg
Bloodstream Infections:
Katthyana Aparicio, Gabriela Garca
Castillejos, Sebastiana Gianci, Chris
Goeschel, Maite Diez Navarlaz, Edward
Kelley, Itziar Larizgoitia, Peter Pronovost,
Angela Lashoher
Central Support & Administration:
Sooyeon Hwang, Sean Moir, John
Shumbusho, Fiona Stewart-Mills
Communications & Country
Engagement:
Vivienne Allan, Agns Leotsakos, Laura
Pearson, Gillian Perkins, Kristine Stave
Education:
Bruce Barraclough, Felix Greaves,
Benjamin Ellis, Ruth Jennings, Helen
Hughes, Itziar Larizgoitia, Claire Lemer,
Douglas Noble, Rona Patey, Gillian
Perkins, Samantha Van Staalduinen,
Merrilyn Walton, Helen Woodward
International Classification for Patient
Safety:
Martin Fletcher, Edward Kelley, Itziar
Larizgoitia, Fiona Stewart-Mills
Patient Safety Prize & Indicators:
Benjamin Ellis, Itziar Larizgoitia, Claire
Lemer
Patients for Patient Safety:
Joanna Groves , Martin Hatlie, Rachel
Heath, Helen Hughes, Anna Lee, Peter
Mansell, Margaret Murphy, Susan
Sheridan, Garance Upham
Radiotherapy:
Michael Barton, Felix Greaves, Ruth
Jennings, Claire Lemer, Douglas Noble,
Gillian Perkins, Jesmin Shafiq, Helen
Woodward

Special technical contribution from:

Benedetta Allegranzi
260

ACKNOWLEDGEMENTS

ci,
Christine
Prepared
ness and
Respons
e,
R Epidemic

ep Goeschel
ort , Helen
in Hughes,
g Edward
& Kelley,
Le
ar and
ni Pandemic
ng Alert and
: Respons
W e,
H Kristine
O Stave
C
oll Health
ab Security
or and
ati Environm
ng ent
D Cluster
ep
art
Researc
m
h and
en
ts: Knowled
ge
G
ab
rie Blood
la Transfusi
G on Safety,
ar Essential
ci Manage
a ment:
C
as Health
till Technolo
ej gies,
os Health
, Systems
M Maria
art Ahmed,
in Katthyan
Wa
H Aparicio,
O David
Ly
on and
Of Services
fic Cluster
e Bates,
for Helen
NaHughes,
tio Itziar
na
Larizgoiti
l
a,
Ep
id Pat
e Martin,
mi Carolina
c Nakandi,

Fl Nittita
et
ch Clinical
er, Procedur
S es,
eb Essential
as Health
tia Prasopana Plaizier,
Gi Kristine
an Stave,
Albert

Te
ch
nol
ogi
es,
He
alt
h
Sy
ste
ms
an
d

W
u,
Lor
ri
Zip
per
er
Se
rvi
ce
s
Clu
ste
r

Sa
fe
Su
rge
ry
Sa
ve
s
Liv
es:
Ma
kin
g
Pr
eg
na
nc
y
Saf
er,
Re
pro
du
ctiv
e

Wil
lia
m
Be
rry,
Mo
ba
sh
er
Bu
tt,
Pri
ya
He
alt
h
an
d
Re
se
arc
h,
Fa
mil
y
an

d kos,

D Elizabeth
es Morse,
ai, Douglas
G
er Medicine
al s Policy
d and
DzStandard
ie s,
ka Noble,
n, Sukhmee
Li t
za Panesar,
be Paul
th Rutter,
Co
m Health
m Systems
un and
ity Services
HeCluster
alt Laura
h Schoenh
Cl
err,
us
Kristine
ter

Ka
ren
Ti
m
mo
ns,
Se
cur
ity
an
d
En
vir
on
me
nt
Clu
ste
r

He
len
W
oo
dw
ard
Permiss
Ta
Stave,
E
ckli
d Thomas
ng
m Weiser,
An
on Iain
tim
Yardley
ds
icr
on
obi
, Vaccine
al
Lu Assessm
Re
ke ent and
sis
Fu Monitorin
tan
nk g,
ce:
Immunization,
V
,
Ch
Biologicals,
At
apt
ul Solutions
ers
G & High
7
a 5s:
to
w
9
an
an
Family
de
d
and
, Communi
21.
Al ty Health
4
ex Cluster
are
H Laura
ad
ay Caisley,
apt
ne Gabriela
ed
s, GarciaGe
S Castillejo
ral
oo s, Felix
d
ye Greaves,
Dzi
on Edward
ek
H Kelley,
an,
w
Fel
an
ix
g, Water,
Gr
A Sanitation
ea
gn and
ve
Health,
s,
s Protectio
Da
Po n
lic Claire
vid
y, Lemer,
fro
Ac Agns
m
ce
Pitt
Leotsako
ss
et8
s,
85
an
d Douglas
Ra
tio of the
na Human
l Environm
Us ent,
e, Health

Le Noble,
ot Dennis
sa OLeary,

an
d
Sa
x1
wit
h
per
mis
sio
n

H hel
ey
m undercurr
an ents
n, influencin
S g hand
oo hygiene
ye Davies,
on Gabriela
H Garcia
w Castillejo
an s, Felix
g,
S promotion
ar in health
ah care.

W
HO
ac
kn
owl
ed
ge
s
the
H
fro American
m Greaves,
pit
El Edward
au
se Kelley,
x
vieOliver
Uni
r. Mytton,
ver
Jo
sit
na
Journal of
air
s,
Infection
es
Iai Control,
n 2009,
de
K 37:28Ge
en Charles
n
ne Vincent,
ve
dy Guang(H
, Zhong
UG
Vi Yang
),
vi
in
an
34
with
par
Ta
tic
ng permissio
n from
ula
Chapter
17
is
adapted
fro
Mosby,
r
Te Inc.
ch
the
no
me
Vincristin
lo
mb
e:
gy
ers
Felix
: Greaves,
of
B Claire
the
et Lemer,
Inf
al. Helen
ect
R Hughes,
ion
eli Douglas
Co
gi Noble,
ntr
on Kristine
ol
an Stave,
Pr
d Helen
cu Woodwar
ogr
ltu d
am
re:
me
po
,
te
for
nti
the
al
ir
R
act
aj
ive
es
par
h
tici
A
gg
pat
ar
ion
w
in
al,
de
Lo
vel
rd
opi
Ar
ng
a
thi
D
s
ar
ma
zi,
R
teri
ac
al.

2
6
1

WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE

four persons
who have
disclosed the
following
information:

Conflict of
Interest
Statement
Developm
ent of the
WHO
Guideline
s on Hand
Hygiene
in Health
Care
For the
purpose
of
finalizing
the
WHO
Guidelin
es on
Hand
Hygiene
in Health
Care,
Declara
tion of
interest
forms
from the
technical
experts
who
contribut
ed to the
content
of the
Guidelines
were
gathered. All
27 of these
experts
contributed to
the
development
of the
Guidelines
through their
participation
in five
experts
consultations
and core
group
meetings.
There was no
conflict of
interest
disclosed
among the
experts
contributing
to the content
of the
Guidelines
apart from

Dr John
Boyce
disclosed
that he
had
contract
agreemen
ts and
consultan
cies with
GOJO,
Clorox,
Advanced
Sterilizatio
n
Products,
Soap and
Detergent
Associatio
n, 3M
Corporatio
n, Dial
Corporatio
n and
Mycrocept
. Some
arrangem
ents with
GOJO
and
Clorox
focused
on hand
hygiene in
healthcare
settings.
He has
received
funding for
research
on diverse
topics
ranging
from
compariso
n of
alcoholbased
hand rub
products
and
frequency
of their
use in an
observatio
nal trial
conducted
in a
healthcare
setting, to
assessing
the
cleanlines
s of

environm
ental
surfaces
in a
healthcare
setting
(not
directly
related to
hand
hygiene)
and
advice
regarding
products
intended
for
surgical
hand
scrub. Dr
Boyce
has
received
honorariu
ms from
Clorox
and
Advanced
Sterilizati
on
Products
as a
board
member
for
attending
annual
meetings
where
hand
hygiene
was one
of the
subject
areas of
discussio
n.

Professor
Barry
Cookson
received
an
education
grant from
GOJO
which was
added to
funding
from
a
Departme
nt

of
Health,
UK,
grant
.The
funds
were
used to
assess

the
effecti
venes
s of
the
nation
al
hand
hygien
e
camp
aign
being
imple
mente
d in all
NHS
Trusts
over a
period
of four
years.
Profes
sor
Cooks
on
has
been
a
consul
tant
for
3M,
Biome
rieux,
Wyeth
,
Sanofi
Paste
ur,
Glaxo
Smith
Kline
Beech
am
and
Mome
ntum
on
matter
s not
relate
d to
hand
hygien
e or
hand
hygien
e
produ
cts.

Dr Ziad
Memish
disclose
d that he
has
contract
agreeme
nts with
GlaxoS
mithKlin
e and

Wyeth on
research
trials on
vaccines
and has
not
provided
consultanc
y on any
matters
related to
hand
hygiene or
hand
hygiene
products.

Dr
Maryanne
McGuckin
disclosed
that she
has
contract
agreeme
nts with
Ecolab,
GOJO
and
Medline
for the
sole
purpose
of
providing
their
clients
(healthcare
facilities)
with
enrolment
in her
hand
hygiene
complian
ce and
benchmar
king
program
me. She
receives
compens
ation from
these
companie
s for this
service
but does
not
recomme
nd or
promote
the use of
any hand
hygiene
products.
Currently,
Dr.
McGuckin
receives
no
funding

from
these
compani
es for her
research
and
develop
ment
work.
She
holds
shares in
Steris as
part of an
independ
ent
portfolio.

betwee
n hand
hygien
e and
acquisi I.17.
tion of
health
careassoci
ated
pathog
ens (J.
Boyce)

With regard
to the
I.13.
specific
Surgical
content
contribution hand
to Guidelines preparation:
development, state of the
the above- art (J.
mentioned Boyce)
experts have I.23.7.
co-authored Safety
or provided issues
input to the related to
alcoholfollowing
based
chapters:
preparations

I.7.
Tran
smis
sion
of
path
ogen
s on
hand
s (J.
Boyc
e)
I.8.
Mod
els
of
hand
trans
missi
on
(J.
Boyc
e)
I.9.

22.

(J.
Boyce)
III.3.
Costeffectiveness
of hand
hygiene (J.
Boyce)
I.1.
Monitoring
hand
hygiene
complianc
e (B.
Cookson)
III.3. Costeffectiven
ess of
hand
hygiene
(B.
Cookson)
VI.
Comparis
on of
hand
Rela hygiene
tions national
hip
guidelines

(B.
Cookso
n)

Religi
ous
and
cultur
al
aspec
ts of
hand
hygie
ne (Z.
Memi
sh)
Patie
nt
involv
emen
t
in
hand
hygie
ne
prom
otion
(M.
McGu
ckin)
None

of

the abovementioned
authors
contribute
d

to

chapter
I.11.
"Review of
preparatio
ns

used

for

hand

hygiene",
or

to

chapter
I.12
"WHOrecommen
ded
handrub
formulatio
n".
2
6
2

World Health Organization

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Switzerland
Tel: +41 (0) 22 791 50 60

Email
patientsafety@who.int
Please visit us at:
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